Kidney exchange scheduled to begin in Hong Kong

The South China Morning Post has the story:

New kidney donation scheme starts in October after change in Hong Kong law allows strangers to donate organs to patients
This is aimed at speeding up the long waiting time for a suitable organ and surgeries will be done at four of the city’s 43 public hospitals

"The paired organ donation arrangement, made legal after Hong Kong passed an amendment to its Human Organ Transplant Ordinance last month, allows a donor-patient pair who may not be a match for each other to donate organs to another donor-patient pair and vice versa, so that patients on both sides get the transplants they need.
...
"There is a huge supply-demand gap for kidney transplants in the city. As of June 30 this year, there were 2,214 patients on the transplant list in Hong Kong but each year there are only about 80 living or deceased donors. Two years ago the average waiting time for a kidney was over four years.
...
"Before the change in the law, strangers could not make live donations to transplant patients. Couples had to be married for more than three years and friends needed to obtain approval from the Department of Health’s Human Organ Transplant Board for live donations.

"Professor Philip Li, the chairman of the authority’s Central Renal Committee said in the UK and the Netherlands, the paired kidney donation programme was very mature and they were now having a very large number of successful matchings.

 “In Hong Kong, we are just starting, it will be quite a while before we actually see a significant effect,” Li said."

Compensation for plasma donors--calls for a ban in Canada

At the same time as there are calls for decriminalizing drug use in Canada (see yesterday's post), there are calls for bans on compensating plasma donors. (Repugnance is a big topic..)

This post collects some thoughts on compensation for plasma donors, following my participation in the recent Plasma Protein Forum.

Much discussed there is the rash of recent legislation and proposed legislation in Canada to ban compensation for donors (a sort of repugnance event...).

E.g.
B.C. joins 3 other provinces in banning payment for blood and plasma
Alberta, Ontario and Quebec already have laws prohibiting profit from blood donations

Senator introducing bill to ban payments for blood donation
"“The point of this bill is better safe than sorry,” Wallin said.

“Canadian blood donors are not meant to be a revenue stream.”

Time to end for-profit plasma donations

Canada must never allow another tainted blood crisis and must put an end to cash-for-blood clinics. by (Senator) PAMELA WALLIN

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One perplexing feature of this debate is that Canada already buys lots of plasma from the U.S., where it is supplied by paid donors. No one seems to be suggesting that should be changed.

(Here are my posts to date on plasma in Canada.)

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In related notes, China seems to be ramping up it's "source" plasma collection (obtained at the source via plasmapheresis, as distinct from "recovered" plasma obtained from whole blood donations), with collection of about 7 million liters in 2017.  My understanding is that Chinese law forbids the importation of blood products except for albumin.

See this Lancet editorial from 2017:

The big business of blood plasma

"China,  a  country  that  holds  the  questionable  honour  of  being a world leader in liver disease, is now also the highest consumer  of  serum  albumin,  using  300  tonnes  annually,  roughly  half  of  the  worldwide  total  use,  according  to  an  article  in  the  Financial  Times. 

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In Brazil, compensation of plasma donors is forbidden (along with compensation of organ donors) in the Constitution, article 199

"(4) The law establishes the conditions and requirements to allow the removal of human organs, tissues, and substances intended for transplantation, research, and treatment, as well as the collection, processing, and transfusion of blood and its by products, all kinds of sale being forbidden."

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."
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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."
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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."
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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.
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Here are my earlier posts on the positions taken by the Pontifical Academy regarding transplantation.

Frank Delmonico and the recent organ transplant meeting at the Vatican

When I was in Trento, I participated in a panel on markets for human organs, and had the chance to ask Dr. Ignazio Marino about the recent

Vatican statement on organ transplantation, which I pointed out seemed to conflate killing prisoners for their organs with much more ordinary attempts to increase voluntary organ donation.  Dr Marino replied that this had been part of the diplomacy involved with the Chinese delegation.

Here's an article about the backstory to some of that diplomacy, and the role played by my old friend Frank Delmonico

One doctor’s war against global organ trafficking
By Ryan Connelly Holmes And Dan Sagalyn May 29, 2017

"A controversy was brewing. Delmonico, a leading voice on ethical organ transplantation, had planned a February 2017 summit in Rome for representatives of more than 40 countries to discuss the ethics of transplanting organs and to sign a pledge to uphold high standards.

