Interaction with Chinese transplant professionals
(Remarks prepared for a poster presentation at the Harvard Medical School Centre for Bioethics Conference April 13, 2018)
by David Matas
In China, there is a lot of money to be made from the sale of organs, a huge organ donor source of dehumanized prisoners, and nothing much to prevent unethical behaviour. This combination is a recipe for abuse. Transplantation is a new technology developed for human good, but, like other forms of technological development, has run up against the hard realities of human nature and its capacity for wrongdoing.
In China, various researchers, including David Kilgour, Ethan Gutmann and I, have concluded that prisoners of conscience, primarily practitioners of the spiritually based exercise regime Falun Gong, are being killed for their organs. The work is set out in several books and manuscripts, consisting of hundreds of pages and thousands of footnotes. Transplant abuse is not unique to China, but the Chinese form of abuse is unique institutionalized and inflicted on prisoners of conscience.
The Government of China acknowledges past sourcing from prisoners sentenced to death, but claims that it has stopped. The Government of China denies having ever sourced organs from prisoners of conscience.
In 2006, David Kilgour and I produced the first version of our report which concluded that practitioners of the spiritually based set of exercises Falun Gong were being killed in China for their organs. Since the release of that report, the medical profession has introduced, internationally and in various countries, ethical standards to prevent foreign complicity in Chinese abuse. Fo r the purpose of this presentation, I want to focus on only one subset of these ethical standards, those which relate to professional collaboration.
According to the Declaration of Istanbul on Organ Trafficking and Transplant Tourism of May 2008, collaboration amongst transplant professionals in different countries must protect the vulnerable, promote equality between donor and recipient populations, and not violate other basic organ transplant principles . According to The Transplantation Society, collaboration within clinical studies should only be considered if the study does not violate ethical principles, for example through the sourcing of organs or tissues from executed prisoners. Collaboration with experimental studies should only be considered if no material derived from executed prisoners or recipients of organs or tissues from executed prisoners is used in the studies.
The Communist Party of China is mostly impervious to pressure for change coming from outside China. Changing China means developing leverage on those inside China who can impress on the Party the need for change.
Peer pressure has turned out to be a more effective lever for change in organ transplant abuse in China than governmental or inter-governmental pressure, because the Chinese transplant profession is more sensitive to the views of their colleagues abroad than the Chinese government is to the views of other governments or inter-governmental agencies. One can understand why this is so.
Transplant professionals in China both learn and achieve status in their profession through contact with their colleagues abroad. Moreover, their connection with the Communist Party is a good deal more tenuous than those in the Government of China.
An article in the China Medical Tribune, an official medical publication available in Chinese in China, reports on a press conference held by Huang Jiefu at the Chinese medical transplant congress in Hangzhou October 30th, 2014. The article refers to a number of foreign criticisms of Chinese organ transplant abuse.
Huang Jiefu told the China Medical Tribune that all the cited foreign sources are “nonsense”, and “rumour”. He asserts “Over time, the truth will be restored”. He states “Justice may be late, but never absent.”
Why did Huang Jiefu feel the need on October 30, 2014 to make this point? The evidence of organ transplant abuse in China had, after all, been accumulating for years. The China Medical Tribune article reports the refusal to allow 35 Chinese participants for ethical reasons to attend the World Transplant Congress in San Francisco in July 2014. It also notes that for the most recent Hangzhou transplant conference “many overseas transplant experts failed to attend”. A year before, in October 2013, the China Transplant Congress, also held in Hangzhou, had a raft of foreign expert attendees.
Many attendees to the 2014 Hangzhou conference were likely asking where all the overseas transplant experts were. Huang Jiefu must have felt compelled to say something to explain and counter their absence.
Those doctors who applied to attend and participate in the World Transplant Congress in San Francisco in July 2014 and were rejected, and their colleagues who knew they were applying to attend, also needed an explanation. The Communist Party may have felt that they could ignore the evidence of the killing of Falun Gong for their organs. However, they could not ignore the fact that Chinese transplant doctors were denied admission to an international transplant congress or that foreign transplant doctors who had come before to China were no longer coming.
