Organ trafficking is a heinous violation of both human rights and medical ethics, but nevertheless, it is also the often overlooked, if not entirely forgotten, element of human trafficking, especially among healthcare professionals—unless of course they are complicit with or active participants in it. Some certainly are engaged in it across the world, since organ trafficking is probably the only crime which would cease overnight if all transplant staff and facilities refused to be involved. It is a uniquely medically dependent crime.
Healthcare is not the only area, however, where organ trafficking has a low or absent profile. Although it involves thousands of people globally, human trafficking for the purpose of organ removal (HTOR) gains far less attention in terms of research output and media coverage than any other element of people-trafficking. A searchFootnote 1 for the terms “organ trade,” “organ trading,” or “organ trafficking” in one of the world’s leading research journals on human trafficking, yielded just two papers.Footnote 2, Footnote 3
A bibliometric analysisFootnote 4 showed that only 138 (6.8%) of the 2,044 papers from 2000 to 2017 identified on human trafficking were about organ trafficking. In spite of this low percentage overall, 3 of the most-cited top 10 papers on human trafficking were specifically about organ trafficking.Footnote 5 This analysis concluded that although research on sex-trafficking dominated the field of human trafficking, “future research plans need to focus on health issues and on exploited/trafficked laborers.”Footnote 6 Four of the top 10 most active journals in the field of human trafficking were classified as medical journals including the Lancet, the International Journal of Obstetrics and Gynaecology, and Transplantation. Footnote 7 The presence of an obstetrics journal almost certainly reflects both the predominance of women among trafficked persons (70%) and the fact that the majority of organ donors worldwide are also women.
This article will briefly consider the definitions of HTOR and organ trafficking, the international protocols and declarations concerning these activities and their prevalence as a crime globally. It will then present evidence concerning organ trafficking in South Africa and China. Finally, it explores how and why healthcare professionals become actively involved in this crime or complicit in its continuance.
HTOR and Organ Trafficking
It is a medical truism that organ transplantation has become a victim of its own success. Since the first successful kidney transplant was carried out in 1954,Footnote 8 transplantation has grown exponentially as a life-saving procedure across the globe. The World Health Organization’s (WHO) Global Observatory on Donation and TransplantationFootnote 9 records the total number of solid organ transplants in 2019 at 153,863. This number is, however, far short of the total number required, a situation made now far worse by reports of a global drop of one-third in organ availability in 2020, due to the COVID-19 pandemic.Footnote 10
Many people dying of organ failure will attempt to acquire an organ by any means they can without asking questions as to where the organ was sourced. “Organ traffickers know this and are only too willing to ensure their victims’ bodies are utilized to meet the demand, so that they can profit from it. Regrettably, healthcare professionals are also willing to either knowingly collude in organ trafficking for profit or at least turn a blind eye to the practice.”Footnote 11 Organ trafficking is a profitable business and was estimated in 2017 to have generated 1.5 billion dollars globally from around 12,000 illegal transplants.Footnote 12 It is estimated that at 5–10% of kidneys transplanted globally each year are taken from trafficked people.Footnote 13, Footnote 14
Although human trafficking has been practised since ancient times, the most significant milestone in combatting HTOR was not reached until the turn the of this millennium, when the UN General Assembly adopted its Protocol to Prevent, Suppress and Punish Trafficking in Persons, Especially Women and Children in 2000. Commonly known as the “Palermo Protocol,” from the place of its signing, Article 2 defined trafficking in persons as:
the recruitment, transportation, transfer, harbouring or receipt of persons, by means of threat or use of force or other forms of coercion, of abduction, of fraud, of deception, of the abuse of power or of a position of vulnerability or of the giving or receiving of payments or benefits to achieve the consent of a person having control over another person, for the purpose of exploitation. Exploitation shall include, at a minimum, the exploitation of the prostitution of others or other forms of sexual exploitation, forced labour or services, slavery or practices similar to slavery, servitude or the removal, manipulation or implantation of organs.Footnote 15
Although “the removal, manipulation, or implantation of organs” in this definition only came at the end of an extensive list of other activities forming the bulk of human trafficking, it did at least for the first time proscribe the practice in an international protocol. It also gave significant impetus to the Transplantation Society and the International Society of Nephrology to jointly convene an international conference in Turkey in 2008, which resulted in the Declaration of Istanbul, which defined organ trafficking as:
the recruitment, transport, transfer, harboring or receipt of living or deceased persons or their organs by means of the threat or use of force or other forms of coercion, of abduction, of fraud, of deception, of the abuse of power or of a position of vulnerability, or of the giving to, or the receiving by, a third party of payments or benefits to achieve the transfer of control over the potential donor, for the purpose of exploitation by the removal of organs for transplantation.Footnote 16
Principle 6 of the Declaration condemned this practice stating, “Organ trafficking and commercialization violate the principles of equity, justice, and respect for human dignity and should be prohibited.”Footnote 17 However, the linkage of the concepts of trafficking and commercialization in the same prohibition, elicited subsequent criticism.Footnote 18
Ten years later, when the Declaration of Istanbul was updated, its definition of organ trafficking was expanded to reflect that fact that illegal organ transplants are acquired by two different pathways—trafficking in organs and HTOR.
