Child organ trafficking: global reality and inadequate international response.

In organ transplantation, the demand for human organs has grown far faster than the supply of organs. This has opened the door for illegal organ trade and trafficking including from children. Organized crime groups and individual organ brokers exploit the situation and, as a result, black markets are becoming more numerous and organized organ trafficking is expanding worldwide. While underprivileged and vulnerable men and women in developing countries are a major source of trafficked organs, and may themselves be trafficked for the purpose of illegal organ removal and trade, children are at especial risk of exploitation. With the confirmed cases of children being trafficked for their organs, child organ trafficking, which once called a "modern urban legend", is a sad reality in today's world. By presenting a global picture of child organ trafficking, this paper emphasizes that child organ trafficking is no longer a myth but a reality which has to be addressed. It argues that the international efforts against organ trafficking and trafficking in human beings for organ removal have failed to address child organ trafficking adequately. This chapter suggests that more orchestrated international collaboration as well as development of preventive measure and legally binding documents are needed to fight child organ trafficking and to support its victims.

Transplant commercialism and organ trafficking: the Declaration of Istanbul with special relevance to disadvantaged populations living with kidney disease.

This paper provides a historical perspective on organ trafficking and transplant commercialism, an overview of the Declaration of Istanbul [1, 2], and an update on current state. We highlight the importance of this problem pertaining to disadvantaged populations living with or at risk for kidney disease. It was presented during the Kidney Disease in Disadvantaged Populations Satellite Symposium of the World Congress of Nephrology in Hong Kong 2013 (www.theisn.org).

Organ shortage: the greatest challenge facing transplant medicine.

The success of organ transplantation as a treatment for end-stage organ disease has yielded a series of ethical quandaries originating from the issue of organ shortage. Scarcity of organs for transplantation necessitates formulation of just and fair allocation policies as well as ethically viable solutions to bridging the vast gap between organ supply and demand. The concept of "triage" provides a useful paradigm in which to contextualize the organ shortage issue. This entails subjugating the welfare of the individual patient for the benefit of the wider community as an ethically justified response to the challenge of scarcity.

Pakistan and kidney trade: battles won, battles to come.

This essay provides a brief overview of the rise of organ trade in Pakistan towards the end of the last century and the concerted, collective struggle--of physicians and medical associations aided by the media, journalists, members of civil society, and senior judiciary--in pressuring the government to bring about and implement a national law criminalizing such practices opposed by an influential pro-organ trade lobby. It argues that among the most effective measures to prevent re-emergence of organ trafficking in the country is increasing ethical live donations and above all, establishing sustainable, public supported deceased donor programs. To do this, the transplant community must recognize that organ transplantation is not merely a donor-recipient-physician transaction but a complex issue in which decisions to donate an organ are influenced by indigenous values and belief systems about human illness, life and death.

Assessing the Potential Impact of the Declaration of Istanbul 2008 on Internet Reporting of Human Organ Transplantation-Related Crimes Using Interrupted Time Series Analysis and Meta-Analysis Approaches.

BACKGROUND: A severe shortage in donor organs is the major driver for organ transplantation-related crimes. The Declaration of Istanbul 2008 (DOI) was created to stop such crimes. We investigated the impact of DOI on Internet reporting of transplantation-related crimes. METHODS: We conducted Google Advanced Searches to collect data on "kidney trade," "kidney sale," "organ trafficking," and "transplant tourism" in 15 original participant and 10 nonparticipant countries, 6 years prior through 8 years after the promulgation of DOI. The data were normalized for population and transformed to a logarithmic scale. Interrupted time series analysis (ITSA) was applied to estimate the changes in slopes of the outcome variables before and after DOI, and then the overall intervention impact was calculated by meta-analysis. RESULTS: The combined results indicated that the overall impact of DOI on the reporting of "organ trafficking" and "transplant tourism" was statistically negative (reporting reduced significantly) as intended but on "kidney sale" and "kidney trade" was statistically positive (reporting increased significantly), and the increase was higher in the nonparticipant countries compared to the participant countries. The rate of reporting on "transplant tourism" declined in the participant countries more pronouncedly than in the nonparticipant countries. CONCLUSIONS: DOI has a positive impact on the reporting of "organ trafficking" and "transplant tourism" but not on the reporting of "kidney sale" and "kidney trade." The increased reporting of "kidney sale" and "kidney trade" can be indicative of an impact of DOI on public awareness and increased reporting of the residual transplantation-related crimes.

