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The Declaration of Istanbul on Organ Trafficking and Transplant Tourism: An Important International Achievement with One Disturbing Loophole

Miran Epstein   (4 July 2008)

The Declaration of Istanbul on Organ Trafficking and Transplant Tourism: An Important International Achievement with One Disturbing Loophole 4 July 2008
Miran Epstein, Physician and medical ethicist Barts and The London School of Medicine and Dentistry; Queen Mary, University of London Send response to journal: Re: The Declaration of Istanbul on Organ Trafficking and Transplant Tourism: An Important International Achievement with One Disturbing Loophole	The Istanbul Summit on Transplant Tourism and Organ Trafficking was held between 30th April and 2nd May 2008. Organised by the Transplantation Society (TTS) and the International Society of Nephrology, the Summit, in which 152 representatives of scientific and medical bodies, social scientists, and ethicists from 78 countries took part, produced a consensus paper titled “The Declaration of Istanbul on Organ Trafficking and Transplant Tourism” (1). The Declaration addresses “the urgent and growing problems of organ sales, transplant tourism and trafficking in organ donors in the context of the global shortage of organs”(2-4). The Declaration condemns and aims to halt ‘transplant commercialism’ (policies or practices which treat organs as objects of commerce), ‘organ trafficking’ (practices surrounding commerce in organs), and ‘transplant tourism’ (travel to a foreign country for transplantation which involves transplant commercialism and organ trafficking). It expresses a particularly strong view against transplant tourism. Its objection to this practice focuses on both its exploitative, degrading, and often violent, implications for the impoverished vendors in the poor ‘destination’ countries as well as its detrimental effect on the availability of organs for local patients on the waiting list. Transplant tourism has some dire implications for the rich ‘recipient’ countries, too. It entails risks to the health and care of the tourists-recipients themselves; it affects local donation rates and thus denies organs from those patients on the waiting list who cannot afford ‘tourism’; it poses a threat to the sustainability of local transplant centres (5- 9). In the understanding that transplant commercialism, trafficking, and tourism have taken place partly as a result of the global shortage of organs, the Declaration further suggests strategies to increase local donor pool and encourage sustainable transplantation programmes. These include development of national and international organ-sharing programmes, promotion of deceased donor transplant programmes, protection of the health, safety, and economic rights of living donors, and removal of financial disincentives to living donation. True, the successful implementation of these recommendations still faces high hurdles, including cultural barriers and economic resistance—for example, some governments and insurance companies are unlikely to abandon the myopic cost-saving element of transplant tourism without a fight. However, its contribution to the ongoing effort to heal the transplant practice should be acknowledged at any rate. Moreover, a declaration that explicitly opposes transplant commercialism seems to deserve a particular praise for gaining the support of those participants in the Summit who maintain that a sweeping rejection of transplant commercialism is counterproductive, and that ‘regulated’ markets in organs within local geopolitical boundaries could have addressed the problems much better (10- 11). In embracing the Declaration, the proponents of transplant commercialism seem to have made a radical concession. This impression deserves a second look, however. It might fall apart, if the Declaration turned out to contain something that could be interpreted as a concession made rather by those who genuinely oppose any form of transplant commercialism. Such possibility might have some serious implications for the Declaration and, even more so, for the plight against ‘transplant tourism’. One thing springs to mind in this respect: the Declaration does not problematise in any way the widespread and for some time already normative practice of ‘altruistic unrelated living donation’ (12). It deals with the category of living donations in general only. Perhaps there is no problem after all. Perhaps the prevailing screening process of unrelated living donors is rigorous enough to effectively sieve out most, even if not all, commercial transactions that present under the guise of altruism. Perhaps unrelated living donations can be confidently regarded as nothing less than heroic acts of genuine altruism. However, the opposite possibility must also be considered. Perhaps our reluctance to employ ‘reverse means testing’ for unrelated donations, where only donors who prove to be rich enough are allowed to donate organs, or, even better, to impose a total ban on unrelated directed donations, has made our screening process essentially weak. Perhaps ‘altruistic unrelated living donation’, as we currently know it, is just a legal fiction that conceals commercial transactions more often than not (13-14). As lack of data makes either possibility difficult to confirm, the latter possibility, plausible as it may seem, remains a suspicion only. However, if this turned out to be the case, if the Declaration transpired to embrace a quasi-legal form of transplant commercialism, then this would inevitably undermine its explicit rejection of the latter. In fact, the Declaration would have to be reread as a subtle attempt to de-globalise organ commerce, not to abolish it. Whatever the case, in an increasingly competitive world, which tends to force almost every form of local commercialism into race-to-the-bottom-like ‘outsourcing’, the prospects of any declaration that calls to eradicate ‘transplant tourism’ depend foremost upon its unequivocal rejection of ‘transplant commercialism’. 1. Steering Committee of the Istanbul Summit. Organ trafficking and transplant tourism and commercialism: The Declaration of Istanbul. Lancet 2008; 372:5-6. 2. Shimazono Y. The state of the international organ trade: a provisional picture based on integration of available information. Bull World Health Organ 2007; 85(12):955-62. 3. Delmonico FL, Dew MA. Living donor kidney transplantation in a global environment. Kidney Int 2007; 71:608. 4. Danovitch GM. From Helsinki to Istanbul: What can the transplant community learn from experience in clinical research? Nephrol Dial Transplant 2008; 23:1089-1092. 5. Prasad GV, Shukla A, Huang M, Dah RJ, Zalzman JS. Outcomes of commercial renal transplantation: A Canadian experience. Transplantation 2006; 20:1130-1135. 6. Danovitch GM, Leichtman AB. Kidney Vending: the “Trojan Horse” of Organ Transplantation. CJSN Doi 10.2215/CJN.03030906 2006. 7. Budiani-Saberi DA, Delmonico FL. Organ trafficking and transplant tourism: a commentary on the global realities. Am J Transplant 2008; 8(5):925-9. 8. Merion RM, Barnes AD, Lin M, Ashby VB, McBride V, Ortiz-Rios E, Welch JC, Levine GN, Port FK, Burdick J. Transplants in Foreign Countries Among Patients Removed from the US Transplant Waiting List. Am J Transplant 2008; 8(4 Pt 2):988-96. 9. Danovitch GM. Who Cares? A Lesson from Pakistan on the Health of Living Donors. Am Journal of Transplantation 2008; 8:1-2. 10. Matas AJ. Design of a regulated system of compensation for living kidney donors. Clin Transplant 2008; 22:378-384. 11. Satel S, Hakim N. ‘What’s wrong with selling kidneys?’ International Herald Tribune, June 20, 2008. Available at http://www.iht.com/articles/2008/06/20/opinion/edsatel.php Accessed 28.6.08. 12. Directive 2004/23/EC of the European Parliament and of the Council. 31 March 2004; Chapter III Article 12.1. Official J Eur Union, 7.4.2004.L102, 54. Available at http://europa.eu.int/eur- lex/pri/en/oj/dat/2004/l_102/l_10220040407en00480058.pdf Accessed 28 May 2008. 13. Stephan A, Barbari A, Younan F. Ethical aspects of organ donation activities. Exp Clin Transplant 2007; 5(2):633-7. 14. Epstein M. The ethics of poverty and the poverty of ethics: the case of Palestinian prisoners in Israel seeking to sell their kidneys in order to feed their children. J Med Ethics 2007; 33(8):473-4. The author was a participant at the Istanbul Summit. Competing interests: None declared