"But there was a hitch: A key invitee to the forum was Dr. Jiefu Huang, who has led reform of China’s organ donation practices. Critics, including some in the Vatican, wanted at the summit no representatives of China, which for years sold and transplanted organs from executed prisoners.

"Delmonico, however, saw the Chinese presence as a good thing. It was “an opportunity for them to proclaim a new day and be accountable” that the practice has stopped, he said. In fact, some of the Chinese old guard have attacked Huang because of his efforts to stamp out unethical and corrupt methods of obtaining organs.
...
"Pope Francis did not attend, but Marcelo Sánchez Sorondo, the chancellor of the Pontifical Academy of Sciences did. In a significant development, China signed the summit’s statement condemning the use of organs from prisoners and advocating the creation of national laws to prosecute transplant-related crimes. Beijing’s two delegates were joined by 75 other signatories representing more than 50 institutions and more than 40 nations at the conference. Delmonico called it a “seminal event” in the fight for global reform."
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I hope that this effort at diplomacy, aimed at ending the practice of using executions as the primary source of organs in China, will not be a source of confusion regarding attempts to increase the availability of organ transplants by ethical means.

More from the Festival of Economics Trento

I'm back home, after two exciting days in Trento (and two long days of travel). There are a bunch of videos, and some press coverage, for those of you who speak Italian or like to use Google Translate.

You can hear the videos in English if you click on the URL, then start the video by clicking on the arrow in the middle of the screen, and then clicking on the gear icon in the lower right hand corner to select English. (It isn't enough to just click on the English symbol in the upper right...)

Here's a 1 minute video in English, a sort of trailer for my talk on global kidney exchange:

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Here's a link to the full video of my first talk, on global kidney exchange.
Mercato e disuguaglianze nella salute

The questions and answer period begins at minute 44, with a question by the eminent transplant nephrologist Giuseppe Remuzzi about his concern (which he mentions is also Frank Delmonico's) that the Philippines and Mexico, where Global Kidney Exchange has begun, are places where there is not only transplant infrastructure, but also illegal, black market organ trafficking.  He ends by saying that he remains to be (but hopes to be) convinced that GKE is a good idea.
My answer begins at minute 46:40.
I replied in part "One reason people get kidneys in illegal black markets is that they don't have better opportunities.  We would like to provide them with a better opportunity..."


Here's a video of the panel on my book: Matchmaking. La scienza economica del dare a ciascuno il suo  Play Video  It begins with a talk about the book, by Professor Dino Gerardi.  Afterwards I spoke in reply to questions from the moderator and the audience, and you can hear me in Italian translation.


And here's the panel on markets for organs "exploitation or opportunity?" also in Italian:
Mercati per il corpo umano: sfruttamento o opportunità?
I very much enjoyed meeting Ignazio Marino, the transplant surgeon who was for a time Mayor of Rome.

Below are some news reports on these sessions

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Here's a news story right after my talk on global kidney exchange, which was introduced by Tito Boeri:
"Il sistema delle catene" per donare gli organi
Al Teatro Sociale il Nobel Roth descrive il suo progetto per incrociare pazienti e donatori di Paesi ricchi e poveri
G-translate: "The Chain" system for organ donation
Al Teatro Sociale Nobel Roth describes his project to meet patients and donors of rich and poor countries

and here:
Dai modelli matematici si possono salvare molte vite umane. Il Premio Nobel Alvin Roth a Trento
"From the mathematical models you can save lives. The Nobel Prize Alvin Roth in Trento
We die because we can not afford a transplant. Roth: "Our program intends to solve the problem by crossing supply and demand"

and here:
Reni, l’algoritmo che ridà speranza Il Nobel Roth: sgretolare le iniquità
Il Nobel Roth: il sistema si autofinanzia. Allo studio anche un’assicurazione

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Here's a story covering my "book talk," in which Prof Dino Gerardi talked about the Italian translation of Who Gets What and Why, and I answered questions:
Matchmaking. La scienza economica del dare a ciascuno il suo

