Transplant surgeons meet in Hong Kong amid questions about China's continued use of organs from executed prisoners

The NY Times has the story: Debate Flares on China’s Use of Prisoners’ Organs as Experts Meet in Hong Kong

It discusses a recent article in the American Journal of Transplantation:
Transplant Medicine in China: Need for Transparency and International Scrutiny Remains by T. Trey, A. Sharif, A. Schwarz, M. Fiatarone Singh, and J. Lavee

Here's the abstract of the article:
"Previous publications have described unethical organ procurement procedures in the People's Republic of China. International awareness and condemnation contributed to the announcement abolishing the procurement of organs from executed prisoners starting from January 2015. Eighteen months after the announcement, and aligned with the upcoming International Congress of the Transplantation Society in Hong Kong, this paper revisits the topic and discusses whether the declared reform has indeed been implemented. It is noticeable that China has neither addressed nor included in the reform a pledge to end the procurement of organs from prisoners of conscience, nor have they initiated any legislative amendments. Recent reports have discussed an implausible discrepancy of officially reported steady annual transplant numbers and a steep expansion of the transplant infrastructure in China. This paper expresses the viewpoint that, in the current context, it is not possible to verify the veracity of the announced changes and it thus remains premature to include China as an ethical partner in the international transplant community. Until we have independent and objective evidence of a complete cessation of unethical organ procurement from prisoners, the medical community has a professional responsibility to maintain the academic embargo on Chinese transplant professionals."
************

The NY Times story includes this:
"In an interview conducted on the messaging app WeChat, Huang Jiefu, a senior Chinese transplant official and a former deputy minister of health, appeared to defend the changes but simultaneously acknowledge they were far from perfect.

“We have finished walking the first step of a long march of 10,000 li, the task is heavy and the road far, but we are walking on a path of light,” he wrote. "

Organs and Inducements: Special Issue of Law and Contemporary Problems edited by Cook and Krawiec

Volume 77	2014	Number 3
Organs and Inducements
Philip J. Cook & Kimberly D. Krawiec Special Editors
Foreword PDF		Philip J. Cook & Kimberly D. Krawiec	i
A Primer on Kidney Transplantation: Anatomy of the Shortage PDF		Philip J. Cook & Kimberly D. Krawiec	1
Six Decades of Organ Donation and the Challenges That Shifting the United States to a Market System Would Create Around the World PDF		Alexander M. Capron	25
Regulating the Organ Market: Normative Foundations for Market Regulation PDF		I. Glenn Cohen	71
Perceptions of Efficacy, Morality, and Politics of Potential Cadaveric Organ-Transplantation Reforms PDF		Christopher T. Robertson, David V. Yokum & Megan S. Wright	101
Philanthropically Funded Heroism Awards for Kidney Donors? PDF		Muriel Niederle & Alvin E. Roth	131
Reverse Transplant Tourism PDF		Kimberly D. Krawiec & Michael A. Rees	145
Organs Without Borders? Allocating Transplant Organs, Foreigners, and the Importance of the Nation-State (?) PDF		I. Glenn Cohen	175
State Organ-Donation Incentives Under the National Organ Transplant Act PDF		Sally Satel, Joshua C. Morrison & Rick K. Jones	217
Designing a Compensated–Kidney Donation System PDF		T. Randolph Beard & Jim Leitzel	253
Altruism Exchanges and the Kidney Shortage PDF		Stephen J. Choi, Mitu Gulati & Eric A. Posner	289
Reciprocal Altruism—the Impact of Resurrecting an Old Moral Imperative on the National Organ Donation Rate in Israel PDF		Jacob Lavee & Avraham Stoler	323
Organ Quality as a Complicating Factor in Proposed Systems of Inducements for Organ Donation PDF		Michael L. Volk	337

A still-skeptical view of transplantation in China

My recent post on transplantation in China reported on optimistic assessments of the move away from using executed prisoners as a source of organs. Not everyone is optimistic: here's a recent editorial from the BMJ:

