"Scraping poison off the bone": Transplants in China without organs from executed prisoners

 Following a long period in which the bulk of China's organ transplants used organs from executed prisoners, there have been steady efforts to create a system of voluntary deceased donation comparable to that in most of the world where transplants are done.

Global Times has the latest bit of that evolving story:

China’s organ donation to be more transparent under newly issued rules By Zhao Yusha and Zhang Yuying   Dec 15, 2023

"Chinese Premier Li Qiang has signed a decree of the State Council to unveil rules on human organ donation and transplantation, media reported on Thursday, with Chinese experts noting that the country’s organ donations will be more transparent under the regulation, which reflects great determination in China's organ donation reform. 

The newly issued rules, which will take effect on May 1, 2024, have been refined from the ones on human organ transplantation issued in 2007 to meet the demands of changing situations and ensure the healthy development of the cause, according to the Xinhua News Agency.

The rules strengthen the publicity and guidance of organ donation. Besides, the regulations stipulate that organ donation must adhere to the principles of voluntary and unpaid participation, and the conditions and procedures of donation should be improved based on the Civil Code. 

...

"China’s organ donations will be more transparent under the newly issued rules, Huang Jiefu, chairman of China Human Organ Donation and Transplantation Committee and chair of the China Organ Transplant Development Foundation Advisory Board, told the Global Times on Thursday.

"Huang noted that the revision of the rules shows the great determination in China's organ donation reform, which he described as scraping poison off the bone. “The regulations reflect the importance the Party and country attach to organ donation, which provides a strong legal guarantee for the high-quality development of organ donation cause.” 

"According to the rules, the application management of organ transplantation technologies should be improved to ensure medical quality. Specifically speaking, the rules define the conditions that medical institutions and practicing physicians must possess when engaging in organ transplantation, and require regular evaluation of the clinical application capabilities of relevant technologies in medical institutions. 

...

"In addition, the rules improve related provisions on legal liabilities and strengthen the punishment of malpractice in the field, Xinhua reported.

"Experts said the new rules call for more people to get involved in organ donations and transplants, and it is hoped that China's organ transplantation technology will spread to more countries in the future."

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Here (in Chinese, but with Google Translate) is the announcement from Xinhua News Agency

李强签署国务院令 公布《人体器官捐献和移植条例》"Li Qiang signed a State Council order announcing the "Regulations on Human Organ Donation and Transplantation"

[The new regulations] "stipulate that patients whose spouses, direct blood relatives and other relatives have donated deceased organs can apply for organ transplantation , priority is given to them under the same conditions. 

...

"Ethical review requirements before organ harvesting will be refined, and the witnessing procedures for harvesting organs from deceased persons will be stipulated. Improve the cadaver organ distribution system, stipulate that the distribution of cadaver organs should meet medical needs, follow the principles of fairness, impartiality, and openness, and distribute uniformly through the distribution system established by the health department of the State Council. It is required to regularly announce the donation and distribution of cadaver organs and accept social supervision.

...

"In addition, relevant provisions on legal liability have been improved, penalties have been increased, and illegal activities in the field of organ donation and transplantation have been severely cracked down on.

　　"(Authorized release) Order No. 767 of the State Council of the People's Republic of China

　　"(Authorized release) Regulations on Human Organ Donation and Transplantation"

HT: Michelle Miao

Deceased organ donation in China, and Hong Kong

I just arrived in Hong Kong (via a fast train from Guangzhou).

On Friday I spoke in Beijing about organ donation and allocation with officials of the Ministry of Health, and today (Tuesday) I'll be speaking with people in Hong Kong who are active in trying to reform the Chinese organ transplant system. Here's some background material (and here):

       Report on the Cooperation of the Chinese Ministry of Health and

           RID 3450 in the Promotion of Organ Donation in China

The Milestone on 26 December 2012

       A Letter of Intent was signed on 26 December 2012 between the Chinese Ministry of Health (MoH) and Rotary International District 3450 (D3450) whereby the two parties, together with the China Organ Transplant Response System Research Center at the University of Hong Kong and the No. 1 Hospital Affiliated to the Sun Yat-sen University in Guangzhou, will cooperate in the promotion of organ donation and international exchanges in this field.

Background

2.   Many major transplant countries used the organs from executed prisoners in the course of developing their organ transplant services.  As this unethical practice was abandoned with social progress, many countries have developed national donation systems to address the need for transplant organs.  In 2007, the State Council of China passed the human organ transplant regulation, a crucial piece of legislation for the development of an organ transplantation system for Chinese people.  The MoH plans to start implementing the new national system in 2013.  This will mark the start of the phasing out of the old practice of relying on organs from executed convicts, who have the right to decide whether or not to donate their organs after death as any other people in the community.  The law is being revised in China to establish the new national system for transplant, including the definition of the role of national accountable organizations and their responsibilities in line with the guidelines of the World Health Organization (WHO).  Apart from scientific issues, the plan also includes addressing cultural and societal issues, i.e. non-scientific aspects of organ donation to gain public confidence and support.