Social world of organ transplantation, trafficking, and policies.

Although success of organ transplants reflects advances in medical procedures, the success has generated debates about the ethical standards and policies that govern transplants, especially the acquisition of organs for transplants. We focus on laws, policies, and organ trafficking to highlight the interdisciplinary perspectives that can shape our understanding of transplantation as a social phenomenon. We discuss international policies and country-specific legislation from Pakistan to point to gaps and their implications for protecting vulnerable people who are exploited for organ removal. International collaboration and the legal framework need to be strengthened to fight the menace globally and to deal with the cases of organ trafficking within the legal ambit of human trafficking so that the rights of victims are upheld by states, justice systems, and ultimately medical establishments and practitioners.

Prevention of Transnational Transplant-Related Crimes-What More Can be Done?

BACKGROUND: Many nations are able to prosecute transplant-related crimes committed in their territory, but transplant recipients, organ sellers and brokers, and transplant professionals may escape prosecution by engaging in these practices in foreign locations where they judge the risk of criminal investigation and prosecution to be remote. METHODS: The Declaration of Istanbul Custodian Group convened an international working group to evaluate the possible role of extraterritorial jurisdiction in strengthening the enforcement of existing laws governing transplant-related crimes across national boundaries. Potential practical and ethical concerns about the use of extraterritorial jurisdiction were examined, and possible responses were explored. RESULTS: Extraterritorial jurisdiction is a legitimate tool to combat transplant-related crimes. Further, development of a global registry of transnational transplant activities in conjunction with a standardized international referral system for legitimate travel for transplantation is proposed as a mechanism to support enforcement of national and international legal tools. CONCLUSIONS: States are encouraged to include provisions on extraterritorial jurisdiction in their laws on transplant-related crimes and to collaborate with professionals and international authorities in the development of a global registry of transnational transplant activities. These actions would assist in the identification and evaluation of illicit activities and provide information that would help in developing strategies to deter and prevent them.

Transplant Ethics.

OBJECTIVES: The aim of this study was to review and discuss the great variety of ethical issues related to organ donation, organ procurement, transplant activities, and new ethical problems created as a result of technologic and scientific developments. MATERIALS AND METHODS: An extensive literature survey was made, and expert opinions were obtained. RESULTS: The gap between demand and supply of organs for transplant has yielded to organ trafficking, organ tourism, and commercialism. This problem seems to be the most important issue, and naturally there are ethical dilemmas related to it. A wide number of ideas have been expressed on the subject, and different solutions have been proposed. CONCLUSION: The struggle against organ trafficking and commercialism should include legislation, efforts to increase deceased-donor donations, and international cooperation. China's policy to procure organs from prisoners sentenced to death is unethical, and the international community should exert more pressure on the Chinese government to cease this practice. Each particular ethical dilemma should be taken separately and managed.

Organ donation in the Philippines: should the dead do more?

This paper asks whether the Philippines should focus on ways of dealing with end-stage renal disease by getting more transplantable kidneys from the dead. Would it be more ethical to put the burden to donate on the dead (who have already lost their chance to consent) than on the living (who can consent)? Given the risks involved in undergoing nephrectomy and the lack of benefits arising from the procedure to donors, the dead should be the first to put their kidneys on the line. In the Philippines, unfortunately, living donors have had to bear the greater burden in this regard. Starting with a brief account of developments surrounding the impact of the Declaration of Istanbul on the situation in the Philippines as well as in other countries, the paper examines what the living have been expected to do, what they have actually done, and what lessons the experience with living donors offers for the understanding of cadaver transplants. The paper then looks at possible ways of increasing the sources of kidneys for transplantation and asks if these ways could be implemented successfully and ethically in the Philippines.

Deceased organ donation in India: where do we go from here?

Transplantation represents one of the best examples of the scientific achievements of medical science. However, its success has also led to some of the fiercest ethical challenges in modern medicine. Partly as a response to the uncovering of a flourishing clandestine kidney trade, the Central government promulgated the Human Organs Transplant Act (HOTA) in 1994. HOTA, along with its amendments, was a step forward in recognising concepts such as brain death. Nevertheless, there are numerous ethical challenges still to be resolved, particularly with regard to consent, incentives to donors and families, and equitable distribution of donated organs.