Engagement vs. isolationism: China’s transplant system
Throughout history when confronting significant moral or ethical issues there is frequently a battle between engagement and isolationism. No singular strategy can claim universal success, those on opposite sides are prone to criticize the other, and progress cannot be assured with either strategy, but engagement and isolationism are at opposite ends of the political spectrum when dealing with such problems. At times, different actors can play roles that enable engagement while simultaneously continuing to isolate. Armand Hammer’s role, as trusted messenger between isolationist United States and isolationist Soviet Union in the 1970s, helped lead to engagement through détente and ultimately reconciliation between the United States and the Soviet Union (1). Thus was the situation with China and their transplant system in the 1990s through the mid-2000s. China proceeded with their transplant system development in isolation and the world generally did not recognize how it was developing until the early 2000s when the ethical issues became so significant that it was impossible to ignore (2).
The response from the international transplant community was to isolate China from major publications and fora (3). China had allowed the lack of regulation to taint the Chinese Transplant community to an extent that formal intellectual exchange was dramatically curtailed. In the mid-2000s, Jiefu Huang, M.D. publically acknowledged the problems associated with transplantation in China and reached out to international experts to help establish transplant regulations that would help move China towards internationally accepted ethical standards. Informal exchange regarding international ethical standards was initiated and supported by a number of organizations including the China Medical Board, Peking Union Medical College, The University of Chicago, World Health Organization, and The Transplantation Society. Although formal intellectual exchange was limited, Jiefu Huang, M.D., a transplant surgeon and Vice Minister of Health with the support of the Chinese government embarked upon a course that ultimately led to the publication: the national program for deceased organ donation in China (4). Hence, while many of the official organizations were still advocating isolation, informal channels had been developed that would allow engagement and help ensure that the changes China made would assist in the development of a system that the international community would see as steps forward.
The article outlines a national program that is based on the pilot program initiated in 2010 and previously published (5). However, the legal and medical legitimacy for such a program was developed by each successive step in transplant regulation since 2006 (6). The pilot program was critically evaluated to determine areas that needed enhancement prior to establishing a national program. The important conclusion from that review was that China, despite lacking a brain death law, has the capacity and ability to provide organs from a citizen based voluntary deceased donor system. The melding of internationally accepted definitions of brain death and donation after circulatory death allowed China a path toward eliminating the use of organs from executed prisoners. China and those that have helped China move incrementally towards the National Program for Deceased Organ Donation in China have been criticized for allowing the system to continue to utilize organs for transplantation from executed prisoners while developing alternatives. It should be noted that abruptly halting the use of executed prisoner organs without a viable voluntary citizen based deceased donor alternative would have put many more living donors at risk in a society that is not well prepared for such a large influx of living donors and likely increased the mortality of those waiting for organs. Importantly, the Chinese government, ministry of health, and the transplant professionals needed each of the steps leading up to this program to establish credibility over such an emotionally charged and ethically challenging field. As there will certainly be future challenges as well, the continued credibility of those in charge of the National Program, the registry and organ allocation must be maintained.
The isolation policy of many organizations certainly had their impact. The Chinese transplant professionals desired access to the intellectual dialogue regarding the continuing development of organ transplantation. The lack of ability to publish clinical reports in leading international journals or present the clinical trials at international meetings inhibited academic progression even in the busiest transplant centers. These barriers provided an additional incentive to keep reforms moving in a direction that would garner international praise rather than condemnation.
The establishment of the National program is certainly not the end of the needed reforms nor is it the end to the discussion regarding the ethical practice of transplantation in China. It is far closer to the beginning than the end, but it is an important step. In reality, it has been a combination of both the isolationists and those engaging in meaningful dialogue that has moved a culture that in 2006 many said would never accept a voluntary citizen based deceased donor system to one in which is poised to be the primary and exclusive organ donor source in the future for China.
Acknowledgements
Disclosure: The author declares no conflict of interest.
References
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- Huang J, Wang H, Fan ST, et al. The National program for deceased organ donation in China. Transplantation 2013;96:5-9. [PubMed]
- Huang J, Millis JM, Mao Y, et al. A pilot programme of organ donation after cardiac death in China. Lancet 2012;379:862-5. [PubMed]
- Huang J, Mao Y, Millis JM. Government policy and organ transplantation in China. Lancet 2008;372:1937-8. [PubMed]
