Ethical standards and organ transplant abuse

(Remarks for a presentation to the United Nations Conference on Bioethics, Medical Ethics and Health Law, Porto, Portugal March 9, 2022)

by David Matas

 

Chinese health practitioners have been killing prisoners of conscience for their organs in the thousands every year from the start of this century.  This is a conclusion to which David Kilgour and I came first in an initial report 2006 and in a sequence of subsequent reports. Primary victims are practitioners of the spiritually based set of exercises Falun Gong. Other victims were Uyghurs, Tibetans and House Christians. 

Independently, American journalist Ethan Gutmann came to the same conclusion in a book published in 2014.  An independent tribunal in 2019 concluded that this mass killing of Falun Gong for their organs was happening beyond a reasonable doubt. 

One foundation for this conclusion, though far from the only, was that the legal and ethical precautions that should be in place to prevent the abuse, both in China and abroad have not been in place.  In China, there is a lot of money to be made from the sale of organs, a huge organ donor source which is dehumanized by its jailers, and nothing to prevent unethical behaviour.  This combination became a recipe for abuse. 

The medical profession has belatedly introduced, internationally and in various countries, ethical standards to prevent foreign complicity in Chinese organ transplant abuse.  These standards need to be adopted more comprehensively. As well, they need to be improved.

I am here addressing professional ethical standards only and not legislation.  The parliaments of some countries have legislated ethical standards.  While legislation is welcome and, in some aspects, necessary, the prevention of transplant abuse should not be left to parliamentarians.

 

From various sources, I have drawn forty three existing relevant ethical principles. Some of them should be adopted as is. Others need reformulation. 

 

Policies

Every national and regional professional association and society should develop a written ethics policy on the clinical practice of transplantation, including the subject of prisoners killed for their organs.(1)

 

Sources of organs

There should be no recovery and no complicity in the recovery of organs or tissues from prisoners killed for their organs.(2)

 

Transplant tourism

Organ trafficking and transplant tourism violate the principles of equity, justice, and respect for human dignity.(3)

Medical personnel should not go abroad with a patient for organ transplantation and receive compensation.(4)

 

Referrals 

In the case of a referral for an organ transplant outside the country from any donor, a doctor would be acting unethically if he made the referral without ascertaining the status of the donor or following these principles:

 

a) The benefit and welfare of every individual donor should be respected and protected in organ transplantation. 

b) Consent must be given freely and voluntarily by any donor. 

c) If there is doubt as to whether the consent is given freely or voluntarily by the donor, the doctor should reject the proposed donation.(5)

 

Medical personnel should not, with or without charge, introduce patients to intermediaries or organ transplant brokers.(6)

 

Medical personnel should not, with or without charge, refer patients to a country where either 

– the local law does not prohibit the sale of organs,  

– information on the source of organs is not transparent, 

– there are gross human rights violations and absence of the rule of law or 

– there are known violations of medical ethics in organ transplantation.(7)

 

Advertising and brokerage

There should be no advertising (including electronic and print media), soliciting, or brokering for the purpose of transplant commercialism, organ trafficking, or transplant tourism.(8)

Medical personnel should not contact foreign organ transplant institutions to broker organ transplantation.(9)

 

Transparency

Mechanisms for transparency of process and follow-up should be established.(10)

The organization and execution of donation and transplantation activities, as well as their clinical results, must be transparent and open to scrutiny.(11)

 

Accountability

The practice of donation and transplantation requires oversight and accountability by health authorities in each country to ensure transparency and safety.(12)

Accountability, to be sure, helps to ensure transparency and safety.  The reverse is also true, that transparency helps to ensure accountability. 

Accountability means more than transparency. It means acceptance and application of the whole gamut of ethical principles set out here.  It also means bringing perpetrators to justice.  Only with that sort of accountability can we hope to see the sort of transplant abuse which has been occurring in China to end.

 

Patient counselling

All patients with end-stage organ failure who are candidates for transplantation should receive information about the dangers and ethical concerns regarding transplant tourism and organ trafficking.(13)

Patients interested in purchasing a solid organ transplant should receive pre-transplant counselling from a health care professional with expert knowledge of the pre-transplant and post-transplant medical and surgical management of transplant recipients.(14)

Patients should be told that individuals who purchase transplants overseas are at an increased risk for complications, including death, organ failure, and serious infections.(15)

Patients should be told that those who obtain a transplant overseas may receive sub-optimal care even when they return because:

– health care providers often receive little or no advance notice or documentation of commercial transplantations making the post-transplant care of recipients of commercial transplantations more difficult. 