The New National System of China on Organ Transplant

3.     A research team of the MoH at the University of Hong Kong has developed a national organ computer system, which allocates organs according to national policy that reflects urgency, compatibility and patient need, known as the China Organ Transplant Response System (COTRS), which is free of human intervention and monitored by many bodies to ensure the transparency, fairness and traceability of organ procurement and allocation.  The Red Cross Society of China has been commissioned by the MoH to run the organ donation system, and to ensure that organ donation, procurement and allocation within the medical system are in accordance with the law.  These measures provide the basis for public trust in organ donation.

4.     The new system will ensure donors not only that they can donate their organs to save people as they wish, but also that their organs will not be traded.  Furthermore, deliberations are being made on how to provide social support for the disadvantaged donor and recipient families, such as using China’s existing social support mechanism to cover their expenses but not to be a form of payment for the organs.  While this is not necessarily reflected in the regulations, it has to be decided and built into policies governing the process as a whole.

Cultural and Societal Issues

5.    One major cultural and societal difference between western countries and China relates to the definition of death.  Brain death, as defined in law, is used to determine death in many countries and is often taken as the basis for the surgical removal of organs for transplant.  Without such legislation on brain death, China makes reference to current cultural and societal norms in its deceased organ donation criteria which provide three options for the Chinese people who want to donate organs after death: (i) organ donation after brain death; (ii) organ donation after circulatory death (heart stop) and (iii) organ donation after brain death followed by circulatory death.  Data from a pilot study in China reveal that only 9% of organ donations were on the basis of brain death, while the rest were based on brain death with circulatory death or just on circulatory death.  It is possible that as China makes progress with the new organ donation system, its cultural and societal norms regarding death will shift.

Future Plan

6.    Based on the results of a two year pilot program, the MoH and the Red Cross Society of China decided to implement the new system on a national scale.  The national organ procurement and allocation system, the centerpiece of the new national organ donation system in China, has been launched in September 2012.  Time and coordination will be needed for the new system to be carried out among hospitals in China.  It is planned that the new system will be implemented in the Guangdong Province as a start, and the experience gained will help improve the system which will ultimately be implemented throughout the nation.   

The Role of D3450

7.    Rotary is no stranger to the MoH with its significant efforts over the years in conducting various humanitarian programs in China.   In particular, the success of the Hepatitis B Vaccination Program conducted for over a million children in China by D3450 has probably engendered trust and confidence of MoH in the professionalism, dedication and capability of Rotary in rendering assistance in this important and nation-wide project of promoting organ donation.  Furthermore, the vast international network available through Rotary connections among its 1.2 million members from 33,000 clubs distributed in more than 200 countries will be an invaluable asset to the project team which would need close and continuous exchange with the international community.

8.    DG Kenneth and his team met Minister Chen Zhu in end August, and Deputy Minister Huang Jiefu in October, to discuss prospective Rotary projects in China.  In December 2012, MoH formally invited D3450 to participate in this project of promotion of organ donation, through the Director of the COTRS Research Center, Dr. Wang Haibo, and proposed that a letter of intent be signed between MoH and D3450 on 26 December 2012.   

9.     The major areas of work in which D3450, through rotary clubs in Hong Kong and Macau, will be engaged according to the letter of intent will include the following:

(i) to support the construction and enhancement of the management system on Organ Donation and Allocation in the Mainland;

(ii) to promote organ donation through publicity and advocacy programs in the Mainland; and

(iii) to promote international cooperation and exchange in organ donation between China and members of the World Health Organization (WHO).

10.     While Rotary Clubs in Hong Kong and Macau will participate in the above work on voluntary basis and provide suitable professional input/advice where appropriate, the MoH will oversee the implementation of the new organ donation and transplant system by the two universities and the hospitals in the Mainland, provide the necessary financing and support to the parties concerned and give due attention and response to the views, assessment and suggestions provided by the Rotary team appointed by the Governor of D3450.  All the above will take place in the Guangdong Province as a start.  It is expected that experience gained from the Guangdong Province will help in further improving the system which will eventually be implemented in all other provinces of China.