Engaging with China on organ transplantation
BMJ 2017; 356 doi: https://doi.org/10.1136/bmj.j665  (Published 07 February 2017)
by Wendy A Rogers, Matthew P Robertson, and Jacob Lavee

It starts with a story from the bad old days, and then turns to the current environment, saying in part:

"Since January 2015, China has vowed to halt the use of organs from executed prisoners. After a pilot in 2010-14, a procurement programme using donated organs from people who meet circulatory death criteria was rolled out nationally. There are now national transplantation registries and organ procurement organisations. Yet there is no new law or regulation in China banning the use of organs from executed prisoners. Nor have existing regulations permitting the use of prisoners’ organs been rescinded. Prisoners remain a legal source of organs if they are deemed to have consented before execution, thus permitting ongoing retrieval of organs from prisoners executed with or without due process.1

"The transplant registries are not open to public scrutiny or independent verification. Inexplicably high volumes of transplantation continue to take place in China,8 and wealthy foreigners can still obtain liver and heart transplants, booked in advance.11 The Transplantation Society’s former president Francis Delmonico acknowledged under oath at a recent US Congressional hearing that he cannot verify claims about reform in China. The main evidence for reform has simply been the public assertions of Huang Jiefu and other government officials."

The effects of Israel's new organ transplantation law on family consent for deceased donation

Deceased donor organs are a scarce resource with the property that how they are allocated may influence their scarcity, by influencing the decisions of potential donors and their families.  Recent changes in Israeli law give us a window on this...
Incentivizing Authorization for Deceased Organ Donation With Organ Allocation Priority: The First 5 Years
by A. Stoler, J. B. Kessler, T. Ashkenazi, A. E. Roth, J. Lavee

American Journal of Transplantation, Volume 16, Issue 9, September 2016
Pages 2639–2645

Abstract

The allocation system of donor organs for transplantation may affect their scarcity. In 2008, Israel's Parliament passed the Organ Transplantation Law, which grants priority on waiting lists for transplants to candidates who are first-degree relatives of deceased organ donors or who previously registered as organ donors themselves. Several public campaigns have advertised the existence of the law since November 2010. We evaluated the effect of the law using all deceased donation requests made in Israel during the period 1998–2015. We use logistic regression to compare the authorization rates of the donors’ next of kin in the periods before (1998–2010) and after (2011–2015) the public was made aware of the law. The authorization rate for donation in the period after awareness was substantially higher (55.1% vs. 45.0%, odds ratio [OR] 1.43, p = 0.0003) and reached an all-time high rate of 60.2% in 2015. This increase was mainly due to an increase in the authorization rate of next of kin of unregistered donors (51.1% vs. 42.2%). We also found that the likelihood of next-of-kin authorization for donation was approximately twice as high when the deceased relative was a registered donor rather than unregistered (89.4% vs. 44.6%, OR 14.27, p < 0.0001). We concluded that the priority law is associated with an increased authorization rate for organ donation.

Israel revamps its priority system for deceased donor organs

In an effort to increase the number of deceased organ donors, Israel has revamped its allocation system to give priority to those who have themselves signed up to donate, and to their relatives and the relatives of previous donors.

New Law For Organ Donation In Israel: Increased Priority For Those Who Are Prepared To Donate