– Without documentation of the surgical procedure, post-transplant course and complications, health care providers may not have the necessary information to provide optimal care, diagnoses may be delayed, and the patient’s well- being may be compromised. 

– health care providers may not be able to obtain reliable clinical information from the centres which performed the transplantations.

– the information which is obtained cannot be trusted or verified. 

–  health care providers have no ability to validate the accuracy of any documents that may be provided by individuals or centres engaging in transplant tourism and have no professional relationship with individuals who may be performing illegal activities in their countries. 

– Uncertainty regarding the details of commercial transplantations may compromise individual patient care.

– Patients are transferred before they are clinically stable:

– Immediate post-transplant care is complicated and is best directed by the original transplant team.(16)

 

It is worth here noting a bit of what Malaysian doctor Ghazali Ahmad wrote in the book State Organs, in the chapter he contributed titled “The Spoils of Forced Organ Harvesting in the Far East”.  He set out: 

“Even though the number of renal transplant patients returning from China had dwindled significantly since 2006 (see table 1) the management of such patients became unfortunately more complicated and challenging. The main reason for this circumstance is due to the fact that ALL new returning transplant recipients from China since 2006 no longer bring along with them any form of documentation to guide the clinicians in Malaysia to provide optimal follow up care. Such a practice is a part of deliberate attempts by the syndicate members to remain anonymous, unaccountable and leave absolutely no trace of their illegal activities. However, the absence of any information on the perioperative as well as postoperative findings, clinical summary, necessary  information on the type and dose of the induction agents given, the best serum allograft function achieved and the lack of many other standard test results had caused a serious gap in the ability of the local clinicians to deliver a quality and effective care deserved by such patients who had not only risked their lives and parted with their hard earned life savings to obtain a new, safer and better quality of life but now faced real and potentially serious transplant related  complications.” 

 

Patients should be educated about the harms that may come to those who provide organs through transplant tourism.(17)

When it comes to transplant tourism into China, patients should be advised that organs may have been taken by force, and individuals may even have been killed to obtain their organs.(18)

The warnings need to be more explicit than that.  Patients need to be advised that a sequence of independent researchers have come to the conclusion beyond reasonable doubt that organs for transplant in China have been and are being extracted from prisoners of conscience and that the victims are killed through the process of organ extraction.  Patients need further to be advised that, by going to China for an organ transplant, they may well be considered criminally complicit in this form of abuse. 

Patients should be advised that the transplant tourism industry relies on secrecy, making it is impossible to determine whether donor information provided by organ brokers, who are motivated by financial gain, is accurate.(19)

Physicians should advise patients, where this is the case, of their unwillingness to provide post-transplant care for patients who obtain transplants through transplant tourism.(20)

 

Insurance

Insurance coverage for medical or surgical expenses should not be extended to patients in jurisdictions outside the country related to the transplantation of an organ obtained through transplant tourism.(21)

Nationals who travel abroad for organ transplants provided on a commercial basis should not be allowed to get a free supply of immunosuppressant drugs from government hospitals.(22)

Health care providers should inform patients that, where this is the case, insurers will not extend insurance coverage for medical or surgical expenses incurred by patients in jurisdictions outside the country related to the transplantation of an organ obtained through transplant tourism.(23)

 

Pre-transplant care

The fiduciary responsibility of physicians to do what is in the best interest of their patients does not include the performance of investigations in preparation for transplantation of a purchased organ.(24)

Physicians should not prescribe medications or otherwise facilitate obtaining medications which will be used during the transplantation of a purchased organ.(25)

Individual physicians may elect not to provide medical records to patients if they believe the information will be used in support of an abusive transplant performed in a system which violates international human rights standards and that there is a significant risk of harm to the patient or organ source.(26)

 

Post-transplant care

In non-emergency situations, individual physicians may elect to defer to another physician care of a patient who has returned from transplant tourism abroad.  In such situations, the physician should ensure that the patient has reasonable access to the proposed alternative care provider.(27)

 

Verification 

At a Congressional hearing on Chinese organ transplant abuse held in Washington DC in June 2016, Dr. Francis Delmonico, a former head of The Transplantation Society, was asked:

“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 Delmonico gave was this: “I am not here to verify. That is not my job.”