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Here's a story about the panel discussion on markets for body parts, moderated by Mario Macis, with Nico Lacetera, me, and Ignazio Marino, the transplant surgeon who was  mayor of Rome:
Mercati per il corpo umano: sfruttamenti o opportunità
Il premio Nobel Roth ha dialogato con l'ex sindaco di Roma (e chirurgo) Marino su trapianti e denaro

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Here's a pre-festival story:

Festival dell'economia, su il sipario

Oggi alle 16 l'inaugurazione al Palazzo della Provincia. Alle 18 al teatro Sociale l'apertura è affidata al Nobel Alvin Roth. Da domani anche la nostra emittente sarà in piazza S.Maria Maggiore 

And here are two article from the Italian Jewish press:
Festival Economia – Pagine Ebraiche
Salute diseguale, in cerca di una cura
Pubblicato in Attualità il ‍‍30/05/2017 - 5

Il Nobel Alvin Roth a Pagine Ebraiche
“L’economia può riparare il mondo”

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Updates:

Business Insider Italia has an interview with Ignazio Marino:
Ignazio Marino: “Il mercato nero dei trapianti si può mettere all’angolo salvando molte vite”
(Google translate doesn't seem to do a good job turning it into English, but the very last sentence is
"Quello che ci ha mostrato Roth è un sistema trasparente e può togliere ossigeno ai trafficanti”.
GT renders that as 'What showed us Roth is a transparent system and can remove oxygen to "traffickers.'


Here's a story with an inflammatory headline but a reasonable account, as near as I can tell from Google Translate:
L'economista che vuole legalizzare il traffico d'organi per salvare ricchi (e poveri) del mondo
"The economist who wants to legalize organ trafficking to save the rich (and poor) in the world
"In the US there are 100 thousand people on the waiting list for a kidney transplant but only 12 thousand a year. In the Philippines you do not pay you dialysis. In China they were using executed prisoners as donors. The organs of the problem is global and the Nobel Alvin Roth has the answer (maybe): scambiamoceli among us"
by Francesco Floris, June 7, 2017 

Vatican statement on organ transplantation

When I posted recently about the Vatican conference on organ trafficking and transplant tourism I focused on the participation of China, and the reaction it drew.

Now I've had a closer second look at the conference statement  (whose title is Statement of the Pontifical Academy of Sciences Summit on Organ Trafficking and Transplant Tourism). (UPDATED LINK HERE: https://www.pas.va/en/events/2017/organ_trafficking/final_statement.html )

It's a very tough statement, which casts quite a broad net when talking about "crimes against humanity." Here's the opening paragraph:

"In accordance with the Resolutions of the United Nations and the World Health Assembly, the 2015 Vatican Summit of Mayors from the major cities of the world, the 2014 Joint Declaration of faith leaders against modern slavery, and the Magisterium of Pope Francis, who in June 2016, at the Judges’ Summit on Human Trafficking and Organized Crime, stated that organ trafficking and human trafficking for the purpose of organ removal are “true crimes against humanity [that] need to be recognized as such by all religious, political and social leaders, and by national and international legislation,” we, the undersigned participants of the Pontifical Academy of Sciences Summit on Organ Trafficking, resolve to combat these crimes against humanity through comprehensive efforts that involve all stakeholders around the world."

Here's the paragraph defining what those crimes against humanity are, which to my eye seems to conflate three very different things. It is number 1 in their list of recommendations.

"That all nations and all cultures recognize human trafficking for the purpose of organ removal and organ trafficking, which include the use of organs from executed prisoners and payments to donors or the next of kin of deceased donors, as crimes that should be condemned worldwide and legally prosecuted at the national and international level."

That is, if I read the full statement correctly (you should read it yourself), they are proposing that 

1. taking organs from executed prisoners, 
2. making payments to living donors, and 
3. making payments to next of kin of deceased donors 

should all be considered crimes against humanity.  

Incidentally, the phrase "crimes against humanity"  is one that I hear most often in the context of genocide, although I recognize that it is also used for other horrific crimes that target populations.

I am not encouraged that this will lead to a sensible discussion about either incentives for donation or (even) removing financial disincentives.