The Signing Ceremony and Press Conference

11.     A Delegation of 46 Rotarians led by DG Kenneth attended the Signing Ceremony held on 26 December 2012 at the International Conference Center of the Guangdong Hotel in Guangzhou, including DGE Eugene, 6 PDGs, Presidents, Past Presidents, District Officers and their family members.  Dr. KO Wing-man, Secretary of Food and Health of the HKSAR Government, and Dr. CH Leong, Chairman of the Council of the University of Hong Kong, also attended and addressed the audience.  The Deputy Minister of Health, the Chairlady of the Red Cross of China and representatives of the HKMAO, the two universities and the No. 1 Hospital Affiliated to the Sun Yat-sen University in Guangzhou represented the Chinese Government.  The Letter of Intent was signed by DG Kenneth Wong and Director General Wang Liji of the MoH and witnessed by all present.  A press conference chaired by the Deputy Minister of Health was held immediately after the signing ceremony.

12.      The subject was widely reported by the media in China, notably by the China Daily and the Phoenix TV Channel.  The presence of RID 3450 as a key party in ensuring the openness and fairness in the promotion and implementation of the new organ donation and allocation system was succinctly presented by the speakers and reflected in the media reporting.  For the easy reference of readers of this report, copy of the full script of the China Daily’s article on the subject is at Appendix 1.  The video script of the Phoenix TV Channel on the subject can be accessed through this link: http://news.ifeng.com/mainland/detail_2012_12/27/20560185_0.shtml.  Some pictures taken on the occasion are also attached.

What Next

13.      No doubt promotion of organ donation is a highly worthwhile project to which Rotarians are expected to be fully prepared to make their contributions.  It will bring significant benefits to people in China which is the country ranked second in the number of organ transplant but with a significant shortfall in organs donated vis-a-vis organs needed for transplant.  Successful promotion of knowledge in and advocacy for organ donation in the Mainland will likely lead to significant increase in the number of organ donors and hence the number of organ recipients (the beneficiaries).   

14.     D3450 will soon initiate programs and activities through which Rotary Clubs in Hong Kong and Macau will be able to contribute to the areas of work mentioned above.  The views of Rotary Clubs will be consulted in drawing up the programs and planning the activities.  Committees for overseeing the implementation of the project will be set up as necessary and appropriate.

Organ donation in China: optimism and skepticism on new policies

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.”

Jump to…

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.”

Jump to…

References

• 1
  Fleck F. New era for organ donation and transplant in China. Bull WHO November 2012. who.int/bulletin/volumes/90/11/12-031112/en. Accessed September 4, 2013.
• 2
  Delmonico FL. A welcomed new national policy in China. Transplantation 2013; 96: 3–4.

  • Find it @ Stanford
• 3
  Wu X, Fang Q. Financial compensation for deceased organ donation in China. J Med Ethics 2013; 39: 378–379.

  • Find it @ Stanford
• 4
  Agence France-Press. China Red Cross in cash for organ allegations: media, afp.com/en/node/1000950. Updated July 9, 2013. Accessed September 4, 2013.

Organ transplants in China: an optimistic assessment

There are optimistic statements about China's progress on developing a system of voluntary organ donation (to replace the prior system of obtaining organs for transplant from executed prisoners.)   Some of these statements originate with the Chinese press. The Vatican is also optimistic.  The Vatican also has wide ranging diplomacy with China concerning quite different issues.  The stories below collectively reflect each of these things.

Here's a story in the SF Chronicle
China to lead in organ transplants by 2020

"China is on track to lead the world in organ transplant surgeries by 2020 following its abandonment of the much-criticized practice of using organs from executed prisoners, the architect of the country’s transplant program said Wednesday.
Chairman of the China Organ Donation and Transplantation Committee Huang Jiefu said the voluntary civilian organ donations had risen from just 30 in 2010, the first year of a pilot program, to more than 5,500 this year.
That will allow around 15,000 people to receive transplants this year, Huang said. The U.S. currently leads the world in organ transplants, with about 28,000 people receiving them each year.
“We anticipate according to the speed of the development of the organ donation in China, the momentum, in the year 2020, China will become the No. 1 country in the world to perform organ transplantation in an ethical way,” Huang said in an interview at his office in an ancient courtyard house inside Beijing’s old city.
China is seeking to expand the number of willing organ donors, but it has run up against some cultural barriers: Family members are still able to block a donation, even if the giver is willing, and Chinese are averse to registering as donors by ticking a box on their drivers’ licenses, considering it to be tempting fate.
Instead, authorities are partnering with AliBaba, China’s virtually ubiquitous online shopping and payment platform, to allow people to register in just 10 seconds, Huang said. Huang said more than 210,000 Chinese have expressed their willingness to become donors, although that’s a drop in the bucket compared with the country’s population of 1.37 billion.
...
"Huang said China has adhered to a complete ban on the use of organs from executed prisoners that went into effect in 2015, although some in the field outside China have called for the country to allow independent scrutiny to ensure it is keeping to its pledge.
Critics have questioned China’s claims of reform and suggested that the World Health Organization should be allowed to conduct surprise investigations and interview donor relatives. The U.N. health agency has no authority to enter countries without their permission.
Chinese officials say China shouldn’t be singled out for such treatment while other countries are not.
Further moving on from the days when foreigners could fly to China with briefcases of cash to receive often risky, no-questions-asked transplant surgeries, China has also taken measures to stamp out organ trafficking and so-called “transplant tourism,” including by limiting transplants to Chinese citizens."
*********
China’s organ transplantation reform hailed by international community