“Organ trafficking consists of any of the following activities:
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1) removing organs from living or deceased donors without valid consent or authorization or in exchange for financial gain or comparable advantage to the donor and/or a third person;
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2) any transportation, manipulation, transplantation, or other use of such organs;
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3) offering any undue advantage to, or requesting the same by, a healthcare professional, public official, or employee of a private sector entity to facilitate or perform such removal or use;
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4) soliciting or recruiting donors or recipients, where carried out for financial gain or comparable advantage; or
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5) attempting to commit, or aiding or abetting the commission of, any of these acts.
Trafficking in persons for the purpose of organ removal is the recruitment, transportation, transfer, harboring, or receipt of persons, by means of the threat or use of force or other forms of coercion, of abduction, of fraud, of deception, of the abuse of power or of a position of vulnerability, or of the giving or receiving of payments or benefits to achieve the consent of a person having control over another person, for the purpose of the removal of organs.”Footnote 19
Furthermore, the 2018 Declaration also distinguished between traveling abroad for transplantation of a legitimately obtained organ and transplant tourism, stating that:
Travel for transplantation becomes transplant tourism, and thus unethical, if it involves trafficking in persons for the purpose of organ removal or trafficking in human organs, or if the resources (organs, professionals and transplant centres) devoted to providing transplants to non-resident patients undermine the country’s ability to provide transplant services for its own population.Footnote 20
Organ trafficking in the 2018 protocol remains unequivocally condemned, but is no longer linked with the more slippery concept of organ commercialization. “Trafficking in human organs and trafficking in persons for the purpose of organ removal should be prohibited and criminalized.”Footnote 21
This is important for focus and clarity in law enforcement as different policies are needed to deal with the crime of trafficking and the ideology of organ markets to increase organ supply. Those engaged in organ trafficking are not doing so with the aim of reducing transplant waiting lists. Their goal is to make as much money as they can for themselves by exploiting the vulnerability of the poor and dispossessed. Wherever the trafficking of people persists, their organs will always remain another means of profit.
And profit is often what drives both healthcare professionals and whole organizations into involvement with trafficked organs. That they in fact do so across the world is beyond dispute as the following cases from south and north hemispheres illustrate.
A South African Scandal
In September 2010, St Augustine’s Hospital in Durban, South Africa, together with its parent company Net-Care, Kwa-Zulu (Proprietary) Limited, pleaded guilty to 102 counts related to 109 illegal kidney transplants into Israeli citizens between June 2001 and November 2003.Footnote 22 Net-Care’s CEO was also charged, along with a renal physician, four transplant surgeons, two transplant coordinators and a translator. Initially transplants had taken place with Israeli donors, but when the kidney broker found he could obtain kidneys from Brazilians and Romanians for less than third of the price paid to Israeli citizens, he switched sources and subsequently people traffickers arranged for dozens of “donors,” five of whom were children, to travel to Durban to have their organs removed.
