Two years ago, on July 1st, scientists from around the world published the 2018 edition of the Declaration of Istanbul, a set of principles and definitions which aimed to address organ trafficking and transplant tourism. The declaration was originally published in 2008, following a summit convened by leading transplantation and medical communities addressing the growing concern of organ harvesting and trafficking. The challenges addressed by the Declaration of Istanbul are multi-faceted and complex, particularly where organ transplantation intersects with medical tourism, resulting in “travel for transplantation,” the practice in which those in need of an organ travel to another country to procure it. Transplantation tourism, while not outright illegal, is an industry that precipitates illicit human trafficking and organ harvesting, and the re-affirmation of the Declaration of Istanbul demonstrates how policy makers in places like the USA, China, India, Turkey and Costa Rica have to adopt systematic changes to dismantle the international organ harvesting system.
While theoretically a legal market for organs may one day be ethical and achievable, the idea is heavily debated and outlawed in most countries. Instead, governments make donation a voluntary opt-in or opt-out system, with those in need of an organ on a state or national waitlist. This ensures that all donating parties can provide consent for deceased donation, where after death, viable organs can be provided to someone else in need. In an opt-in system, like in the United States, each person must “opt-in,” to becoming a donor. Otherwise post-mortem, families must provide the consent on behalf of the deceased individual. In opt-out systems, everyone is by default a donor, and the state presumes consent for deceased donation unless otherwise stated. While opt-out systems generally enable greater demand to be met, since there are fewer barriers to someone becoming a donor, some conditions can make a deceased donor ineligible to donate, and waitlists are still significantly larger than supply in most nations.
The wide disparity between high demand and low supply enables illegal systems to take root, cashing in on the demand by fulfilling supply through other incentives. Black markets and middlemen facilitate transplant tourism in order to help a paying individual bypass their position on donation waitlists in their own countries. While it may help one paying individual receive their needed organ transplant, it can often come at the cost of exploiting vulnerable local populations. It is particularly dangerous for those in extreme poverty, those at risk of human trafficking, refugees, and in some cases, prisoners, contributing to a $1 billion illegal organ transplant industry in China alone.
In 2015, India ranked as the third most popular destination for medical tourism and was one of the most commonly travelled to countries for transplants. Because of wealth inequality and high demand for organs, black markets have emerged to provide wealthier patients with organs from strangers. Sellers are often impoverished or in debt and are recruited by middlemen to sell their organs with fraudulent documentation, sometimes in collusion with doctors or hospitals which would be providing the transplantation procedure. In 2015, Sundar Singh Jatav was duped into selling his kidney, and later would help expose an illegal organ racket in India that misled those in financial distress. Jatav was connected with an individual who suggested he sell his kidney to help pay off his family’s debt. The middleman, called Sandeep, assured Jatav that donating a kidney would be no different from giving blood. Jatav believed that Sandeep and the doctors involved wanted to help him out of his financial situation, however Sandeep did not offer Jatav a specific price for his kidney. Jatav never received payment following the operation and would later partner with an activist in the government who then helped notify the authorities and expose the illegal scheme. In other cases, sellers would receive $3,000, complicit hospitals would receive $7,000, and buyers would pay $30,000 for the operation. Transplant coordinators would keep the rest.
Refugees are often vulnerable to exploitative systems as well. It’s estimated that Turkey took in over 3.5 Million Syrian refugees, mainly concentrated in urban centers, and that over 64% of urban Syrian households are living below the poverty line. In 2020, an award-winning documentary series called “Selling Organs to Survive” highlighted the stories of those refugees who would strike deals with organ brokers because of difficult financial situations. Abu Abdullah, a refugee working as a metal worker in Turkey, earned just $300 per month. Abdullah found a post on Facebook offering $10,000 for one kidney. He agreed to the price, with the associated hospital only requiring verbal confirmation that he was related to the buyer. By agreeing that he was (falsely) cousins with the buyer, the transplant would appear to occur legally with the money being exchanged after the operation. The middleman who Abdullah worked with would later only pay half the agreed price and disappeared.