"An article published Online First and in The Lancet reports that a unique new law comes into effect in Israel in January 2010. It states that people who are prepared to sign donor cards themselves receive priority when they are in need of an organ transplant. In addition, increased priority is given to first degree relatives of those who have signed donor cards, to first degree relatives of those who have died and given organs, and to live donors of a kidney, liver lobe or lung lobe who have donated for as yet undesignated recipients. The article is the work of Professor Jacob Lavee, Director of the Heart Transplantation Unit, Sheba Medical Centre, Ramat Gan, and the Israel Transplant Centre, and colleagues. "
...
"There are different levels of priority concerning the different situations. A transplant candidate with a first-degree relative who has signed a donor card would be given half the allocation priority that is given to a transplant candidate who has signed his or her own donor card. Then again, a transplant candidate with a first-degree relative who donated organs after death or who was an eligible live non-directed organ donor would be given allocation priority 1.5 times greater than that given to candidates who have signed their own donor cards. Among candidates with the same number of allocation points, organs will be allocated first to prioritisation-eligible candidates. Regardless of the new law, patients in urgent need of a heart, lung, or liver transplant due to their serious condition will continue to receive priority. However, in the event that two such people are eligible for the same organ, their priority status under the new law would decide who receives the organ. Candidates under 18 and those unable to express their wishes due to physical or mental disability will retain their priority status versus an adult who merits priority."

This priority system is more nuanced than the one enshrined in Singapore law (see the bottom of this post). And of course legislation on a national scale gives donors a priority for all deceased donor organs, not just those from like-minded donors, which is the path being taken by Lifesharers, an interesting organization about which I posted here.

HT: Steve Leider

Update: here's a YNet followup from March 2010 Radical way to boost organ donation.It discusses, among other things, political obstacles to implementing the new law...

"Execution by organ procurement: Breaching the dead donor rule in China," by Matthew P. Robertson, and Jacob Lavee in the AJT

 Prior to 2015, it was legal in China to transplant organs recovered from executed prisoners. When I visited China in those days to talk about kidney transplantation from living donors, it was sometimes pointed out to me that, as an American, I shouldn't object to the Chinese use of executed prisoner organs, because we also had capital punishment in the US, but we "wasted the organs."  I replied that in the US we had both capital punishment and transplantation, but were trying to limit one and increase the other, and that I didn’t think that either would be improved by linking it to the other.  

So here's a just-published retrospective paper looking at Chinese language transplant reports prior to 2015, which identifies at least some instances that it regards as "execution completed by organ procurement."

Execution by organ procurement: Breaching the dead donor rule in China, by Matthew P. Robertson1, and Jacob Lavee2, American Journal of Transplantation, Early View, First published: 04 April 2022 https://doi.org/10.1111/ajt.16969

1 Australian National University |  Victims of Communism Memorial Foundation, Washington, D.C., USA

2 Heart Transplantation Unit, Leviev Cardiothoracic Center, Sheba Medical Center, Faculty of Medicine, Tel Aviv University, Ramat Gan, Israel

Abstract: The dead donor rule is fundamental to transplant ethics. The rule states that organ procurement must not commence until the donor is both dead and formally pronounced so, and by the same token, that procurement of organs must not cause the death of the donor. In a separate area of medical practice, there has been intense controversy around the participation of physicians in the execution of capital prisoners. These two apparently disparate topics converge in a unique case: the intimate involvement of transplant surgeons in China in the execution of prisoners via the procurement of organs. We use computational text analysis to conduct a forensic review of 2838 papers drawn from a dataset of 124 770 Chinese-language transplant publications. Our algorithm searched for evidence of problematic declarations of brain death during organ procurement. We find evidence in 71 of these reports, spread nationwide, that brain death could not have properly been declared. In these cases, the removal of the heart during organ procurement must have been the proximate cause of the donor's death. Because these organ donors could only have been prisoners, our findings strongly suggest that physicians in the People's Republic of China have participated in executions by organ removal.

"how should we understand the physician's role in a context where executed prisoners are the primary source of transplant organs? Might the transplant surgeon become the de facto executioner? Evidence suggestive of such behavior has emerged over many years from the People's Republic of China (PRC).8-14 To investigate these reports, this paper uses computational methods to examine 2838 Chinese transplant-related medical papers published in scientific journals, systematically collecting data and testing hypotheses about this practice. By scrutinizing the clinical procedures around intubation and ventilation of donors, declaration of brain death, and commencement of organ procurement surgery, we contribute substantial new evidence to questions about the role of PRC physicians in state executions.