The renal specialist in this case, Dr Jeff Kallmeyer, sought to escape punishment by migrating to Canada but was tracked down there and fined R150,000—although this sum should be viewed in the light of the estimated R21 million profit from the illegal transplants.Footnote 23
In his review of this case in 2011, Allain concluded:
At St Augustine’s Hospital, over a hundred times, in side-by-side surgical theatres, two foreigners, speaking different languages were operated upon: one affluent, older and ill; the other poor, young (in five cases, a child), but healthy. That the practice persisted for more than two years without anybody, the surgeons, the doctors, the scrub nurses, the administrators, or the blood technicians, bringing these illegal activities to the attention of the police is an indictment of the profession.Footnote 24
However, around the same time as this review, it became evident that transplanting of trafficked organs in South Africa was not confined to St Augustine’s when Profs John Robbs and Ariff Haffejee, along with Drs Neil Christopher and Mahadev Naidoo, the fours surgeons indicted over the Durban scandal, came to trial on charges of fraud, conspiracy, and contravention of the South African Human Tissue Act. The four defended themselves by stating the transplants had only started in Durban because surgeons and their teams in both Cape Town and Johannesburg had not been able to cope with the numbers of transplants of trafficked organs there and so the four in Durban had agreed to take the “overspill.” Why had those involved in identical practices in at least two other cities not been charged also? Prof Robbs protested, “We are carrying the can for just about every transplant surgeon in sub-Saharan Africa. Most transplant surgeons in South Africa were involved with this…”Footnote 25
After two more years of legal wrangling, the charges against all four surgeons were eventually dropped. A former President of the South African Transplant Association commented afterwards, “It must be an enormous relief for the people concerned and one would be happy that they can now carry on with their lives.”Footnote 26 The lives of the 100 or so trafficked peoples they operated on, however, may well not have been able to carry on as before. The outcome for the majority of trafficked peoples whose organs are removed is not a good one.Footnote 27, Footnote 28
China and Conscience
The first clause of the 2018 revision of the Declaration of Istanbul, considered earlier, defines organ trafficking as, “removing organs from living or deceased donors without valid consent or authorization…”Footnote 29 In the light of this definition, China has historically by far and the away the largest amount of systematized trafficking of organs of any country because of its practice of transplanting organs from executed prisoners. These include prisoners of conscience, most of whom are comprised of Falun Gong practitionersFootnote 30 and Uyghur Muslims.Footnote 31 Delmonico et al.Footnote 32 estimate that 90% of transplants carried out in China in 2010 were removed from prisoners. In some cases, organs were removed from prisoners as the actual means of completing their execution.Footnote 33
In the face of mounting international pressure, the Chinese Transplant Congress passed the 2013 Hangzhou Resolution at a ceremony in the People’s Great Hall of Zhejiang Province, which was “to ensure the source of the organs for transplantation meeting the commonly accepted ethical standards in the world.”Footnote 34 It also resolved that all transplantation centers throughout China would use the China Organ Transplant Response System (COTRS) to ensure organ acquisition and allocation were transparent, fair, and legal.
A year later in 2014, the Chinese government announced that from 2015, it would no longer allow organs to be harvested from prisoners,Footnote 35 followed by the pronouncement in 2015 itself, that removing organs from coerced or condemned prisoners was incompatible with the COTRS civilian donation program.Footnote 36 A group of Chinese doctors duly lauded this announcement in a world-leading bioethics journal, as “a step in the right direction.”Footnote 37 This enthusiasm was not universal, however, as shown by the swift riposte in a piece entitled “Smoke and Mirrors”Footnote 38 that, “[a] real step in the right direction would be providing uncensored and transparent access to China’s transplant and organ donation numbers and permitting independent international inspections.” This response proved to be prescient in the light of subsequent developments.
In 2017, a review paper of the state of organ transplantation in China was dismissive of any meaningful change from 2014, detailing evidence inter alia of the continuance of organ removal from prisoners without consent, including organ removal from still living prisoners without anesthesia. The paper concluded:
The unethical practice of organ procurement from executed prisoners in China is associated with a large scale of abuse and a cascade of severe human rights violations, including, we contend, organ explantation from still alive human beings, and, upstream, conditioning the supply of prisoners exploited per se or then solicited to ‘freely’ offer organs as atonement for real or supposed crimes. Those involved in organ harvesting from still alive prisoners must be prosecuted.Footnote 39
In 2020, the full judgment was published from the UK’s Independent Tribunal into Forced Organ Harvesting from Prisoners of Conscience in China,Footnote 40 chaired by Sir Geoffrey Nice QC. In its 562 pages, this judgment details both direct and evidence of forced organ removals in China, and evidence of systematic medical testing, torture, and incarceration of Falun Gong practitioners, Uyghurs, Christians, Tibetans, and other foreign nationals. It also gives details of organ transplantation numbers and the waiting times in China using data up to 2017, which lead to conclusions including the following:
382—Such waiting times are not compatible with conventional transplant practice and cannot be explained by good fortune. Predetermining the availability of an organ for transplant is impossible in any system depending on voluntary organ donation. Such short-time availability could only occur if there was a bank of potential living donors who could be sacrificed to order.Footnote 41
457—Forced organ harvesting has happened in multiple places in the PRC and on multiple occasions for a period of at least 20 years and continues to this day.Footnote 42
The waiting time of only a few weeks at most for a double lung transplant for a COVID-19 patient reported in the Chinese pressFootnote 43 only a few days before the China Tribunal judgment was published, provides further evidence that the conclusions of the tribunal were justified.