Vatican conference on organ trafficking and transplant tourism

A recent meeting at the Pontifical Academy of Sciences of the Vatican:
Summit on Organ Trafficking and Transplant Tourism resulted in a statement and a number of news stories.  Here are several that caught my eye, with divergent views on the situation in China and how it is changing:

From the NY Times: Debate Flares Over China’s Inclusion at Vatican Organ Trafficking Meeting
"China has admitted that it extracted organs from death row prisoners for decades, in what critics have called a serious violation of the rights of inmates who cannot give genuine consent. Since Jan. 1, 2015, Chinese officials have said they no longer use prisoners’ organs, though doubts persist.

“We urge the summit to consider the plight of incarcerated prisoners in China who are treated as expendable human organ banks,” wrote the 11 signatories, who included Wendy Rogers of Macquarie University in Australia; Arthur Caplan of the New York University Langone Medical Center; David Matas and David Kilgour, both Canadian human rights lawyers; and Enver Tohti, a former surgeon from the western Chinese region of Xinjiang."
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From Statnews.com
China moves to stop taking organs from prisoners, WHO says
"The World Health Organization says China has taken steps to end its once-widespread practice of harvesting organs from executed prisoners but that it’s impossible to know what is happening across the entire country.

At a Vatican conference on organ trafficking this week, a former top Chinese official said the country had stopped its unethical program, but critics remain unconvinced.

In an interview Thursday, WHO’s Jose Ramon Nunez Pena said he personally visited about 20 hospitals in China last year and believes the country has reformed. But he acknowledged that it was still possible “there may still be hidden things going on.” China has more than 1 million medical centers, although only 169 are authorized to do transplants.

Nunez Pena said he had seen data including organ transplant registries and was convinced the country was now shifting away from illegally harvesting organs.

“What is clear to me is that they’re changing,” he said. “But in a country as huge as China, we can’t know everything.”
...
"Campbell Fraser, an organ trafficking researcher at Griffith University in Australia, agreed the trends over the past few years have shown a drop in the number of foreigners going to China for transplants and an increase of organ seekers heading to the Middle East.

At a press conference at the Chinese Embassy in Italy following the two-day Vatican organ conference, Fraser said migrants — including Syrians, Somalis and Eritreans — sometimes resort to selling off a kidney to pay traffickers to get them or their families to Europe.

“Egypt is where the biggest problem is at the moment,” he said, adding that it has the best medical facilities in the region and can perform the live donor surgeries.

He estimated as many as 10 such illicit transplants could be happening per week, though he had no statistics and said he based his research largely on anecdotal information from recipients, law enforcement, doctors and even some organ “brokers.”

Fraser said he has access to transplant patient “chat boards” because he himself had a kidney transplant in his native Australia in 2003.

Nunez Pena said it was likely that organ trafficking would find its way to conflict-plagued regions.

“We’re hearing about a lot of problems in Egypt, Pakistan and the Philippines,” he said, predicting that authorities were poised to break up an organ smuggling ring in Egypt in the next few weeks. “Wherever you have vulnerable people, you will see these kinds of problems.”

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From Science:

Study retraction reignites concern over China’s possible use of prisoner organs

By Dalmeet Singh ChawlaFeb. 6, 2017 , 4:15 PM

A journal has decided to retract a 2016 study because of concerns that its data on the safety of liver transplantation involved organs sourced from executed prisoners in China. The action, taken despite a denial by the study’s authors that such organs were used, comes after clinical ethicist Wendy Rogers of Macquarie University in Sydney, Australia, and colleagues authored a letter to the editor of Liver International on 30 January, calling for the paper’s retraction in the “absence of credible evidence of ethical sourcing of organs.”

For years, Chinese officials have come under fire for allegedly allowing the use of organs from executed prisoners for transplants, including for foreigners coming to the country for so-called medical tourism. In January 2015, it explicitly banned the practice and set up a volunteer donation system, but doubts persist that much has changed.

The disputed study—published online in October 2016—analyzed 563 consecutive liver transplantations performed before the ban (from April 2010 to October 2014) at a medical center in China. Suspicious, Rogers organized the protest letter to the journal. “Publication of data from prisoners is ethically inappropriate given that it [is] not possible to ensure that the prisoners freely agreed either to donate their organs, or to be included [in] a research program,” she tells ScienceInsider.

China, transplants, and executed prisoners: is the situation getting clearer?

