Reforms in organ donation in China: still to be executed?

Articles on organ transplantation often start by declaring it to be a miracle of modern medicine. The virtues of refinement in surgical techniques, advances in immunosuppression, refinements in laboratory tests and improved management of complications all receive due credit.

At its heart, however, organ transplantation is based on the ultimate good a human can do to another—by donating an organ. This is true both for living donors and for those who become organ donors after death. Altruistic organ donation is the bedrock of successful transplant programs.

Unfortunately, in some ways transplant programme has become a victim of its own success. The fact that the medical and surgical hurdles became less threatening put added pressure on the organ source. Legitimate attempts have been made to expand the donor pool by relaxing the criteria for accepting donors.

At the same time, unscrupulous practices sprang up around organ donation; in the form of a market where organs from the poor became available for a price to the rich. Human body was turned into a commodity, leading to exploitation of the impoverished and the uninformed, not in a position to give informed consent. It is important to point out that this was not because of some desire to do good to patients who needed a transplant, but fuelled primarily by human greed. In addition to the recipients, the major beneficiaries of the enterprise were transplant professionals, middlemen and hospitals.

Most countries with active transplant programs put in place rules and safeguards to make sure that that organ transplantation remained a voluntary and altruistic activity and did not exploit the vulnerable. The World Health Organisation (WHO) (1), the World Medical Association (2) and the Declaration of Istanbul (DOI) (3), a joint initiative of the Transplantation Society and International Society of Nephrology, came out with documents that provide guidance for ethical practices that protect the vulnerable and help establish a sustainable transplant program. They have been widely endorsed and accepted by professional societies and governments.

Despite the existence of laws and rules, there are parts of the word where practices around organ donation are not entirely consistent with these. In such cases, it becomes a law and order issue prosecutable by the authorities.

The Chinese system of procuring organs from executed prisoners, discussed in many places—most recently by Sharif and colleagues (4)—presents a unique and difficult situation, because the practices are deeply embedded in the political system, which is remarkably impervious to outside influence. A major feature of the Chinese system is its reliance on organs from executed prisoners—something that has not been described from anywhere else. The recipients of such organs were wealthy Chinese and transplant tourists from around the world.

It took disclosures by a political defector to bring to light the violation around the human rights of these prisoners in 2001 (5). Some of the descriptions—in particular the targeting of certain groups on the basis of ideological differences and the execution on demand—are particularly gruesome, if true.

The closed nature of the Chinese organ transplantation system, with the alleged involvement of the military, led to stories that cannot be independently verified or refuted. In contrast to the rest of the world, where unethical practices—when they exist—are investigated and exposed; the Chinese system is fiercely protective of what goes on inside.

The existence of many of these practices no longer is in doubt. The universal global condemnation it attracted seemed to initially matter little to those who control the organ procurement machinery in China. Its spokespersons first kept on dismissing the allegations as baseless, but were forced to acknowledge its existence in the face of mounting evidence (6).

At the same time, the Chinese transplant community found it increasingly difficult to be integrated in the global scientific exchanges, such as having papers accepted in journals or conferences.

Whether as a result of outside pressure or a desire to change from within, an important step was taken in 2013 with the announcement of the Hangzhou resolution (7). The resolution committed the Chinese National Organ Transplant System to be consistent with the World Health Organization guiding principles and the DOI on Organ Transplantation. A framework for managing this system was also announced, with five working components: an organ donation system, procurement and allocation system, a transplant clinical service system, a scientific registry for human organ transplantation, and the organ transplant regulatory system. Even in this resolution, however, there were disturbing elements such as the declaration that this process would be rooted on Chinese culture and socioeconomic reality. This led the critics of the system to suggest that this was a smokescreen, meant to deflect the adverse international attention. The Transplantation Society was forced to write an open letter to Mr. Jinping Xi, President of the People’s Republic of China expressing its concern and making an appeal to end this practice (8).

Recent months have given fresh reason for hope: almost all based on statements from a single individual—vice minister Dr. Jiefu Huang (9). By all accounts, he has been the face of the proposed reforms of the Chinese organ procurement system. One would hope very much that his widely reported statements that promise that organ procurement from executed prisoners will totally cease in China from January 1, 2015 are indeed accurate. Lancet has lavished praise on this development (10). However, other statements and events that have not received as much publicity, but have been quoted by Sharif et al. (4), introduce elements of sobriety in this celebration. Rather perplexing is the new Chinese offer of sharing organs procured in mainland China with Taiwan (11), given the fact that one would expect a drastic decrease in the number of available organs, and the first order of business for the government would be to ensure supply of organs to its own needy citizens.