"By CGTN’s Yang Jinghao

A sensitive issue just a decade ago, organ donation and transplantation in China has seen a remarkable shift during the past few years. A total of 7,000 organs were voluntarily donated between January and July this year, according to a conference on organ transplantation held in China over the weekend.

Comparatively, the number in 2010 was just 34 for the whole year.

The conference, held in Kunming, southwest China’s Yunnan Province, gathered top organ transplant professionals from major international organizations. They reviewed the achievements China has made and discussed how to strengthen international cooperation."
**********

And here's a story from Crux (whose subhead is "Taking the Catholic Pulse")
Chinese state media highlights Vatican official at organ trafficking conference in Beijing

"In a sign of the slow thawing of relations between China and the Vatican, a Chinese state newspaper reported positively on a Vatican official’s remarks at an organ trafficking conference taking place in Beijing.
Argentine Bishop Marcelo Sánchez Sorondo, the chancellor of the Pontifical Academies of Sciences and Social Sciences, attended the conference on Thursday, part of China’s ongoing efforts to convince the world it has reformed its organ donation procedures.
In 2015, the communist country announced it was stopping the practice of using organs from executed prisoners. In 2016, official statistics stated surgeons in China had harvested organs from 4,080 donors and performed 13,263 transplant surgeries, the second highest in the world. Officials said all donors were through a registered volunteer donor system. By 2020, China is expected to surpass the United States to take the top spot.
Last month the Pontifical Academy of Sciences, the World Health Organization , the Transplantation Society (TTS), and the Declaration of Istanbul Custodian Group (DICG) - four of the most influential societies in promoting global ethical practices in organ transplantation - sent a letter expressing their appreciation for China’s efforts in organ donation and transplantation reform.
Despite the assurances of the government, many human rights activists are skeptical such numbers could be achieved through an exclusively voluntary system, especially after decades of reliance on the organs of prisoners."
*************

Here are comments from Chancellor Marcelo Sanchez Sorondo commending the development of the China Model

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And here's a story about another realm in which China and the Vatican are simultaneously engaged.

Vatican official hints at unofficial agreement with China on bishops
"HONG KONG (CNS) -- A senior Vatican official has hinted there is an unofficial agreement between the Holy See and Beijing on the appointment of bishops, even as negotiations to formalize arrangements continue to hit roadblocks, reported ucanews.com.

Argentine Bishop Marcelo Sanchez Sorondo, who attended a conference on the sensitive topic of organ donation and transplants in the southern Chinese city of Kunming, offered the hint during an interview with state-run Global Times Aug. 4.
**************
Here are my earlier posts on the positions taken by the Pontifical Academy regarding transplantation.

Organ transplantation in China: in transition--and controversy about paying funeral costs

 I recently spoke at the CAST transplant conference in Hong Kong (see picture), and the underlying theme of my talk, and of many talks there, was the transition of transplantation in China, and what its future might hold.

Jie-Fu HUANG is the other speaker on Zoom (to my right and your left), and Haibo Wang is on the far left on stage.

Here are two of my opening slides (using 2021 data from the Global Observatory on Donation and Transplantation)

On the left, you see that, today, China and India already perform more kidney transplants than any country in the world except the U.S.  On the right, you see that, by virtue of their large populations, they accomplish this despite their quite low rates of transplants per million population, compared to the U.S. and countries in Europe.  So if China and India can raise their transplant rates to rates comparable to the U.S. and Europe, most of the transplants in the world will be done in Asia, and many many additional lives will be saved.

Note that China mostly transplants kidneys from deceased donors, while India mostly transplants kidneys from living donors. So they have different paths (and plenty of untapped potential) for raising donation and transplantation rates.  And their paths to their current positions have also been very different.