A recent meeting in China cautiously suggests that there may be some concrete change in the practice of transplanting organs from executed prisoners:
Doctors hail China’s pledge to stop harvesting inmate organs

"Doctors from the World Health Organization and the Montreal-based Transplantation Society who were invited to the conference by China praised Chinese officials for reforms they have made in the transplant system, including a ban put in place last year on using organs from executed inmates.

"Doubts persist that China is accurately reporting figures or meeting its pledge given its severe shortage of organ donors and China’s long-standing black-market organ trade. By its own figures, China has one of the lowest rates of organ donation in the world, and even the system’s advocates say it needs hundreds of additional hospitals and doctors.

"While China suppresses most discussions about human rights, government officials and state media have publicly talked about their commitment to ending a practice opposed by doctors and human rights groups due to fears that it promotes executions and coercion.
...
"Others offered praise for Chinese officials, but stopped short of saying whether they could confirm China had stopped using executed inmates’ organs.

“It’s not a matter for us to prove to you that it’s zero,” said Dr. Francis Delmonico, a longtime surgeon and a professor at Harvard Medical School. “It’s a matter for the government to fulfill what is the law, just as it is in the other countries of the world that we go to.”

"China is believed to perform more executions than any other country, though the government does not disclose how many.

"The former vice minister of health, Dr. Huang Jiefu, publicly acknowledged in 2005 that China harvested executed inmates’ organs for transplant, and a paper he coauthored six years later reported that as many as 90 percent of Chinese transplant surgeries using organs from dead people came from those put to death.

"Huang has also responded to a report earlier this year that a Canadian patient apparently received a kidney from an executed inmate by announcing that the doctor and the hospital in question were suspended from performing more transplants."

Voluntary deceased organ donation in China

It's always hard to parse the Chinese organ data, and know what is going on in the military hospitals, but here's an encouraging story

Chinese Organ Donation on the Rise
   2015-12-06 21:11:39    Xinhua      Web Editor: Guan Chao

"Chinese organ donation has been on the rise after the country banned the use of prisoners' organs for transplant starting Jan. 1 this year, a top medical expert said Sunday.

As of Nov. 9, China has recorded 5,384 voluntary organ donors, who donated 14,721 various organs, said Huang Jiefu, head of a national human organ donation and transplant committee and former vice health minister.

China is expected to top the world in terms of organ donation in several years, said Huang at a forum in the central city of Changsha.

"As long as the donation system is transparent, most of citizens will be willing to join the program," he said.

The shortage of qualified transplant doctors is a major bottleneck. There are only 169 hospitals across the country eligible for organ transplant, with some 100 doctors able to do the operation, said Huang.

Huang called for speedy training of medical talent and expanding the number of hospitals eligible for organ transplant to 300 and the number of doctors to 400 to meet the public demand.

China began a voluntary organ donation trial in 2010 and promoted the practice across the country in 2013. Now, it tops Asia in the number of organ donations."

In defense of pilot studies for organ donor incentives

The third in the series of forthcoming AJT papers about incentives/disincentives for donation discusses the basis for pilot studies (see earlier posts 1 and 2)

Between Scylla and Charybdis: Charting an Ethical Course for Research Into Financial Incentives for Living Kidney Donation
J. S. Fisher1, Z. Butt, J. Friedewald, S. Fry-Revere, J. Hanneman, M. L. Henderson, K. Ladin, H. Mysel, L. Preczewski, L. A. Sherman, C. Thiessen andE. J. Gordon*
Article first published online: 31 MAR 2015
DOI: 10.1111/ajt.13234

"The transplant community appears to be in a state of equipoise regarding the ethical soundness of empirically investigating a regulated system of financial incentives for living kidney donation. ...Proponents of financial incentives for nondirected living donors posit that incentives would increase the supply of high quality organs, prolong quantity, improve quality of life of recipients, and offset the societal cost by reducing the patient population receiving dialysis [10, 11]. Opponents argue that financial compensation beyond recovering expenses would: (1) cause undue pressure to donate, (2) exploit at-risk individuals (such as the poor), (3) commodify the human body, (4) exacerbate disparities in access to transplants between different socioeconomic strata, and (5) negatively impact public opinion and potentially lead to decreased organ donation rates [12, 13]. However, the debate over the intended and unintended effects of a federally regulated system of financial incentives in the United States remains unresolved partly due to a lack of empirical data.