Huang Jiefu was then complaining about the global rejection of his colleagues. That, he claimed, was an injustice which would eventually be remedied. He parleyed the global concern about killing of innocents for their organs into a complaint of ostracization where he and his colleagues, rather than those killed for their organs, became the victims. Though the Party was not willing to do anything to remedy the victimization of Falun Gong, transplant professionals in China were prepared to act to counter what they saw as their own victimization.
Chinese transplant professionals and health officials have made an effort to be engaged in international transplant events and collaborate with international transplant personalities. Chinese government spokesman Huang Jiefu and others were active participants in The Transplantation Society Congress in Hong Kong in August 2016 and the Vatican sponsored Pontifical Academy of Sciences summit on organ trafficking and transplant tourism in February 2017 as well as its follow up in March 2018. They invited a delegation of transplantation professionals to visit China in August 2017.
The official Chinese delegation took advantage of these fora to deny the evidence of ongoing organ transplant abuse. They were provided a setting where they did not have to confront and answer the evidence they denied.
Many people objected to these one sided situations. Those objections generated a sequence of justifications from the hosts or their defenders.
Justifications and responses
The organizers intend for the events to be academic exercises. Huang Jiefu and other invited Chinese health officials and transplant professionals were making academic presentations of current data and current experience.
The Communist Party is engaged actively in whitewashing, seeking to wash its hands of the blood of innocents by attempting to dupe innocents abroad. Huang Jiefu has a long history of developing and parroting Communist Party propaganda as well as contradicting himself over the years as the propaganda of the Party has shifted, including his own views of what sounds best at the time. The fact that he has at times been actively involved in the formulation of this propaganda does not make his work academic.
2) Claimed justification
Organ transplant abuse researchers, such as myself, are repeating contentious political assertions.
The suggestion that a Communist government spokesperson, such as Huang Jiefu, is an academic and that those who have done serious academic research are doing nothing more than making political assertions is a denial of reality. The academic nature of the work that I and others have done has been demonstrated by the acceptance of our presentations at a wide variety of academic conferences after peer review of abstracts as well as publications and university invited lectures.
The claim that our work is politically motivated echoes Communist Party propaganda. The Communists too like to say that the criticism of their organ transplant abuse is politically driven, by Falun Gong.
Falun Gong practitioners, to be sure, oppose human rights violations directed against them in China. Yet, human rights are not political. They are universal.
3) Claimed justification
Those concerned about the killing of prisoners of conscience for their organs in China have participated in political events on the condemnation of China such as the European Parliament and June 2016 US Congressional Hearing.
There are, of course, some politicians, albeit far too few, interested in the independent research I and others have done on organ transplant abuse in China. That interest, however, does not make our work political.
4) Claimed justification
The Chinese officials and professionals invited to participate in international events are those who are trying to reform the system.
The Communist Party of China rejects the conclusions of our research without evidence and with obvious political motivation. Yet, the evidence on which our conclusions are based comes mostly from official Chinese sources. For instance, the joint update of June 2016 of the work of Ethan Gutmann, David Kilgour and myself had 2,400 footnotes; 2,200 of these footnotes cited official Chinese sources .
Huang Jiefu’s involvement in organ transplants in China, according to his own statements, is deeply troubling. An excerpt of an interview with Phoenix TV posted in January 2015 on their website www.ifeng.com shows the problem:
“Reporter: Minister Huang, have you ever taken organs from executed prisoners?
Huang: I said I went there once, but I was not the one who did the extraction. But after that one time, I did not want to go again. I am a doctor. Doctor has a moral bottom line, which is respecting life and helping the sick. This must be done in sacred places, otherwise, it is against the moral bottom line of a doctor.
Reporter: Do you remember which year was it?
Reporter: Was that the first year you did human organ transplant?
Huang: First year. Because organ transplant is divided into two teams. One is the donor team, who extracts the organs. One is the recipient team, who transplants the organs.
Huang: I am in the recipient team. I’ve never been in the donor team. But I did go once to see how they do it. So, I have only been there once. After that time, I never wanted to have anything to do with the donor team. But I feel that I need to change it.
Reporter: When you help the recipient, you think it is saving a life. But do you try not to think about the donor?
Huang: Majority of the transplant surgeons feel helpless. On the one hand, you face the patient who has a failing organ. As a doctor, you have the technique and responsibility to save people. But the other side of the story, when you think about the organ source, you feel helpless.”