Here is a recent account reflecting China's recent progress:

Chen, Zhitao, Han, Ming, Dong, Yuqi, Zeng, Ping, Liao, Yuan, Wang, Tielong, et al. (2023). First Affiliated Hospital of Sun Yat-sen University, Guangzhou, People's Republic of China: 5-year Experience at a High-volume Donor and Recipient Liver Transplant Center. Transplantation, 107, 1855-1859. https://doi.org/10.1097/TP.0000000000004561

" In 1972, our center performed the first living donor kidney transplantation in China. Since then, kidney and liver transplant programs have evolved. By the beginning of the 21st century, organ transplantation had advanced, and clinical liver transplants have been performed successfully at the First Affiliated Hospital of Sun Yat-sen University.1

"Organ shortage has been a prominent feature at our institution as it has been around the world. Starting in the early 1980s, many organs had been procured from inmates on death rows. This unethical approach has been rightfully criticized by the worldwide community. As a consequence, the source of organs for transplants has solely been replaced by voluntary donations from Chinese citizens since January 1, 2015.

...

"Moreover, policies and methods for humanitarian aid to donor families were established. Those policies follow WHO guidelines while recognizing specific aspects of the Chinese culture. The State Ministry of Health and the Red Cross Society of China launched a pilot project on organ donation after the death of citizens in 2010 and established the China Organ Donation Committee. The principle of this pilot project was to learn from the experiences and standards in developed countries while recognizing national conditions and the social reality in China aiming to build an ethical and effective scientific organ donation and transplantation system.2

**********

In the same issue of Transplantation as the above article is this invited commentary by Ascher and Delmonico, both former Presidents of The Transplanation Society (of which Transplantation is the official journal). They largely approve of the effort China has made in transplants, but they have a big reservation.

Ascher, Nancy, MD, PhD & Delmonico, Francis. (2023). Organ Donation and Transplantation in China. Transplantation, 107, 1880-1882. https://doi.org/10.1097/TP.0000000000004562

"The date of 2015 is important for the review of any organ transplantation report from China because of the public proclamation in the media in 2015 prohibiting the use of organs from executed prisoners. Clinical transplantation articles antecedent to 2015 have been consistently rejected by Transplantation and the international community because the source of the transplanted organs was most often an incarcerated prisoner. China took a major step to condemn this practice publicly in 2015. However, because there is no law or regulation that prohibits this unethical practice, there has been ongoing concern that this practice may be continuing. Notwithstanding such a reality, there have been regulations that are citable and may be reflective of the changing experience of organ donation and transplantation in China that are consistent with the World Health Organization (WHO) Guiding Principles.

...

"WHAT CONTINUES TO BE OBJECTIONABLE

"The Chinese Red Cross is prominent in the organ donation process and a center of support for deceased donor families designated by the Red Cross as humanitarian aid to donor families.7 However, such humanitarian aid, although not limited to China, should not be misinterpreted to be an effort because it includes payment to elicit consent for donation. The Sun Yat-sen publication suggests that the Red Cross policies follow WHO guidelines while recognizing specific aspects of Chinese culture without elaboration as to the cultural details. A payment to donor families for funeral expenses or other monetary incentives should be recognized as a form of commercialization and would not comply with WHO guidelines."

**********

Some background may help put this objection in perspective. Doctors Delmonico and Ascher are prominent signatories of a declaration that payments to families of organ donors are crimes against humanity (as are payments to living donors, and both are declared comparable to transplanting organs from executed prisoners, and to be organ trafficking. See my 2017 post.)

So, they raise the question of whether saving many lives by increasing deceased donation in China will be justified if it involves paying funeral expenses of donors.  

My guess is that Chinese health authorities, thinking of the many lives to be saved, will think that this act of generosity to families of deceased donors will indeed be justified, taking account of (see above) "national conditions and the social reality in China aiming to build an ethical and effective scientific organ donation and transplantation system." 

Many people in China and elsewhere might even think that little if any justification is needed for generosity, particularly generosity to families of deceased donors, that is to families who are themselves generous.

New reports that China to stop harvesting executed prisoners' organs

But no word on how they propose to manage the transition from executed prisoners to developing a voluntary source of donated organs for transplant.

Here's a BBC story: China to stop harvesting executed prisoners' organs

China has promised to stop harvesting organs from executed prisoners by 1 January, state media report.

It has said for many years that it will end the controversial practice. It previously promised to do so by November last year.

Death row inmates have long served as a key source for transplants.

China has been criticised for taking their organs without consent, but has struggled to encourage voluntary donations due to cultural concerns.

Prisoners used to account for two-thirds of transplant organs, based on previous estimates from state media.

For years, China denied that it used organs from executed prisoners and only admitted to the practice a few years ago.