Critics commonly turn to national programs outside the United States (e.g. India, China, Philippines, Eastern Europe) where black market incentives are the rule to justify concerns that financial incentives are exploitative of living donors. We do not disagree that paying donors illegally is exploitive. Other countries like Israel, Saudi Arabia, Iran, Singapore, and Ireland, however, have implemented legal compensation policies that assist living kidney donors to varying degrees and with varying success. However, these programs developed organically without extensive transparency or oversight, rather than as part of a prospective study designed with embedded outcome measures. Thus, it is unclear whether the successes of such policies are translatable to the US context given the differences in our governmental, medical, and societal infrastructures. Until rigorous, relevant data are properly collected, there is no way to determine whether concerns are warranted about potentially adverse effects of financial incentives on patient safety, exploitation, autonomy, and public trust as part of a US federally regulated system.

Members from several academic and professional organizations have called for pilot studies to investigate the provision of financial incentives to eligible living kidney donors to increase donation rates [14-17]. Logistical parameters for such studies have been suggested [18, 19]. However, while proposals for pilot studies commonly advance arguments for financial incentives, they have not systematically addressed the ethical concerns raised by opponents of a pilot study. This paper provides an ethical justification for conducting a pilot trial to study the feasibility and impact of a federally regulated system utilizing financial incentives on living kidney donation rates.''
...
in conclusion...
"the first step to resolve equipoise will require one or more carefully designed pilot studies to assess individual perceptions to determine if a course can be charted between exploitation and undue influence. Only such pilot studies can inform the transplant community as to whether larger, randomized controlled trials may be ethically undertaken to determine if ultimately, a federally regulated financial incentives program could feasibly and effectively increase living kidney donation rates without living donors incurring perceptions of negative psychological experience or generating negative public reaction.

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.

More on This Story

Related Stories

• China to stop taking inmates' organs by Nov 2013
  16 AUGUST 2013, CHINA
• China to end prison organ donors in five years
  23 MARCH 2012, CHINA
• China admits death row organ use
  26 AUGUST 2009, ASIA-PACIFIC

Black markets for kidney transplants

miscellaneous black market links I've been collecting, of different vintages:

Nancy Scheper-Hughes in the New Internationalist magazine, May 2014: Human traffic: exposing the brutal organ trade

Arabianbusiness.com reports, April 2014: 410 Saudis said to buy organs on black market
"As many as 410 Saudis have bought organs – mainly kidneys – from the black market for illegal transplantations over the past two years, Makkah daily reported.

Dr Faisal Shaheen, director of the Saudi Center for Organ Transplants, was quoted as saying: “A total of 220 Saudis bought organs for transplants from markets in Pakistan, China and Egypt in 2013 and 190 did the same in 2012 at their own personal expense.”

CNN, March 2014: Lebanese mayor arrested in Spain, accused of attempted organ trafficking
"A wealthy mayor from Lebanon has been arrested in Spain for allegedly offering to pay $55,000 to poor people to obtain liver tissue for his liver transplant, police and a government official announced Wednesday.
...
"The mayor's alleged accomplices recruited and later paid for nine poor people -- eight immigrants and a Spaniard -- to have specialized liver compatibility tests at a clinic in Valencia last summer, police say. The combined tests cost $16,000, which the mayor's aides allegedly paid. Some of the nine people also received small sums of money for taking part, police said.

Just one man, a Romanian immigrant, met the medical criteria for the liver tissue removal and, posing as a legitimate donor, he accompanied the Lebanese mayor last summer to a Barcelona clinic that specializes in liver transplants. But medical workers there, following strict protocols against human organ trafficking, prevented it."

(same story here from another source: http://www.thelocal.es/20140312/police-thwart-first-illegal-organ-sale-in-spain )


Frank Delmonico's 2011 slides: WHO Perspective on Self-sufficiency--Accountability on the National Level calling for countries to develop organ donation sufficient to cover their national needs for transplantation.