...

"The data we rely on in this paper involves transplant surgeries from 1980 to 2015. During this period, there was no voluntary donation system and very few voluntary donors. According to three official sources, including the current leader of the transplant sector, the number of voluntary (i.e., non-prisoner) organ donors in China cumulatively as of 2009 was either 120 or 130,30-32 representing only about 0.3% of the 120 000 organs officially reported to be transplanted during the same period (on the assumption that each voluntary donor gave three organs).18, 33, 34 The leader of China's transplant sector wrote in 2007 that effectively 95% of all organ transplants were from prisoners.35 According to official statements, it was only in 2014 that a national organ allocation system could be used by citizens.36

...

"Procuring vital organs from prisoners demands close cooperation between the executioner and the transplant team. The state's role is to administer death, while the physician's role is to procure a viable organ. If the execution is carried out without heed to the clinical demands of the transplant, the organs may be spoiled. Yet if the transplant team becomes too involved, they risk becoming the executioners.

"Our concern is whether the transplant surgeons establish first that the prisoners are dead before procuring their hearts and lungs. This translates into two empirical questions: (1) Is the donor intubated only after they are pronounced brain dead? And (2) Is the donor intubated by the procurement team as part of the procurement operation? If either were affirmative the declaration of brain death could not have met internationally accepted standards because brain death can only be determined on a fully ventilated patient. Rather, the cause of death would have been organ procurement.

...

"We define as problematic any BDD in which the report states that the donor was intubated after the declaration of brain death, and/or the donor was intubated immediately before organ procurement, as part of the procurement operation, or the donor was ventilated by face mask only.

...

"The number of studies with descriptions of problematic BDD was 71, published between 1980 and 2015. Problematic BDD occurred at 56 hospitals (of which 12 were military) in 33 cities across 15 provinces. 

...

"We have documented 71 descriptions of problematic brain death declaration prior to heart and lung procurement. From these reports, we infer that violations of the DDR took place: given that the donors could not have been brain dead before organ procurement, the declaration of brain death could not have been medically sound. It follows that in these cases death must have been caused by the surgeons procuring the organ.

"The 71 papers we identify almost certainly involved breaches of the DDR because in each case the surgery, as described, precluded a legitimate determination of brain death, an essential part of which is the performance of the apnea test, which in turn necessitates an intubated and ventilated patient. In the cases where a face mask was used instead of intubation48, 49—or a rapid tracheotomy was followed immediately by intubation,50 or where intubation took place after sternal incision as surgeons examined the beating heart44—the lack of prior determination of brain death is even more apparent.

"If indeed these papers document breaches of the DDR during organ procurement from prisoners as we argue, how were these donors prepared for organ procurement? The textual data in the cases we examine is silent on the matter. Taiwan is the only other country we are aware of where death penalty prisoners’ vital organs have been used following execution. This reportedly took place both during the 1990s and then once more in March 2011.51, 52

...

"The PRC papers we have identified do not describe how the donor was incapacitated before procurement, and the data is consistent with multiple plausible scenarios. These range from a bullet to the prisoner's head at an execution site before they are rushed to the hospital, like Tsai's description, or a general anesthetic delivered in the operating room directly before procurement. Paul et al. have previously proposed a hybrid of these scenarios to explain PRC transplant activity: a lethal injection, with execution completed by organ procurement. 

...

"We think that our failure to identify more DDR violations relates to the difficulty of detecting them in the first instance, not to the absence of actual DDR violations in either the literature or practice. Our choice to tightly focus only on papers that made explicit reports of apparent DDR violations likely limited the number of problematic papers we ultimately identified.

...

"As of 2021, China's organ transplant professionals have improved their reputation with their international peers. This is principally based on their claims to have ceased the use of prisoners as organ donors in 2015."