In criminal law, there is a term for this sort of behaviour. It is called wilful blindness. A person who commits a criminal act and is wilfully blind is as guilty of a crime as a person who commits the act with full knowledge.
Huang said he felt helpless. But he was not helpless. He could have said “no” to participation in organ transplantation using an organ from an improper source. If Huang truly “never wanted to have anything to do with the donor team” then he should have stopped transplanting. The notion that he has nothing to do with the donor team when he is taking organs from the donor team is a fantasy.
If organ harvesting goes against the moral bottom line of a doctor, and in this case Huang acknowledged that it did, then using an organ in a transplantation from an improper source also goes against the moral bottom line of the doctor. There is no difference in the morality of harvesting from an improper source and transplanting an organ harvested from a source which the transplanting doctor knows to be improper or to which the transplanting doctor is wilfully blind.
5) Claimed justification
The foreign transplant professionals are professional colleagues to whom deference is due.
The foreign transplant professionals and the organ transplant abuse researchers bring to the issue of organ transplant abuse in China different professions and accordingly different perspectives.
I do not pretend to know anything much about transplantation technology. I would not dream of walking into an operating room and attempting a transplant, even if I were allowed to do so. I am confident that, if I tried, I would make a total mess of the operation and put the life of the patient at risk. I do have, in contrast, extensive experience in dealing with human rights violators in general and Chinese human rights violations in particular.
Human rights belong to all humanity. Their rights should be asserted by everyone. Nonetheless, there remains such a thing as human rights expertise – knowledge of the international human rights instruments, familiarity with discourse and patterns of behaviour of human rights violators, the lessons of history and so on. A person without human rights expertise or experience who attempts to presume human rights knowledge and assume human rights leadership is as dangerous, puts lives as much at risk, as I would in a transplant operating room.
6) Claimed justification
The foreign transplant professional and organ transplant abuse researchers have the same goal, to stop the use of organs from the executed in China.
My goal goes beyond that in three respects. I also want
a) an end the use of organs from prisoners of conscience,
b) full accountability for past abuse,
c) justice for the victims and their surviving family members.
As well, commonality of goals is not sufficient for us to agree. Means matter. To take an extreme example, one can say that Nazis and the Jewish community before and during World War II shared a common goal, a better world, and just differed on the means. Yet, the difference in means made all the difference.
7) Claimed justification
The Congressional hearing on Chinese organ transplant abuse was done by Republican congressmen Chris Smith and Dana Rohrabacher to embarrass the Obama Administration.
What people say should be judged by content and not dismissed because of speculation about their motives. If someone tells you the truth, saying that the person’s motives are impure is no excuse for ignoring the truth.
As a lawyer, I am trained to accept a presumption of good faith. The presumption is rebuttable, but only by evidence, and not by speculation.
The attribution of bad faith to the Congressmen who conducted the hearing on Chinese organ transplant abuse is a game anyone can play. If event hosts can claim that US Congressmen are acting out of venal motives, why could I not say the same about event hosts? Why could I not say that their real motivation is not ending organ transplant abuse but rather the red carpet treatment event hosts are getting from Chinese officials by their turning a blind eye to their abuse and pretending to go along with their pretend attempts at reform?
I would not say that about event hosts because I presume that the hosts are acting in good faith. Event hosts should extend a similar courtesy to US Congressmen.
It strikes in any case, me as an outsider to US politics, that it is imprudent to dismiss Republicans, simply because they are Republicans, when the Republican Party controls the White House, both Houses of Congress, and a large majority of state governorships and assemblies. However, even if Republicans were a tiny minority in the US, what they say should still be judged by its content and not by speculation about motives.
Moreover, what I heard from the two Congressmen struck me as worthy of attention. What I saw them bringing to the discussion was a long experience in addressing human rights abuse in China, indeed, considerably more than mine. They pointed to Chinese discourse about organ transplant abuse and its similarity to discourse about a long list of other well documented violations.
Congressman Smith referred to the Tiananmen square massacre, forced abortion and sterilization, torture, forced labour camps, sex trafficking, censorship and prison conditions. He asked former head of The Transplantation Society Francis Delmonico:
“How do you independently verify that even though he [Huang Jiefu] may be very sincere that anything he says, zero foreign customers for organ trafficking in 2016, how do you independently verify that when there has been such a backdrop of terrible duplicity, lies, and deception on the part of the government?”