Healthcare Complicity in Organ Trafficking: A Global Problem
Some elements of organ trafficking are so horrific that incredulity and denial that healthcare professionals could be in any way complicit in it, are understandably widespread.Footnote 44, Footnote 45 At a conference in Sydney in early 2020, after I raised the issue of abuse of human rights through systematic healthcare involvement in transplanting trafficked organs in China, the only comment made by a leading Australian surgeon on the expert panel alongside me was, “The situation is improving there.” Hardly an adequate response to an ongoing crime there which is totally dependent on the involvement of surgeons and allied professionals.
There can be no doubt about the reality of medical professionals’ ongoing participation in organ trafficking across the world; there are news reports within the past 5 years of doctors being arrested or convicted on charges on involvement in it in Egypt,Footnote 46 India,Footnote 47 Kazakhstan,Footnote 48 Kosovo,Footnote 49 Nepal,Footnote 50 as well as China.Footnote 51 However, as the United Nations Office on Drugs and Crime laments, “Of all actors, however, probably least is known about the involvement of transplant professionals and other medical personnel in trafficking in persons for the purpose of organ removal.”Footnote 52
In what ways are healthcare professionals complicit in organ trafficking and what is known about why it happens?
Lack of Awareness and Education
When we are unaware of what we are looking for, we are unlikely to see it. Medical school curricula are increasing crowded with new topics continually competing for a place. A 2018 survey of 34 UK medical schoolsFootnote 53 found that only 28% provided any teaching on human trafficking at all and of those, only 56% integrated such teaching within the core curriculum. The study concluded, “Medical education on trafficking in the UK is variable and often absent.”
In a UK questionnaire study,Footnote 54 13% of participating healthcare professionals across a range of disciplines and 20% of those in maternity services, reported contact with a patient they knew or suspected had been trafficked, but 71% of such clinical staff felt they had insufficient training to be able to make appropriate referral to further help the patient. In order to produce future clinicians who are competent and capable to know what to do, “there is a need for expanded education on trafficking and research into optimal curriculum design.”Footnote 55 Studies indicate even a short, single education session on human trafficking significantly increases the knowledge and self-reported recognition of trafficked individuals among healthcare professionals.Footnote 56
At postgraduate level, especially in those specialties such as emergency medicine,Footnote 57 renal medicine, and transplant surgery, who are most likely to encounter patients whose have been trafficked or received trafficked organs, training in detection of the signs and symptoms of being traffickedFootnote 58 and knowing what action to take should be mandatory.
Turning a Blind Eye
In an era of intercontinental travel, healthcare professionals inevitably encounter patients who will have been harmed by the illegal removal of organsFootnote 59 or those they suspect of being recipients of trafficked organs. There is, however, remarkably little discussion of about this aspect of organ trafficking in the general media and very little in research literature. What little there is, is almost all published in journals of criminology with virtually nothing in medical or bioethics journals at the time of writing.
A questionnaire study on the issue in the NetherlandsFootnote 60 received responses from 241 (44%) of the 546 transplant professionals approached, of whom half had treated patients who had travelled to another country for an organ transplant. The majority of those who had seen such patients suspected that the organ had been purchased and a one-third of them reported they were certain the organ had been purchased. Qualitative interviews were carried out with 41 of the healthcare professionals who reported having contact with those they suspected of having received trafficking organs. The interviews revealed that the majority of patients presented after the transplant, but even in those who presented prior to travel, the professionals curiously stated they “were unware of patient’s plans.”Footnote 61 The researchers concluded that, “Respondents described their experiences with recipients of suspected kidney purchases as an unwelcome issue that they were unwillingly confronted with and had no control over.”Footnote 62
The reluctance of healthcare professionals to inquire about the sourcing of organs with their patients was emphasized by the researchers, who notably attributed it to “an oath of secrecy”—a phrase having quite a distinct nuance from describing it as a duty of confidentiality. One verbatim transcript from a research participant is particularly clear in conveying a policy of turning a blind eye to the organ trafficking element of their patient encounter.