Police have begun to crack down on these illicit organ trafficking rings, specifically focusing on arresting the middlemen. In these cases, already desperate people and their situations are being exploited for the financial gain of third parties, often with sellers finding very little of the large sums of money that organ buyers are committing. Some middlemen like Abu Jaafar from Lebanon, however, claim that while they are exploiting refugees, the refugees do benefit by receiving financial compensation, which could improve their quality of life. This money would otherwise be unrealistic for them to acquire in the systems in which they are seeking refuge given the rampant poverty and debt.
In December 2019, prosecutors in Costa Rica investigated a suspected organ trafficking ring tied to a hospital in the country’s capital, San José. The hospital, operated by the Costa Rican Social Security Fund, had been linked again to brokering kidneys to buyers in Israel, Ukraine, the USA, and Eastern Europe. While Costa Rica has become a popular destination for lower cost cosmetic surgery, transplant tourism is another challenge for the country’s medical tourism industry due to corruption and exploitation of the healthcare system. Costa Rica became one of the first Latin American governments to sign onto international treaties to combat organ trafficking and in 2018, agreed to enforce laws implemented by the Council of Europe Convention Against Trafficking in Human Organs. Additionally, PROMED, a Costa Rican non-profit, has supported the Declaration of Istanbul, agreeing to promote medical tourism under strict safety standards. However, due to the country’s dual public-private medical system, some journalistic investigations have suggested that transplant surgeons could earn more money by performing transplants at private hospitals, where they are not paid monthly wages, rather they are paid per case they address. Despite the commitment of NGOs and professional networks, some doctors still see opportunities to exploit the hospital system, using its resources to enable matching international buyers with financially stressed locals who feel donation is the best way to make fast money.
While doctors and hospitals play a role in enabling transplants, brokers, like Maureen Patricia Cordero Solano, can also exploit their roles for financial gain. By day she was a police officer and taxi driver, but behind the scenes, she could earn as much as $1,000 for every donor she referred to the organ ring. Alongside doctors, the ring would use public hospital data to find suitable kidney harvesting candidates who could match with buyers. She herself had sold her kidney after falling on difficult financial times, yet still solicited donors, sometimes through her day work, because these people were in desperate economic need. While Solano was eventually arrested in 2013 following the arrest of a prominent, complicit doctor, Dr. Francisco José Mora, the stories of donors turning to selling their organs for financial alleviation is still an issue. It will take continued adherence to ethical standards if the country aims to keep promoting its legal medical tourism, while mitigating corruption that enables the much darker, illegal transplant tourism.
The Declaration of Istanbul affirms that by outlining clear principles and definitions around organ trafficking, it can better equip policymakers with the tools to craft better and more effective legislation on these topics. Additionally, it aims to provide advice to and guide health professionals in related fields. Some of its principles include:
- The optimal care of organ donors and transplant recipients should be a primary goal of transplant policies and programs
- Trafficking in human organs and trafficking in persons for the purpose of organ removal should be prohibited and criminalized
- Organ donation should be a financially neutral act
- Health professionals and healthcare institutions should assist in preventing and addressing organ trafficking, trafficking in persons for the purpose of organ removal, and transplant tourism
The declaration has been endorsed by 135 professional societies around the world. Endorsement requires participants to rigorously apply the ethical principles of the declaration in their policies, practices, and activities, with mechanisms to promote, implement, and present on the declaration. Participants in the 2018 summit welcomed the renewed interest and commitment in combatting organ trafficking, believing that it would provide a clearer structure to guide policy and practice.
Organ trafficking has been estimated to account for 5-10% of annual kidney transplants, globally. While each of us can do our part by opting into donation systems and becoming educated on how these systems exploit others, it will ultimately take government and private sector reform to provide policy solutions and root out internal corruption. As they celebrate their 12th anniversary, the Declaration of Istanbul has continued to raise attention for its causes and encourage other governments and professional organizations to commit to its cause.
If you are not already an organ donor and live in the United States, the Health Resources and Services Administration offers a guide on registration, here.