Excellent article. At WorlMed Assist, we couldn’t agree more. The reference to Medical Tourism and Medical tourism companies is made in this article several times and correctly so. Some of these companies engage in the selling of organs. WorldMed Assist specifically does not: we have helped many people obtain organ transplant surgeries, but in all cases the recipient had to provide a family member and the organ donor. To read more about our ethical guidelines, please see: http://www.worldmedassist.com/medical_tourism_guidelines.htm To read more about one of our past patients, please see: http://www.worldmedassist.com/Liver_Transplant_India_jo_ann.htm
http://www.worldmedassist.com
Organ transplant tourism is not a fad nor a fashion, but a serious 21st century problem for health service providers and governments. In this article I try to identify the basic ethical and political issues.
“The core of the debate is how best to put an end to such abuses.” The abuses Dr Gabriel Danovitch, writing in Nephrology Dialysis Transplantation, is referring to is the commercialising of organs from live donors. Organ transplant tourism is the common term used to describe people who travel abroad, usually to poor countries, to have organ transplant operations. The organs come from live donors who sell their organs, such as kidneys, not because they act from altruistic motivation, but because they are poor, vulnerable or simply easy to coerce.
Organ transplant tourism is not a fad nor a fashion but the result of two factors. The first is that life saving transplantation of organs is a successful procedure. In the Bulletin of the World Health Organization, December 2007, Dr Yosuke Shimazono writes that in 2005 around a total of 93,000 kidney, liver and heart transplants were carried our globally. The second factor is that this success has also created a problem with the supply side. For example, the NHS website, UK Transplant, illustrates the point with these simple words: “Today more than 9,000 people in the UK need an organ transplant… But less than 3,000 transplants are carried out each year.” Shimazono confirms the scale of the problem when he writes, “The shortage of organs is virtually a universal problem.”The term Organ transplant tourism is itself disputed. In a paid for article by Prof. Leigh Turner, in the June 2008 edition of the British Medical Journal, he objects to the use of the term in both the media and academic circles. But semantics and style apart, Shimazono, in 2007, gives the following definition of the term: ““Transplant tourism” involves not only the purchase and sales of organs, but also other elements relating to the commercialization of organ transplantation.” The Declaration of Istanbul (2008) (pdf) (via Transplantation Society), proposed, in April-May 2008, the following definition, “Travel for transplantation becomes transplant tourism if it involves organ trafficking and/or transplant commercialism or if the resources (organs, professionals, and transplant centres) devoted to providing transplants to patients from outside a country undermine the country’s ability to provide transplant services for its own population.” (see the Declaration itself for a fuller description).
There is a difference between organ transplant tourism and health service providers outsourcing medical services abroad. For example, the British NHS has a programme to outsource certain medical procedures in the rest of Europe. And in the abstract of a paid for paper, Dr K. A Bramstedt et al (Pubmed), in Ethics Corner American Journal of Transplantation (July 2007), write about the various insurance programmes in the US who encourage policy holders to travel abroad. The organ transplant tourism that is repugnant and objectionable is the one that exploits living donors directly, and in many cases the patients.
The circumstances of obtaining organs from live donors and the consequences of organ transplant tourism are the main concerns of international health organisations, such as the WHO, governments, NGOs and professional groups.
Live organ donors are usually people from countries without a regulatory framework to protect donors from, as Shimazono describes the situation, coercion, exploitation and physical harm. Danovitch writes, “Potential living donors who may be educationally, socially or economically vulnerable…” And a Lancet commentary (pdf) (via Transplantation Society) describes live donors as possibly being: illiterate and impoverished individuals, undocumented immigrants, prisoners, and political or economic refugees. But what does this really mean?.
Shimazono, refers to a study were 71% of the Indian donors were below the poverty line. What is more revealing about this study is that from the 305 donors, 71% were female and 96% of all the donors sold a kidney to “pay off” debt.
Ironically, if exploiting live organ donors seems bad, the consequences of organ transplant tourism are much worse. For donors, the list of consequences is nearly endless, the money they might have made from selling an organ would soon disappear. In a study of Egyptian donors, 78% of the group spent their money within five months (Shimazono). But the more serious consequences for donors, are deterioration of health, psychological effects, discrimination, inability to do labour intensive jobs, and lack of follow up health care.
Recipients (organ transplant tourists) of organs from live donors are themselves not immune from consequences of the transplant. Like donors, organ transplant tourists can be the victims of fraud and more seriously sometimes die from the procedure. Dr Michael D. Horowitz et al, writes in Medscape Journal of Medicine, that transplant tourists may also find it difficult to “identify well trained physicians and modern hospitals.”