The Chinese authorities put more prisoners to death every year than the rest of the world combined - an estimated 2,400 people in 2013 - according to the San Francisco-based prisoners' rights organisation, Dui Hua.

'Fair, just and transparent'

State media reported on Thursday that the head of the country's organ donation committee Huang Jiefu said that by 1 January 2015, only voluntarily donated organs from civilians can be used in transplants.

So far 38 organ transplant centres around the country, including those in Beijing, Guangdong and Zhejiang, have already stopped using prisoners' organs, according to reports.

Dr Huang, who was addressing a seminar, said that every year about 300,000 people in China need transplanted organs, but only 10,000 operations are carried out.

Analysis: Celia Hatton, BBC News, Beijing

It's taken years for the Chinese authorities to end their own practice of harvesting organs from executed prisoners.

In 2006, Dr Huang admitted China must reduce its reliance on prisoners' organs. He repeated that again in 2009, when announcing the establishment of a national organ donation network. And finally, in 2012, Dr Huang surfaced in Chinese state media once more with a promise to end all prisoners' donations within a few years.

Why did it take so long? Thousands of people are on China's transplant waiting list in desperate need of organs, with no clear solution in sight. Attempts to address the need, by encouraging public organ donations, have faltered.

But many in China believe that bodies should remain intact after death. China's also home to a thriving illegal trade in body parts, making would-be donors nervous they will contribute to a wider problem.

A 2012 poll conducted in the southern city of Guangzhou revealed that 79% of respondents believed organ donation was "noble". However, 81% were concerned the donations "inevitably feed the organ trade."

Clearly, Chinese health officials have a lot of work to do to change public perceptions.

With a donation rate of only 0.6 per 1 million people, China has one of the world's lowest levels of organ donation. Dr Huang compared it to Spain, which has a rate of 37 per 1 million.

"Besides traditional beliefs, one of the major roadblocks to the development of our organ donation industry is that people are concerned that organ donation will be fair, just and transparent," he was quoted as saying.

Dr Huang, who used to be the vice minister for health, had last year pledged to phase out prisoner organ transplants by the end of 2013.

Amnesty International's William Nee told the BBC that halting prisoner organ transplants would be "a positive step forward in China's human rights record", although some challenges remain.

"It will be worth seeing not only how effective a new voluntary organ donation system is, but it will also be crucial that the government becomes fully transparent about the number of people sentenced to death, the number of executions per year, and how the executions are carried out," he said.

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Cross-border transplantation between China and Hong Kong

 Here are two recent reports of the first cross-border transplant between China proper and Hong Kong.

From the Global Times:

First organ donation between mainland and HK saves 4-month old baby By Wan Hengyi

"A medical team of the Hong Kong Children's Hospital successfully transplanted a heart donated from the mainland to a 4-month-old baby in Hong Kong Special Administrative Region on Saturday, achieving a historic breakthrough in the sharing of human organs for emergency medical assistance between the two places for the first time.

"The donated heart, which had been matched by China's Organ Transplant Response System (COTRS) through several rounds and had no suitable recipient, was successfully matched in Hong Kong through the joint efforts between 24 departments and 65 medical experts in the mainland and Hong Kong.

"Cleo Lai Tsz-hei, the recipient of the transplant from Hong Kong, was diagnosed with heart failure 41 days after birth and was in critical condition. Receiving a heart transplant was the only way to keep her alive, according to media reports.

"Moreover, the acceptable heart donation for Cleo requires a donor weighing between 4.5 kilograms and 13 kilograms, and the chances of a suitable donor appearing in Hong Kong are slim to none.

...

"COTRS initiated the allocation of a donated heart of a child with brain death due to brain trauma in the mainland on December 15. As a very low-weight donor, no suitable recipients were found after multiple rounds of automatic matching with 1,153 patients on a national waiting list for heart transplants in the COTRS system. In the end, the medical assistance human organ-sharing plan between the Chinese mainland and Hong Kong was launched.

"Some netizens from the Chinese mainland asked why a baby from Hong Kong who has not lined up in the COTRS system can get a donated heart when there is a huge shortage of donated organs in the mainland.

"In response, the organ coordinator told the Global Times that the requirements for organ donation are extremely high, noting that all the prerequisites including the conditions of the donor and recipient, the time for the organ to be transported on the road and the preparation for surgery must reach the standards before the donation can be completed.

"The COTRS system has already gone through several rounds of matching, which is done automatically by computer without human intervention, said the organ coordinator. 

"Medical teams from both jurisdictions, as well as customs officers in Shenzhen and Hong Kong, carried out emergency drills to reduce the customs clearance time to eight minutes, racing against the four-hour limit for preserving donated hearts, said Wang Haibo, head of the COTRS for medical assistance contact between the mainland and Hong Kong.