The kidney was purchased outside our institution. We deliberately do not ask, because we do not want to know. We do not want to hear that he bought the kidney from a poor person who sold his kidney in order to provide shelter for his family. We want to protect ourselves from such sad stories.Footnote 63
Comparing such attempts to justify the ignoring of malpractice with behavior in the Enron scandal, bid-rigging in the Dutch construction industry and sexual abuse in the Catholic Church, the researchers conclude “that medical professionals can be added to the list of those who make claims and rationalizations in turning a blind eye to practices that they would rather not know about.”Footnote 64
This conclusion sheds some light perhaps on why medical journals are reluctant to publish research on this topic. Whistleblowing on such practices may also expose healthcare professionals to personal danger of reprisals from criminal gangs, institutional gas-lighting, and damage to their career prospects and income.Footnote 65 In spite of such disincentives to speaking out, Caplan insists, “Intentional ignorance about the fact that a person or an organ has been trafficked is not an acceptable ethical stance …Trafficking flourishes not because anyone has made a convincing case that it is morally or legally defensible but in part due to the willful ignorance of transplant centers eager to help their patients and to turn a profit doing transplants tolerating trafficking.”Footnote 66
Advocacy of Organ Markets
Although not all commerce in organs involves the trafficking of humans for the purpose of organ removal, nevertheless all organ sales were condemned by the WHO in 1987Footnote 67 and again in 2010Footnote 68 on the grounds that “payment for organs is likely to take unfair advantage of the poorest and most vulnerable groups, undermines altruistic donation, leads to profiteering and human trafficking [and] conveys the idea that some persons lack dignity, that they are mere objects to be used by others.”Footnote 69
Such condemnation, however, has not been universally accepted, especially among philosophers, notably Cherry,Footnote 70 Radcliffe-Richards,Footnote 71 and Taylor.Footnote 72 Very few transplantation surgeons or nephrologists support organ sales, however, with some notable exceptions being HippenFootnote 73 and Matas,Footnote 74 both from the United States.
Hippen’s main reasons for supporting organ markets, however, are political and ideological rather than medical.Footnote 75 He considers that “in a nation that grants individuals a considerable amount of freedom in the body, prohibiting the sale of organs is an unnecessary and unwise limitation on the basic right of self-determination,” and that “In a free society, a hallmark of which is an irreducible moral pluralism … the burden of proof [is on] those who insist on maintaining the current legal proscription on a regulated market in organs.”Footnote 76 In a world in which there is so much evidence of worse outcomes to paid donors and recipients of their organs, however, I would counter that the burden of proof rests rather with those advocating organ markets and that those healthcare professionals who support organ sales are de facto supporting organ trafficking and indirectly are encouraging the trafficking of human persons for the purposes of organ removal.
Financial Gain
Medical healthcare professionals are no less vulnerable than the rest of humanity to pressure to compromise their ethical standards for either financial gain and/or to avoid engaging in what may be perceived to be unnecessary questions regarding organ sourcing. They are, however, arguably under greater moral obligations than many other professionals because of their particular powers and responsibilities in regard to the life and death of those in their care.
A report from the Organization for Security and Co-operation in EuropeFootnote 77 gives detailed recommendations and guidance about healthcare professionals’ responsibilities regarding organ trafficking in relation to recruitment of donor and patient, transplantation surgery itself and patient follow-up, and postoperative care. In regard to those who claim it is not their responsibility to exercise due diligence over the legality of procurement of organs for transplantation, the report states “Such arguments appear not so much an attempt at plausible deniability (as they are manifestly implausible) but rather, as… ‘wilful blindness.’”Footnote 78 It goes on to endorse the World Medical Association 2006 Statement on Human Organ Donation and Transplantation which expressly states that a “physician’s responsibility for the well-being of a patient who needs a transplant does not justify unethical or illegal procurement of organs”Footnote 79 and that “Transplant surgeons should attempt to ensure that the organs they transplant have been obtained in accordance with the provisions of this policy and shall refrain from transplanting organs that they know or suspect have not been procured in a legal and ethical manner.”Footnote 80
In spite of “the impunity enjoyed by a professional medical elite”Footnote 81 which may enable its members to avoid prosecution, medical professionals have a greater, not lesser, duty to prevent the exploitation of the vulnerable. Silence, turning a blind eye, putting commerce and personal gain before the welfare of both organ donor and recipient risks bringing the whole of transplantation medicine into disrepute, as well as perpetuating a crime which is totally dependent on doctors’ participation in or collusion with it.
Conflict of interest
The author is on the UK Committee of ETAC - End Transplant Abuse in China.
