Historical contributor Sophia O'Sullivan gives an account of the history of organ transplantation, organ donation systems and the illegal organ trade, complete with graphical representation.

Like many illegal industries, the international organ trade has flourished due to scientific advancements and the subsequent spread of regulated and professionally performed transplants. While the first successful organ transplant operation was first performed in 1954, the invention of the immuno-suppressant drug cyclosporine in 1983 drastically reduced the rejection rate, making organ transplants universally viable. As medical knowledge has expanded, the range of transplants available has become broader, and accompanying medical procedures safer; however, the rapid increase in demand for organs has lead to the illegal organ trade which threatens the health and integrity of both vendor and recipient, encouraging exploitation of some of the world’s most desperate people.

Primary International Response to the Development of Transplant Technology

In many first world countries, legislation on the movement and donation of organs within the country has long been present; as with any new ethically sensitive science, the transplantation of organs was regulated before it became widespread. In America, the National Organ Transplant Act of 1984 restricted the sale of organs and established Organ Procurement Organizations (Griffin and Fitzpatrick 2009); a law ahead of its time in its willingness to address the root of the problem instead of implementing rarely-heeded bans. On the other hand, Japan's 1968 ban on cadaveric organ donations, which despite being overturned with 1997 legislation, has lead to little increase in the country's donation of organs (The Japan Organ Transplant Network). 

Reasons for the Failure of Legal Systems

Perhaps due to the increased feasibility of organ transplantation, but more pressingly due to the alarming increase of conditions which cause organ failure, the number of transplants performed has increased steadily across the globe, mainly in first world nations. As noted by the 2011 Arbor Research Collaborative for Health, primary causes of organ failure, such as hypertension and diabetes type two—responsible for 62% of all kidney disease in the US—have increased significantly in those countries able to afford organs and are mainly caused by lifestyle factors such as obesity.

Similarly, in Australia, the demand for organs has increased by 34% from 1991 to 2007; according to the Australian Parliamentary Library the waiting list has increased from 1308 to 1757 people. This increase, as noted by in 2008, parallels a 13% rise in obesity rates in the same period (Kidney Health Australia). However, the increase in donation reported by the Scientific Registry of Transplant Recipients, whether from a living relative or a cadaver, has not matched the demand (Scientific Registry of Transplant Recipients). This has lead to lengthened waiting lists in most countries; around 2000 people are added to the US waiting list per month as of 2010 according to the Organ Procurement and Transplantation Network (Organ Procurement and Transplantation Network 2011).

The reasons for the lack of organ donors may often be due to the donation system which exists within a country; Johnson and Goldstein note that when opt-in donation systems are present: donation rates can be as low as 4.25% of the population, as in Denmark; conversely donation rates for opt-out systems average around 98%, a trend demonstrated in countries such as France, Austria and Portugal. Cultural differences appear to have an impact on donation, New Mexico Donor Services 2003 report states that the Roma people are opposed to the donation of organs, a tentative link may be made between their high concentration in Eastern Europe and those countries’ low donation rates (New Mexico Donor Services). The Japan Organ Transplant Network argues that the scandal and corruption surrounding the country’s first heart transplant operation has lead to a national mindset of distrust (Japan Organ Transplant Network). This has been substituted for the crippling lifestyle disease rates that have caused organ shortages in the western world.

History of the Trade

Any information on the beginning of the illegal organ trade is likely to be flawed in some way, due to the illicit nature of the transaction and the lack of transparency in donor countries. Statistics are mainly gleamed from the governments of poorer nations and the investigations of authorities such as the World Health Organisation (hereafter WHO); both may carry bias (especially as third world nations may be under-reporting such incidences in order to encourage a huge industry (Budani-Saberi 2008).

The December 2007 “Bulletin” of WHO identifies 1990 as the earliest point at which the organ trade began; this information would only have been recognized and compiled if the organ trade was already a widespread practice. Thus, we can conclude that the organ trade began sometime between 1983 and 1990, established almost in parallel to the legitimate transplantation of organs and growing steadily since. This may be due to the fact that as soon as organ transplantation became widespread within first-world countries, it was strictly regulated. An example of this regulation is the United Network for Organ Sharing’s requirements for any alcoholic wishing to be placed on the waiting list for a new liver. It is therefore conjecturable that, as soon as there was a legitimate organ transplant practice, there would be those who were unable to receive organs legitimately, a situation likely to cause the desperation for something as risky as the organ trade.