After an operation abroad, who does the recipient consult should a problem develop? In a Canadian study, Dr Leigh Turner, writing in Canadian Family Physician, 2007, says that family doctors back home might have to deal with the problems. As for the success rate of the procedure Shimazono says that some studies show that results are considerably lower than international standards, while other studies show results “comparable with local results.” Giving specific examples, Shimazono says that there is a, “heightened frequency of medical complications, including the transmission of HIV and the hepatitis B and C viruses”
Organ transplant tourism would not be a global medical issue if it did not involve some serious ethical problems. Maybe the most relevant of these problems is the implication organ transplant tourism has on the medical profession itself.
Danovitch describes how the Declaration of Helskinki (1964)(pdf)(Wikipedia) can be applied in the context of the Declaration of Istanbul. For example, responsibility for human subjects should always rest with the medically qualified person even if consent is given by the patient, “consent does not free the physicians from responsibility….” The Lancet commentary is more forceful, “The success of transplantation as a life-saving treatment does not require-nor justify-victimising the world’s poor people as the source of organs for the rich.”
It is not surprising, therefore, that Organ transplant tourism, is a serious concern for the medical profession. Coercion, commercialisation of organs and lack of follow up treatment does not exactly meet the criteria of what an honest medical health carer ought to be associated with. That organ transplant tourists can just pay their way to the front of the queue only confounds the ethical issues.
It would be rather odd to write an article on the theme of tourism, even if we have to stretch the meaning of the word here, and not mention money and countries. For practical reasons, the money aspect is not that relevant because this changes with time. But how does one calculate a market value for an industry that can easily be described as murky? Horowitz, gives some figures, for example, some studies suggest annual revenues from global medical tourism (Wikipedia) (and not just organ transplantation tourism) to be US$60 billion, but other studies dispute this and project a figure of US$40 billion by 2010. Shimazono calculates renal “transplant packages” to range between US$70, 000 to US$160, 000.
Given that Organ Transplantation Tourism depends on poor people giving up their organs it is not difficult to imagine the origin and destination of this trade. David Spurgeon (quoting Professor Daar, Canada: BMJ) identifies the Philippines, Iraq, China, India, South Africa, Turkey and Eastern Europe as destinations for transplant tourists. However, the Lancet commentary reports that the representatives of the Declaration of Istanbul have “played major roles in the promulgation” of laws and regulations affecting transplantation tourism in China, Pakistan and the Philippines. Although the Australian website abc.net.au on 12 August 2008, had a story with the headlines: Australia urged to ban China’s ’transplant tourism’. Shimazono quoting an Organs Watch report, identifies the following major countries as “organ importing countries” (origin of tourists): Australia, Canada, Israel, Japan, Oman, Saudi Arabia and the USA.
The Declaration of Istanbul is a major step forward in curbing organ transplant tourism by apply pressure on the relevant authorities and governments. Some advocate going the commercial route and let market forces decide. Of course, market forces with the right sort of regulations and safeguards.
The Iran model is often quoted as an example of a successful organ transplantation programme for a country where the donor is paid from an official fund. Donors and recipients are managed by this programme with the result that there were no waiting lists. This model is supposed to maintain the equitable nature of organ transplantation and still reward the family of the deceased. Details of the model are described by Ahad J. Ghods et al, in a paper, Iranian Model of Paid and Regulated Living-Unrelated Kidney Donation, published in 2006, in the Clinical Journal American Society of Nephrology.
The Committee on Environment, Public Health and Food Safety of the European Parliament, (March 2008) have urged the Commission to introduce an European donor cards and regulations to fight organ transplant tourism. Another solution aimed at addressing the shortage of organs is to modify genetically animals to provide the necessary organs. However, Prof. Robert Winston, Imperial College, in 2007 failed to persuade the Department for Environment, Food and Rural Affairs (UK) to start research on modifying pigs. In the same article, the Guardian.co.uk (UK) reported that Prof. Winston moved his research to the USA. Prof Winston was also reported as saying that it was ethical to eat pigs as food, but not ethical to provide us with life saving organs.
No doubt organ transplant tourism is a serious ethical and philosophical issue in bioethics. It is also an issue that cannot be solved by a single lobby or group with vested interests. Nor is organ transplant tourism a problem for the medical profession alone to solve or politicians to fudge. What is clear, however, is that this is a twenty first century problem. But despite the various efforts to deal with this problem the situation is still, to use Shimazono words, “provisional and tentative.”
I don’t usually write about hotels on this site, because I don’t want to get into the business of doing hotel reviews. I have been prodded by many people to at least give a list of my favorite places I’ve stayed in the last 4 years, so I figure I’d give it a go. I also don’t normally do lists, but considering this is a list made up of things I’ve actually done, I figure I’ll cut myself some slack.