"The collection of donated hearts began at 17:00 pm on Friday, and the hearts were delivered to the Hong Kong Children's Hospital at 20:00 pm under the escort of Hong Kong police on the same day. At 1:00 am on Saturday, Cleo's heart transplant operation in Hong Kong was successfully completed, and she has not required extracorporeal circulation support at present."

********

And from the South China Morning Post:

Hong Kong could greatly benefit from cross-border organ imports mechanism, doctors say after local baby receives heart from mainland China  by Jess Ma

"Hong Kong could greatly benefit from cross-border organ donations given the city’s persistently low rate of residents willing to sign up to become donors, doctors have said after a local baby girl received a heart from mainland China in the first arrangement of its kind.

...

"Hong Kong’s organ donation rate is currently among the lowest in the world, at 3.9 donors per a million people in 2019, down from 5.8 in 2015, according to research conducted by the Legislative Council.

...

"Medical lawmaker David Lam Tzit-yuen and election committee legislators Elizabeth Quat Pei-fan and Rebecca Chan Hoi-yan urged the government to begin discussions on legal frameworks and procedures for cross-border transplants, saying that the mainland had a robust donation system and that organ sharing between the city and the mainland was not unusual.

"Human rights groups and lawyers have accused the mainland of forcibly harvesting organs from executed prisoners, a practice that then health minister Huang Jiefu publicly acknowledged in 2005. The government announced in 2015 that organ donations would only come from “voluntary civilian organ donors,” but critics argued prisoners were not excluded under the system.

But Chan argued that the mainland’s efforts to improve the transparency and ethics of its organ donation system over the past decade should be acknowledged.

“I disagree that this would be the beginning of a slippery slope. The transparency of the mainland’s organ donation system has been a lot clearer and stricter,” Chan said, adding that a lot of work had been done across the border to prohibit organ harvesting and trading."

Misc. organ transplant links

The links below, which I collected over some time but never turned into blog posts, all have something interesting to say about transplantation.

Should We Legalize the Market for Human Organs? An NPR debate among Sally Satel, Amy Friedman, and Lloyd Cohen (arguing for), and James Childress, Frank Delmonico, and David Rothman (arguing against).

Lingering myths discourage organ donation from American Medical News:
"Only 38% of licensed drivers have joined their states' organ donor registries, with many deterred by long-held misconceptions about how the transplant system works, according to poll results released in April."

Organ donations decline with economy from the Miami Herald.
The numbers of organ donors is down, and experts say one reason may be the recession. But "Because of legislative action, Floridians starting in July will be able to register online to be an organ donor at donatelifeflorida.org ."

In the Kidney Trade: Seller Beware
"Need a kidney? You may be able to buy one in Pakistan, which has become one of the world’s largest “kidney bazaars,” according to an article published in the May-June issue of The Hastings Center Report, a bioethics journal.
But who sells their kidneys, and what becomes of these people afterwards? The article, by two doctors and a psychologist from Karachi, paints an ugly picture of the kidney business and challenges the argument made by some that selling organs is a great financial boon to the poor and that they are grateful for the chance to do it. "

A Better Way to Get a Kidney Daniel Rose in a NY Times OpEd proposes we shift to "opt out" for deceased donors.

National Paired Donation Network (Steve Woodle) does an exchange in Pittsburgh: Kidney exchange benefits boy, 5, and woman

Larissa MacFarquhar: Paying for Kidneys
Megan McArdle: Department of Bizarre Arguments

"Exploitation" of the Poor is a Poor Reason to Ban Organ Markets from the Volokh Conspiracy

Milford men take part in four-way kidney swap (when we helped start NEPKE, only pairwise exchanges were initially feasible, but NEPKE became a pioneer in including 3- and 4-way exchanges in its optimization algorithm...)


Britain's only saviour sibling twins: At the age of two, little do they know it but Amy and Anthony Maguire are Britain's only 'saviour sibling' twins, created to be donors for their sick older brother.
Bone marrow donation requires a perfect match.
"The twins were born after IVF treatment was used to select embryos which are a match for their brother Connor so that blood taken from their umbilical cord at birth may one day be used to offer him life-saving treatment."