The answer of Francis Delmonico was: “I am not here to verify. That is not my job.”
8) Claimed justification
Foreign transplant professionals, on visiting China, can see that organ transplant abuse in China has been curtailed.
There is a difference between a practice being curtailed and a practice ending. I accept that foreign transplant professionals were told, in the places they have visited in China, that transplant abuses have been curtailed. However, that is different from their being actually curtailed. What do the foreign visitors do to look behind the Potemkin village put up for them to see?
Whatever was done, two things are essential. One is the ability to make visits announced. Visits prepared in advance in China are bound to be cosmetic. China has a long history of arranged visits to prisons which hide the reality of the prisons to the visitors. Why should arranged visits to hospitals be any different? Second, foreign visitors need to have access to the original files both of the patients and the donors.
9) Claimed justification
Organ transplant abuse researchers have presented data that is not verifiable.
The statement that the research is not verifiable could be made only by someone who has not examined the research. The research that I, Ethan Gutmann and David Kilgour have done now going over ten years is all not just verifiable, but verified. We followed a simple principle, that anything we saw or heard or read an independent outside research could also see or hear or read. We turned aside all hearsay or rumour.
The claim of unverifiability echoes Communist Party propaganda. The statement that our research is not verifiable is a standard Communist Party response to our work.
10) Claimed justification
Organ transplant abuse researchers have presented data that is not up to date.
The current joint update of David Kilgour, Ethan Gutmann and myself was released in June 2016. Work on the update began in September 2015. All the update is current. All of it post-dates the Chinese claimed cessation as of January 2015 of organ sourcing from prisoners.
Chinese officials consistently block access, take down and falsify any data stream to which researchers refer. What that means is that it is impossible to follow the data from the period after we quote or cite it.
11) Claimed justification
The events have worldwide support; and that worldwide support has no objection to the representation of China by Huang Jiefu.
I support the opportunity given by these events to address the issue of organ trafficking. However, that is different from saying that this worldwide support has no objection to the representation of China by Huang Jiefu and his colleagues. I and many others world-wide who support the current opportunity given by these events to address the issue of organ trafficking object to the representation of China by Huang Jiefu and his colleagues.
12) Claimed justification
The events are global in scope; they are designed to combat organ transplant abuse. The potential good from the events in combating organ trafficking and organ transplant abuse far exceeds the negative history of China.
A conference during World War II on global surgery techniques which had Dr. Mengele representing Germany could not possibly have been defended on the basis that the focus of the conference was world-wide, or that Dr. Mengele’s presentation would be academic only, or that the potential to end surgical abuse far exceeded the negative history of Nazi Germany. Who participates matters.
13) Claimed justification
There is a difference between collaboration and engagement. P. J. O’Connell N. Ascher F. L. Delmonico, two former presidents and the then current president of The Transplantation Society, wrote in a letter to the American Journal of Transplantation, “TTS remains strongly committed to engagement with those who are willing to support reform”.
The emphasis here is on willingness. But are Communist Party officials just saying what the authors want to hear?
China invited the three authors of this letter to China from July 30th to August 5th, 2017. The report on their visit was titled “Progress in China”. The executive summary of their visit states that they
“were part of a delegation to China to observe and endorse China’s progress in organ donation and transplantation reform”.
The Frank Delmonico who endorsed China’s progress in organ donation and transplantation reform in August 2017 is the same person who testified to the US Congress in June 2016 “I am not here to verify. That is not my job.” Endorsement without verification is meaningless.
Whatever the intellectual merit of the distinction between collaboration and engagement, making the distinction ignores the Communist Party propaganda machine. Chinese state news media reported that the holding of The Transplantation Congress in Hong Kong demonstrated that China’s transplant system “had global backing”. About the Vatican summit, state news media reported
“China, once an organ transplant pariah, is now accepted as global leader after reform, papal recognition”.
14) Claimed justification
The engagement has led to reforms. The letter from the three leaders of The Transplantation Society states that
“The consensus of the WHO (World Health Organization) and international transplant professionals who have visited China in the past 2 years is that those tasked with the oversight of organ donation and transplantation within China are bringing about reform”.
On what is that consensus based? It is just statements of reform and opaque systems.