 

The answer should instead be that the onus lies on China to establish beyond reasonable doubt that they are not sourcing organs from prisoners of conscience.  Until there can be an independent, outside, expert verification that this is done, there should be no cooperation or collaboration with the Chinese transplant system or its professionals.

 

Admissions

The Vatican hosted a Summit on Organ Trafficking and Transplant Tourism in February 2017.  About Huang Jiefu, the chief Chinese Communist Party/state health official invited, Israeli transplant surgeon Dr. Jay Lavee said:

“Given his personal record and the fact that he still does not admit the use of organs of prisoners of conscience, he should not have been invited,”

But he was invited anyway. 

 

The principle here is that those involved in health administration in China should not be invited to participate in international transplant events unless they have admitted that China has used organs of prisoners of conscience for transplants.  This is so even if they have not personally been involved in the past in organ transplant abuse.

 

Membership 

In 1977, the World Psychiatric Association condemned the Soviet Union by resolution for its abuse of psychiatry.  The Soviets withdrew from the Association in 1983 when it faced almost certain expulsion.(28)  There needs to be something similar for The Transplantation Society and its official sections.

Right now, The Transplantation Society has as a membership requirement “Accept the policies of the Ethics Committee by signing the Society Ethics Statement”.(29)  There needs to be more than that.  TTS should deny membership to and eject from membership all those who can not establish that they have not been involved in abuse of transplantation.

There could be a rebuttable presumption in favour of anyone who accepts the ethics policy of TTS. However, given the widespread and systematic organ transplant abuse in China, that presumption is rebutted for every Chinese transplant professional.  Something more specific than just signing an ethical statement would be needed. The applicant or member would have to demonstrate awareness of the prevalence of abuse and the steps taken to avoid complicity in it. 

Only those doctors who conduct clinical practice ethically should be permitted to become members of professional associations.(30)

It is noteworthy that, though TTS expresses this as a principle, TTS itself does not respect this principle. For TTS, a mere signature on an ethical statement is enough.   There needs to be added to this statement the principle that anyone about whom there are reasonable grounds to believe has participated in sourcing organs from prisoners would, if not already a member, not be allowed to join, or, if already a member, have his or her membership revoked.

 

Invitations 

Health practitioners should accept invitations to give lectures or provide expertise to support transplant program activities in China as long as the participation does not promote the practice of transplantation of organs from executed prisoners.(31) The principle should be instead that health practitioners should not accept invitations to give lectures or provide expertise to support transplant program activities in China until it can be established beyond a reasonable doubt that China has stopped sourcing organs from prisoners of conscience or executed prisoners.  

 

Meetings

Health care personnel from countries which utilize organs from executed prisoners or prisoners of conscience for transplants should not be accepted as registrants in meetings unless they can establish that they themselves have not used and will not use organs from executed prisoners or prisoners of conscience for transplants.  This is the opposite of a principle adopted by The Transplantation Society, which is that health care personnel from countries which utilize organs from executed prisoners for transplants should be accepted as registrants in meetings of The Transplantation Society.   

The Transplantation Society refused to allow 35 Chinese participants for ethical reasons to attend the World Transplant Congress in San Francisco in July 2014.(32)  For the October 2014 Hangzhou, China transplant conference, many invited overseas transplant experts failed to attend. 

However, that behaviour was short lived. The Government of China announced that as of January 2015 they would cease using organs from executed prisoners.  And that announcement, without a serious attempt at determination whether the change in fact happened, was, for The Transplantation Society, enough.

 

Collaboration  

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.(33)

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.(34)

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.(35) That principle is fine, with the caveat that to the phrase executed prisoners should be added the phrase “prisoners of conscience”.  As well, the onus should fall on those engaged in the studies to show beyond a reasonable doubt that there is no sourcing of organs from executed prisoners or prisoners of conscience. 

 

Presentation 

Clinical scientific studies which analyze patient outcome or entail therapeutic or mechanistic approaches should be considered for acceptance only if they have been performed under ethical principles.(36)

Presentations of studies involving patient data or samples from recipients of organs or tissues from executed prisoners should not be accepted.(37)

This principle needs tweaking. The phrase “executed prisoners” should be instead “executed prisoners or prisoners of conscience”. 