The international transplant community very much wants that all countries of the world—including China—bring their practices in accordance with the accepted global norms as stipulated by the WHO and DOI. Besides having an ancient and rich civilization, China is the most populous country of the world and the fastest-growing economy. Therefore, the onus is on China to be an exemplar for other countries that will inevitably look up to it for leadership.

One could argue that the Sharif et al. (4) are unduly sceptical and present an exaggerated view of the situation. Perhaps it is true, but is it not largely a result of failure of the Chinese system to be open and transparent about its practices?

What can the Chinese authorities do to reassure these critics?

• A clear statement of intent would be an immediate and public abrogation of the 1984 Act.
• Being open to visits by observers from international organisations like the Declaration of Istanbul Custodian Group (DICG) and the WHO will also go a long way in assuring the outside world that China has nothing to hide and is ready and willing to enter the mainstream ethical organ procurement framework.

Many societies, especially those in the east, instinctively react negatively when there is a perception of imposition of Western values. Recommendations as made by Sharif et al. (4) are bound to lead to a reduction in the number of transplanted organs, which will potentiate the pushback. Taking a position where the only advice from well-meaning outsiders is to stop things is unlikely to be helpful. We do need to support building up mechanisms such that while one choice is no longer available, the alternate one more than makes up for it. The international professional societies should support Chinese professionals and administrators in developing a robust deceased donor transplant program to take care of the transplant needs of its citizens (12).

Make no mistake, where we are today represents a position of tremendous progress—thanks primarily to a number of courageous Chinese colleagues, who must have faced tremendous odds from within the system that will resist change. They deserve our accolades and continued support.

The fight against malpractices around organ donation is being fought—and won—at multiple fronts around the world. I have no doubt we will reach there in China as well.

Acknowledgements

Disclosure: The author declares no conflict of interest.

References

1. WHO Guiding Principles on Human Cell, Tissue and Organ Transplantation. Available online: http://www.who.int/transplantation/Guiding_PrinciplesTransplantation_WHA63.22en.pdf?ua=1
2. WMA Statement on Organ and Tissue Donation. Available online: http://www.wma.net/en/30publications/10policies/o3/
3. The Declaration of Istanbul. Available online: http://www.declarationofistanbul.org/
4. Sharif A, Singh MF, Trey T, et al. Organ procurement from executed prisoners in china. Am J Transplant 2014;14:2246-52. [PubMed]
5. Forced Organ Harvesting in China. Available online: https://www.dafoh.org/unethical-organ-harvesting/forced-organ-harvesting-in-china/
6. Huang J. Ethical and legislative perspectives on liver transplantation in the People’s Republic of China. Liver Transpl 2007;13:193-6. [PubMed]
7. The Hangzhou Resolution and Report of Meeting with Minister Bin Li of the National Health and Family Planning Commission of the People’s Republic of China. The Declaration of Istanbul on Organ Trafficking and Transplant Tourism. Available online: http://www.declarationofistanbul.org/index.php?option=com_content&view=article&id=424:the-hangzhou-resolution-and-report-of-meeting-with-minister-bin-li-of-the-national-health-and-family-planning-commission-of-the-peoples-republic-of-china&catid=50:articles-relevant-to-the-declaration&Itemid=67
8. Delmonico F, Chapman J, Fung J, et al. Open letter to Xi Jinping, President of the People’s Republic of China: China’s fight against corruption in organ transplantation. Transplantation 2014;97:795-6. [PubMed]
9. Huang J, Vice-Minister of the Ministry of Health, Alternate Member of the 16th CPC Central Committee. China Vitae. Available online: http://www.chinavitae.com/biography/Huang_Jiefu%7C1540
10. Weaning China off organs from executed prisoners. Lancet 2015;385:1. [PubMed]
11. China’s proposed organ exchange platform threatens to pull Taiwan into complicity in unethical medical practices. Available online: http://www.dafoh.org/pr122214/ Accessed 03 Feb 2015.
12. Millis JM. Engagement vs. isolationism: China’s transplant system. Hepatobiliary Surg Nutr 2013;2:295-6. [PubMed]