Organ Trafficking: An Interview with Dr. Francis L. Delmonico

Interview By Dhweeja Dasarathy

Demand for organ transplant surpasses the supply. The Council of Europe has defined organ trafficking as a crime, when there is a monetary transaction for financial gain as the motivation for someone to sell his or her organ. It is estimated by the World Health Organization that 10% of the organ transplants performed worldwide are done with a monetary transaction between the donor and recipient. To explore this topic further, Dhweeja Dasarathy, associate editor of HHPR, conducted a phone interview with Dr. Francis L. Delmonico, chief medical officer of the New England Organ Bank (NEOB), and Professor of Surgery in Harvard Medical School at the Massachusetts General Hospital. In addition to his service as a past president of the United Network Organ Sharing (UNOS), and past president of The Transplantation Society, he currently serves as an Advisor to World Health Organization in Organ Donation and Transplantation.

Dhweeja Dasarathy (DD): Since the United States is facing an acute organ crisis, is it possible for desperate recipients to travel to other countries to receive an organ transplant?

Dr. Francis L. Delmonico (Dr. FLD): It’s conceivable, but I don’t think it happens very often. It is a very encouraging time for organ transplantation in the U.S. There is a large increase in organ transplantations in the past five years to approximately 34,000 in 2017 and we have increased the number of deceased donors to the greatest number ever, to exceed 10,000. Nevertheless, I don’t think many patients travel to foreign countries for organ transplants, because of the unreliable quality of transplantation and more importantly the need for sophisticated post transplantation follow-up close to where patients reside.

DD: What are your thoughts about whether one should be allowed to sell his/her kidneys or other organs?

Dr. FLD: Congress has not been disposed to rescind the 1984 National Organ Transplant Act (NOTA) that prohibits individuals buying or selling organs. That policy has been most effective as a model for the rest of the world with the only exception being Iran. The Declaration of Istanbul and the Principles of the World Health Organization adopted by all Member States the World Health Assembly in 2010 prohibits individuals from selling organs.

DD: Iran currently has a legal market for selling organs. Does that system work? How does it help reduce the organ crisis?

Dr. FLD: The key question here is, “Is it ethically proper to buy and sell organs whether Iran or not?” It is exploitation of those who sell themselves in need of money. The money that is provided by the government for the exchange of the organ is not the final amount of money that may be transacted. The dynamic becomes, “I need more money from the vendor seller, I can’t give you more money from the buyer, with the potential conclusion from the vendor, then you find yourself another donor etc.” “Under the table” aspects of this bartering prevent it from being regulated or monitored and it becomes a black market. Iran is not the model for the U.S. or elsewhere in the world.

DD: How can we improve ethical organ donation and ensure equity in transplant access in developing nations?

Dr. FLD: By assuring transparency and recording every transplant performed. The identity of donor for every recipient is known and recorded. A system is in place that generates a computerized list that is used for the selection of the recipient, a list that is developed by medical criteria of the candidate, and not by the social status or ethnicity. That is the approach that the WHO brings to all member states regarding transplantation. Transparency is everything!

DD: Do you think part of the problem is the commercialization of medicine now that market forces and supply demand are driving an organ black market?

Dr. FLD: The impact of commercialization on organ transplantation has been limited by the system of organ allocation that we have adopted. We have people in need of money for whom there are no other options other than sell their organs. There are members of each transplant selection team who specifically evaluate if any form of pressure is applied, it does not have to be necessarily a financial incentive, though that is what comes most often to reality. Commercialization is one aspect that affects priority listing. Commercialism and markets are not really the drivers of potential incentivization of donors. Ultimately commercialization does not drive the need of organs, rather it is the need for organs and organ shortages that drives the commercialization.

DD: With Australia and Singapore legalizing monetary compensation for donors, is there potential for abuse in those and other developed countries since economic disparities exist even in such countries?

Dr. FLD: It’s a context of the compensation. If compensation is provided so that it removes a financial burden from the donor, the compensation provided by Singapore or any other in the world, is to take away that disadvantage that someone is not at a monetary loss to be a living donor. The compensation should be processed in a regulated way to know that it is distinguished from enabling a monetary gain. In both Australia and Singapore – the intention is financial neutrality – no loss but no gain.

DD: Is there a concern for murder for organs as a criminal activity. Criminal and racketeering organizations have adapted to market needs and if illegal drugs support criminal enterprise, do you think the next unexplored arena is organ trafficking. What can countries or the UN do to tackle this?

Dr. FLD: You have seen reports in the press that individuals in Sinai are murdered for the organs. I am unaware of a transplant doctor that is a murderer. There are very specific scientific circumstances that are required for successful organ transplantation not accomplished surrounding the claims that were made about the Sinai. Sinai – evidently there were investigations; but nothing was proven. There were individuals in China who were executed as a capital punishment — and organ were being taken from them – but the International community strongly objected – and that practice has virtually stopped.

DD: Everywhere in the world, stories about organ trafficking are heart breaking. In developing countries, how does the law protect the civilian from kidney trafficking? As an advisor to the WHO, what is your take on it?

Dr. FLD: Governments have a responsibility as organ transplant programs are emerging in Kenya, Ethiopia, and Nigeria. The Ministry of Health must authorize transplant centers and there should be an agency that oversees the practice. The information to be monitored includes: Who is the donor? Who is the recipient? Date of outcomes; the distribution of the deceased organs for transplantation, what is the outcome for the living donor? The elements are clearly presented in the WHO Guiding Principles. From the WHO standpoint, in an underdeveloped country, we suggest that the Ministry follow the principles of the WHO. I am hoping that we can develop a task force of the WHO that is available to the governments for these principles to be implemented.

DD: What is your final comment on organ transplantation?

Dr. FLD: Organ transplantation is the microcosm of the society: referable to our common humanity. It is a noble act, but it is subject to abuse. There is a need for social justice that we do not rely on poor indigent individuals, to be the source of a deceased donor, or be a living donor.

Social justice says if you can be a donor, you should be able to be a recipient.

Similarly, if you can be a recipient, then there should be no cultural or societal objections to your being a donor. If a living person is willing to be a donor at the time of death, then no society or culture should have an objection to that decision.