The letter refers to a registration system for hospitals. But there is no reference to the aggregated minimum required transplant volume of all registered hospitals for registration. There is nothing about the accumulated totals of actual posted hospital figures for transplant volumes of registered hospitals. Consequently, the fact that these figures are far above official Beijing figures of transplant volumes and any official explanation of sources goes unnoticed. Nor does the letter mention continuing transplantation by unregistered hospitals.
The letter refers to 2007 regulations and a 2013 resolution, without regard to the fact that China is not subject to the rule of law and that there is no mechanism to enforce statutes, regulations and policies against the state. It omits reference to the fact that a 1984 law sits on the statute books unrepealed which allows the sourcing of organs from prisoners without their consent.
The letter further speaks of a
“Chinese regulatory change announced in December 2014 progressively restricted and then ceased the use of executed organs and developed a national program of organ donation after circulatory death”.
Yet there was no such regulatory change, just an announcement.
Louise Greve wrote that what changed that made China respectable to at least elements of the global transplantation community was not so much a change in official Chinese practices as change in the official Chinese narrative. Greve called it a Swiss cheese narrative, because it is so full of holes. But it was enough to get on board sufficient numbers of leading transplant professionals to allow the Government of China to tout respectability.
15) Claimed justification
The letter from the three leaders of The Transplantation Society refers to the China Organ Transplant Response System and states that the System “should improve transparency”.
The Government of China says all is fine, in a variety of detailed ways. However, both its general and specific assertions are impossible to verify.
The United Nations on several occasions has asked China to explain the discrepancy between the volume of transplants and the identified sources, without success. The Government of China responded asserting that
“China’s annual health statistics are compiled on the basis of categories of health disorder and not in accordance with the various types of treatment provided.”
China has claimed in the past that death penalty prisoners were a source of organs, but did not and does not provide death penalty statistics. This issue was raised by the United Nations Universal Periodic Review Working Group in February 2009. At the Universal Periodic Review Working Group, Canada, Switzerland, United Kingdom, France, Austria, and Italy recommended that China publish death penalty statistics. The Government of China said no to this recommendation.
The turn of China at the United Nations Universal Periodic Review Working Group came up again in October 2013. This same recommendation on death penalty statistics was repeated then by Belgium, France, New Zealand, Norway, Switzerland, UK, and Italy. This time China made the alarming assertion that they do not keep statistics on the number of those subject to the death penalty who are executed.
The China Liver Transplant Registry in Hong Kong used to provide public access to statistical aggregate data but has now closed off the site. Access is available only to those who have a Registry issued login name and password. The other three registries, kidney and heart in Beijing and lung in Wuxi, are also accessible only to those who have registry issued login names and passwords.
China has set up an Organ Transplant Response System (COTRS) which is meant to allocate donated organs. However, its website, like the specific organ registries, is available only to those who have issued login names and passwords. It is impossible, by looking at the website, to figure out what the system does.
The Government of China occasionally makes public statements about the number of donations registered in its Organ Transplant Response System. These figures are contradictory. One can not determine, by looking at the wealth of contradictory statements which, if any, of these figures represents reality.
One rotten apple can spoil a whole barrel. I, of course, am concerned about global transplant abuse. But unverified assertions that Chinese transplant abuse with prisoner of conscience victims never existed or no longer exists does not just undermine efforts to end transplant abuse in China. It undermines efforts to end transplant abuse world-wide.
The ability of transplant professionals outside of China to stop the killing in China of prisoners of conscience for their organs is limited. Yet, there are two practical steps they can take. One is to do nothing to be complicit in the Chinese abuse. The second is to avoid giving any status to the abusers.
A significant driver for change of transplant practices in China is the desire to achieve international respectability. Giving Chinese transplant professionals any form of international status while transplant abuse continues in China undermines the efforts to end the abuse.
Chinese transplant professionals can be influenced by global peer pressure. The opportunity to use that influence can be better exploited by better development and application of transplant ethical standards.
The development of ethical standards on collaboration and their application to China could have a substantial impact on access to information on transplant abuse in China, transplant tourism into China and transplant abuse in China. These standards would avoid complicity. They would also avoid giving respectability and status to the Chinese transplant profession in advance of conformity to international ethical standards.
David Matas is an international human rights lawyer based in Winnipeg, Manitoba, Canada