The American Journal of Transplantation carried this account of China's moves to end its reliance on executed prisoners for transplant organs, in its 24 Sept 2013 issue:
China's transplantation system has undergone a substantial makeover that may end its longstanding reliance on executed prisoners for organ transplants. A new national program for deceased-organ donation based on Chinese cultural and societal norms was announced by Chinese health officials, who say the new system adheres to World Health Organization (WHO) guiding principles and is compliant with the Declaration of Istanbul. Health officials say that with the new program, the use of organs from executed prisoners will be phased out within two years.
The transplant program is based on pilot trials that took place between 2010 and 2012 in 19 of the 31 provincial regions in China, in which organs were obtained from donors after circulatory death.
According to an interview with Haibo Wang, MD, director of the Chinese Organ Transplant Response System Research Center of the Ministry of Health, that appeared in the Bulletin of the World Health Organization in November 2012, “It is not customary—in term of our culture, law and medical practice—to take brain death as the definition of death in China.”[1] For this reason, the new national program will respect Chinese cultural and social values with three categories of donation: 1) organ donation after brain death; 2) organ donation after circulatory death; and 3) organ donation after brain death followed by circulatory death.
The third category “is an important approach that is very unique to China due to its social and cultural perspective regarding death,” says Jiefu Huang, MD, China's former Vice Minister of Health and current head of the Organ Transplant Committee of the National Health and Family Planning Commission (NHF-PC) of the country's Ministry of Health. “The data from the pilot program indicated that China Category in accounted for approaching 50% of overall deceased donors,” says Dr. Huang.
He adds that “another issue is that the final decision making of organ donation rests on family wishes, regardless of the individual's wish before death. This is to respect the Chinese culture, which is very family centered.”
Waitlists, Registries and Allocation
An important aspect of the program is use of a computerized waitlist developed and maintained by the Chinese Organ Transplant Response System based at the University of Hong Kong, which also runs the Chinese Liver Transplant Registry. The kidney registry is based at the 309th Hospital of the People's Liberation Army, the heart registry at The Fuwai Cardiovascular Disease Hospital and the lung registry at Wuxi People's Hospital.
Although the Red Cross Society of China oversaw donation during the pilot trials, there is currently “a battle for the authority to distribute organs,” said Frank Delmonico, MD, president of The Transplantation Society, in a commentary in the July issue of the journalTransplantation.2 He quoted an article published earlier this year in the Journal of Medical Ethics that said the Red Cross would pay families of the deceased for donor organs.[3] Additionally, the Beijing News reported in July that the Red Cross charges hospitals the equivalent of $16,000 US to receive an organ for transplant.[4]
Another option for organ allocation might be one of the registries. Gabriel Danovitch, MD, director of the Kidney and Pancreas Transplant Program at the University of California, Los Angeles, says the international transplant community strongly advocates “the standards of access, transparency, fairness and justice in allocation that is appropriate for a nation as important as China.” He adds, “I sincerely hope that the Chinese Liver Transplant Registry will be given the opportunity to provide access and transparency of allocation for organ transplants within China.”
KEY POINTS
- China says the new program adheres to WHO guidelines and Declaration of Istanbul principles.
- The program includes three categories of donation, and use of a computerized waitlist.
- Transplant professionals have expressed guarded optimism and areas of concern about the new program.
Guarded Optimism or Skepticism?
While Drs. Delmonico and Danovitch have expressed guarded optimism, they note areas of concern. “One is the continued use of donation by execution,” Dr. Danovitch says. “The second is commercialization of organ donation from both deceased- and living-donor sources.” Dr. Delmonico notes that the financial compensation program for deceased-donor organs suggested in the Journal of Medical Ethics article may undermine the trust of families in the determination of death and a societal trust that organs are being distributed fairly.[3]
Three frequent critics of Chinese transplantation say they remain skeptical. Torsten Trey, MD, PhD, co-editor of State Organs: Transplant Abuse in China, and executive director of Doctors Against Forced Organ Harvesting, says that “with the continuous lack of transparency, the new program is as vague as the Chinese Medical Association pledge to the World Medical Association in 2007,” in which China agreed to end organ sourcing from prisoners. Dr. Trey says he's concerned that “prisoners of conscience, in particular unjustly detained Falun Gong practitioners, are forcibly enrolled into the organ donation program. In order to meet international standards, openness to scrutiny is indispensable. Chinese officials often speak of ending China's reliance on prisoners, yet ending reliance—defined (by them) as less than 50%—does not guarantee a complete end.”
David Kilgour, co-author with David Matas of the 2007 report Bloody Harvest: Revised Report into Allegations of Organ Harvesting of Falun Gong Practitioners in China, is also skeptical. He says he doesn't believe China will phase out the use of organs from executed prisoners in the next two years. “The party-state in Beijing knows that governments, legislators, medical professionals and ordinary people across the world are increasingly aware of its inhuman organ pillaging, mainly from Falun Gong prisoners of conscience in forced labor camps, and thus wants to create for the naive the impression that trafficking in organs will soon end,” he says. “All persons of good will wish it would, but it has now gone on since 2001 and still shows no sign of ending.”
Matas says, “I can't predict the future. I'm skeptical for a number of reasons. One is that they are complaining about cultural inhibitions. But this has never been an issue for anything else with the Communists.” He adds, “Will the numbers in the new system ever be sufficient to replace the numbers they are getting from prisoners? It's not clear. I don't think we should take the assurances of the Chinese government that everything is going to be fine and just give us time. I don't think that's an acceptable answer.”
In China, Dr. Huang says “the success of the new deceased organ donation program is the key to end China's reliance on prisoners' organs.” After the pilot trials, “many hospitals decided to abandon the practice of prisoner organ use,” he adds. “The capacity of the new deceased-organ donation is far beyond the prisoner organs and certainly will ease the donor shortage if we can build an effective OPO [organ procurement organization] system in a relatively short time.”
International Forums
A step toward that development took place in May with the First Chinese Organ Procurement Organization International Forum, held in Shenzhen, China. It was announced that the National Italian Transplant Center will help China build and maintain its national organ distribution and safety monitoring system for donors and recipients, as well as provide training on advanced organ donation practices used in the European Union. A five-year cooperative agreement with the Spanish Transplant Procurement Management and Donation and Transplantation Institute will include training programs with Chinese medical staff in China and overseas.
“In May 2014, one year after the kickoff meeting of the new deceased donor program,” Dr. Huang says, “NHFPC is going to host an international conference to create a platform for international and Chinese transplant communities to exchange knowledge from their own experience and, more importantly, work together to review and improve the design of the new deceased-organ donation program.”
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