Organ donation to get halachic approval
A uniquely Israeli obstacle to organ donation wends its way towards resolution:
"Chief Rabbinate tries to encourage religious public to become organ donors by resolving halachic quandaries surrounding process, issuing special donor card "

Public call for organ donations (China Daily), and
China Announces Voluntary Organ Donor System (NY Times)
CD: "China launched a national organ donation system yesterday in a bid to gradually shake off its long-time dependence on executed prisoners as a major source of organs for transplants and as part of efforts to crack down on organ trafficking."...
"Currently about one million people in China need organ transplants each year while only 1 percent receive one, official statistics show.
Only about 130 people on the mainland have signed up to donate their organs since 2003, according to research on the promotion of organ donation after death by professor Chen Zhonghua with the Institute of Organ Transplantation of Tongji Hospital."...
"China issued an organ transplant law in 2007 that bans organ trafficking and only allows donations from living people to blood relatives and spouses, plus someone considered "emotionally connected."
However, organ middlemen have been faking documents in order to make a person who is desperately in need of money be considered "emotionally connected" to the recipients, reports said.
Living transplants increased to 40 percent of total transplants from 15 percent in 2006, Chen Zhonghua said.
"That's one of the daunting tasks facing us as we try to end the organ trade by establishing this system," Huang noted.
Other goals include preventing organ tourism, improving transplant quality, better defining donors' rights and satisfying patients' needs for transplants in an ethical manner."

NYT: "At least one million people in China need organ transplants each year, but only about 10,000 receive them, according to government statistics. Dr. Huang said that most of those organs — as high as 65 percent, by some estimates — are taken from death row inmates after their executions."...
"The practice of harvesting organs from executed Chinese convicts has been widely reported in the past, although it was only confirmed in 2005, by Dr. Huang, at a medical conference in Manila. The government has routinely denied other allegations that prisoners’ organs regularly found their way to the black market, often for sale to wealthy foreigners, and that executions were sometimes scheduled to coincide with the need for a specific organ.
At a news conference in Shanghai held Wednesday to unveil the new organ-donation system, one transplant surgeon was quoted by the newspaper as saying that the taking of organs from convicts was sometimes subject to corruption. "

Organ transplants and executed prisoners in China

It appears that China's reliance on executed prisoners for transplantable organs is unlikely to end soon, but will be incorporated into what Chinese officials hope will be a more transparent system:

Govt seeks fairness in organ donor system for inmates

Updated: 2014-03-07 07:20

By Shan Juan (China Daily USA)

"China is set to further strengthen the regulation of organ donations from executed prisoners and integrate it into the existing public voluntary organ donation and allocation system, according to a political adviser close to the situation.

Huang Jiefu, director of the China Organ Donation Committee and former vice-minister of health, made the remarks on Tuesday on the sidelines of the ongoing two sessions.

"By doing that, organs from death-row inmates used for life-saving operations are secured in a fair, transparent, and corruption-free manner," he said.

Previously, organ donations from executed prisoners were handled inappropriately by "some doctors and law enforcement officers", which might lead to malpractice and corruption, he said.

To end that, "we will regulate the issue by including voluntary organ donations by executed prisoners in the nation's public organ donation system to help ensure an open and fair practice", he said.

China launched the system in 2010 to make it easier for the public to donate organs and ensure the organs are given based on need rather than the "highest bidders".

As of Sunday, 1,570 organ donations had been facilitated via the system, according to Huang.

Donations from executed prisoners were initially not covered by the system. Zhu Jiye, director of the liver and gallbladder surgical department of Peking University People's Hospital, called for changes to the system, to ensure that death-row inmates are not coerced into donating organs.

"We respect their right to donate, but it must be voluntary and their donated organs should be used fairly," he said.

According to Zhu, transplant surgery using organ donations from death-row inmates has declined in recent years, and there were only two such operations at his hospital last year.

Huang added: "China is gradually moving away from a long-term reliance on executed prisoners as a major source for organ donations."

In November, 38 out of the 165 transplant centers in China signed a declaration vowing to stop using donated organs from executed prisoners, according to Huang.

He expects that procedures that include the procurement and allocation of organs from inmates who have been executed will be integrated into the national system soon.

"We've reached consensus with the legal and law enforcement departments on that," he said.

To ensure that donations are voluntary, written consent from the inmate and the family is required, he said.

Another source who didn't want to be named but is close to the situation said written consent from the executed prisoner's lawyer will be added as well.

Also, only designated organ procurement organizations will be allowed to approach law enforcement departments regarding the issue, Huang said.

Most importantly, "donated organs from executed prisoners will be put into a computerized system to ensure fair allocation", he said.

"Any organ donations, including those by executed prisoners, have to go through the system and the computerized allocation process," he added.

Statistics from the National Health and Family Planning Commission show that about 300,000 Chinese people need organ transplants every year.

However, only around 10,000 eventually receive one.

shanjuan@chinadaily.com.cn"

**************************

HT: Jay Lavee

Here are some earlier posts on organ donation in China.