 

Publication

Transplant journals should not publish research using data from transplantation where the organ sources were prisoners.(38)

Typically, what happens is that authors sign a statement to that effect.  However, research shows that this standard has been widely violated, when it comes to publication of China based transplant research, leading to several paper retractions after publication.  In order for the standard to function in an effective manner, there should be, at least a checklist tool for all transplant papers, itemising mandatory information about organ sources.(39)

 

Training

Hospitals should not train Chinese surgeons in transplant surgical techniques.(40)

Hospitals should accept trainees from transplant programs that use organs from executed prisoners, provided care is taken that it is their intention that their clinical career will not involve sourcing organs from prisoners.(41) The principle should be the reverse that members of Society should not accept trainees from transplant programs that use organs from executed prisoners or prisoners of conscience.

Hospitals should not accept for clinical or pre-clinical training any candidate for training in transplant surgical techniques unless the candidate accepts the membership policy and code of ethics of The Transplantation Society.(42)

 

Registry data

International registries should accept data from patients transplanted with organs from executed prisoners, provided the source of the organ is clearly identified and recorded as procured from an executed prisoner and provided also that the data are not incorporated in the total analysis of outcomes of transplantation or other scientific registry studies.(43)   The principle should be that international registries could accept data from patients transplanted with organs in countries which source organs from executed prisoners or prisoners of conscience, as long as the data are classified as problematic, until it is established beyond a reasonable doubt that they are not.

 

Conclusion

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.  

Adopting and then following the policies set out above would achieve both those goals.  They 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.

 

References

(1) The Transplantation Society Ethics Committee Policy Statement Chinese Transplantation Program November 2006 and Mission Statement (TTS)
(2) TTS and World Medical Association Statement on Organ and Tissue Donation October 2012 (WMA)
(3) The Declaration of Istanbul on Organ Trafficking and Transplant Tourism May 2008 (Istanbul)
(4) Taiwan – Ethical norms for physicians and other medical personnel in relation to brokerage of organ transplantation for nationals abroad, August 2006 (Taiwan).
(5) Hong Kong – Professional Code and Conduct for the Guidance of Registered Medical Practitioners, Medical Council of Hong Kong (Revised in November 2000) (Hong Kong)
(6) Taiwan
(7) Taiwan
(8) Istanbul
(9) Taiwan
(10) Istanbul
(11) World Health Organization Guiding Principles on Human Cell, Tissue and Organ Transplantation, May 2008 (WHO)
(12) Istanbul
(13) Gill JS, Goldberg A, Prasad GV, et al. “Policy statement of Canadian Society of Transplantation and Canadian Society of Nephrology on organ trafficking and transplant tourism”. Transplantation 2010; 90:817-20. (Canada)
(14) Canada
(15) Canada
(16) Canada
(17) Canada
(18) Canada
(19) Canada
(20) Canada
(21) Canada
(22) Malaysia – Policy on supply of immunosuppressant drugs from government hospitals to Malaysians who travel abroad for organ transplants provided on a commercial basis, October 2011 (Malaysia).
(23) Canada
(24) Canada
(25) Canada
(26) Canada
(27) Canada
(28) https://endtransplantabuse.org/david-matas-speaks-at-international-academy-of-law-mental-health-congress/
(29) https://tts.org/join-tts#:~:text=The%20principal%20requirement%20for%20membership,sustained%20interest%20in%20the%20field
(30) TTS
(31) TTS
(32) http://www.cmt.com.cn/detail/623923.html&usg=ALkJrhj1Ume7SWS_04UtatL3pWKYRbFxqw See Matthew Robertson, “From Attack to Defense, China Changes Narrative on Organ Harvesting” Epoch Times, November 24, 2014,

http://m.theepochtimes.com/n3/1099775-from-attack-to-defense-china-changes-narrative-on-organ-harvesting/?sidebar=hotarticle

(33) Istanbul
(34) TTS
(35) TTS
(36) TTS
(37) TTS
(38) Journal of Liver Transplantation Author Information Pack
(39) Rogers W, Robertson MP, Ballantyne A, et al. “Compliance with ethical standards in the reporting of donor sources and ethics review in peer-reviewed publications involving organ transplantation in China: a scoping review.” BMJ Open 2019;9:e024473. doi:10.1136/ bmjopen-2018-024473
(40) Australia – Policy of major transplant hospitals on training Chinese surgeons in transplant surgical techniques, in Queensland December 2006 and in New South Wales January 2013. Queensland, Australia
(41) TTS
(42) New South Wales, Australia
(43) TTS