The Guardian, in Dec 2010 (with various Eastern Europe mentions): The doctor at the heart of Kosovo's organ scandal As Kosovo's prime minister denies links to organ trafficking, 'Doctor Vampire' is the subject of an international manhunt
"Azerbaijan's prosecutor-general's office said last month that an investigation prompted by information from Ukranian police found "citizens of various countries" had been brought into the country for illegal kidney transplants. Four Ukrainian doctors have been arrested in connection with the alleged racket. Azerbaijani press reported that Sonmez was "involved" in the ring, which also did operations in Ecuador. "

AzeriReport.com reports, August 2010, on Illegal Organ Transplant Mafia Exposed
"The group has been disclosed by the Trafficking Prevention Department of the Ukrainian Ministry of Internal Affairs. The trans-national criminal group was involved in illegal transplantation of kidney and it included 12 members. Yurii Kucher, representative of the Ukrainian Ministry of Internal Affairs, said over three years the group has recruited online and transported Ukrainian, Russia, Moldavian, Belarus and Uzbek citizens to Azerbaijan and Ecuador.
...
The Azerbaijan law enforcement agencies are unavailable for comments. It has been established that the operations were performed in a private clinic inBaku. The lawyers claim if the donors sold their kidney voluntarily, this is not a crime and any accusations are groundless. Many people are ready to sell their internal organs to make money.  A few days prior to the arrests in Ukraine, Yeni Musavat, an Azeri newspaper, sent a journalist to an area in downtown Baku where the illegal organ donor recruiters gathered and formed a market. The Yeni Musavat journalist was offered to go to a hospital to negotiate terms for the kidney removal.  In the clinic, the journalist was asked to consider selling part of his liver."


Yosuke Shimazono, "The state of the international organ trade: a provisional picture based on integration of available information, Bulletin of the World Health Organization Volume 85, Number 12, December 2007, 901-980


HT: various correspondents

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.

Ohio execution stay for Ronald Phillips for possible organ donations

This will complicate my discussions in China...

Ohio execution stay for Ronald Phillips for possible organ donations

November 14, 2013 (COLUMBUS, Ohio) -- Ohio's governor delayed the execution of a condemned child killer to consider the inmate's unprecedented organ donation request, acknowledging that it's ''uncharted territory'' but expressing hope that the man might help save a life before losing his own.

Ronald Phillips, 40, was scheduled to be put to death Thursday with a lethal injection of a two-drug combination not yet tried in the U.S., but Gov. John Kasich issued a stay of execution Wednesday. The execution date has been reset for July 2.

"I realize this is a bit of uncharted territory for Ohio, but if another life can be saved by his willingness to donate his organs and tissues then we should allow for that to happen," Kasich said in a statement. He said he wanted to allow time for medical experts to study whether Phillips could donate non-vital organs, such as a kidney, before being executed.

Related Content

STORY: Organ-donor request delays Ohio killer's execution

Phillips, who was sentenced for raping and killing a 3-year-old girl in Akron in 1993, asked this week to donate a kidney to his mother and his heart to his sister. His attorney said it was an attempt to do good, not a delay tactic.

Ohio's prison medical policy accommodates organ donations, but prison officials rejected the request, saying it came too late to work out logistics and security concerns.

Kasich said Phillips' crime was heinous but his willingness to donate organs and tissue could save another life and the state should try to accommodate that.

Some 3,500 people in Ohio and more than 120,000 nationally are awaiting organ donations, said Marilyn Pongonis, a spokeswoman for the Lifeline of Ohio organ donation program.

If Phillips is a viable donor for his mother, who has kidney disease and is on dialysis, or for others awaiting live transplants of non-vital organs, the stay would allow time for those procedures to be performed, Kasich said.

Phillips' sister suffers from a heart ailment and he also wants to donate his heart to her.

Richard Dieter, executive director of the Death Penalty Information Center, said a Delaware death row inmate was permitted in 1995 to donate a kidney to his mother while in prison, though he was not facing imminent execution like Phillips.

"This step by the governor puts it into a more normal discussion of (how) an inmate, without any security problems, can help save another person and is that the right thing to do," he said. "With 24 hours to go before an operation had to be carried out, it definitely gets in the way of that process."

Vital organ donations raise larger ethical issues and have not been allowed during U.S. executions but have occurred in China, Deiter said.

Dieter, whose group opposes the death penalty, added: "If the whole idea is to save a life, there's one life to be saved simply by not executing the person at all."

Phillips made his request after the governor denied him mercy and Phillips had exhausted his other legal options. The state had left it up to Phillips' family whether the organs would be harvested after his death.

HT: Bernadette Keller

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.”

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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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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.