Interestingly, as soon as organ transplantation became viable (circa 1984) the Chinese passed a law dictating that the use of organs from condemned prisoners was acceptable and could be encouraged. It is thus apparent that a legal supply of organs for such a trade was established in one country at least. However, it is also certain that there were well-established organized crime syndicates which would have had sufficient resources to institute an international organ market from these poorly regulated Chinese organs. Porter and Johnson report that in the US, when an organ broker’s trade with Israel was busted, he was also found guilty of importing fake designer handbags, suggesting that those who run the organ trade may be branching off well-established illegal operations.

History of the International Identification and Response to the Organ Trade

The severity of the international organ trade has been recognized by world authorities. The WHO established a set of guidelines in 1991 to protect organ donors. However, few donor countries have heeded it and, as observed by Budani-Saberi, Iranian law, with its system of paid donors as opposed to purely altruistic transplants, actually runs counter to it. The WHO held its first Global Consultation on Human Transplantation in 2004, at least a decade after the practice was first studied academically; the European Parliamentary Assembly first identified the issue in 2003. Budani-Saberi documents multiple regional consultations, all of which appear to be for the donor countries alone. This targeting of the suppliers of organs, instead of the root demand, appears to be the standard modus operandi of health authorities.

Interestingly, the illegal organ trade has only been made illegal in the last decade or so, and even today some countries have no restrictive legislation on the sale of organs. 
Arab News reports that it was not until 2008 that the Philippines, one of the biggest transplant destinations (especially after the enactment of legislation in China), banned the buying of organs. Scott Carney for Wired magazine details India’s 1994 legislation, an effort to curtail the country’s thriving organ industry, but notes that this a step many leaders of poorer nations are unwilling to take for fear of economic downturns. Similarly, as described by Jonathan Watts for The Lancet, China’s 2007 Human Transplantation Act bans the sale of organs, legislation that has reduced the number of foreign transplant tourists by half (Watts, J 2007).

The need for laws which restrict transplant tourism has been identified by many conferences on the subject; an Epoch Times report by J. Fakkert notes legislators in wealthier countries have been called upon by the European Parliamentary Assembly and the WHO to restrict the movement of their citizens to poorer countries for the purpose of buying an organ. This is an especially pressing issue given L. Rohter’s statement for the New York Times: he notes that “donors” in places such as Brazil can face criminal charges for selling an organ. Griffin and Fitzpatrick highlight that such laws have been passed by Israel, while other countries have stated that they have no obligation to monitor their citizens abroad. In 2004, the British Parliament passed the Human Tissue Act, reported by the BBC, which forbid the sale of organs; however, this prohibition on trade was not the main focus of the law, which instead sought to regulate the distribution and exhibition of organs by hospitals.

Overall, worldwide legislation has been widely ineffective, either due to the blatant ignorance of these laws or the exploitation of loopholes, many of which are utilized by the law enforcers themselves. Scott Carney reports that many members of an ethics committee in India admit to approving transplants which are commercial in nature, resulting in at least 500 more illegal kidney sales in one village after the passing of the 1994 legislation. Similar circumstances have been described by Porter and Johnson; bribery and corruption have been exposed in India, China and the US. The role of hospitals and even religious leaders is also instrumental in stopping the trade, given their ability to change public opinion of the practice of organ donation to encourage greater levels of donation, with the hospitals having the opportunity to sway opinion at a crucial time, while religious leaders have a greater opportunity to challenge more deep-seated beliefs and values regarding organ donation.

The Future of the Organ Trade

As the demand for organs rises, and waiting list times stretch out by years, it seems logical that the illegal organ trade will grow. A significant improvement in the lifestyles of first world countries and new cures for organ-destroying disease may reduce the demand for organs. However, the best alternative to organ transplantation appears to be the artificial growth of organs in a laboratory. The Human Genome Project reports that while this is still a science in its early stages, these organs would be a healthy clone of the organ in need of replacing and would contain the patient’s DNA, thus reducing the risk of rejection. It is likely that this will not become as widespread as transplantation for at least a decade; ethical, legal and clinical concerns must be addressed before such a treatment is perfected and offered to the public. It is interesting to note that, at present, these organs are grown from embryonic stem cells, a process which many consider unethical. It is for this reason that this science has stalled; conservative legislators refuse to allocate government funding to the development of embryonic technology. In the face of a possible solution to the exploitative organ trade, is it morally better to allow the destruction of embryos or to allow the organ trade, which harms donors and recipients, to continue? These are questions which those in government and medical technology sectors must address.

The impact that this “organ growing” has on the illegal organ trade will undoubtedly be determined by the cost to the  party in need of an organ; it is safer and preferable than travelling overseas for a transplant but if it is significantly more expensive the organ trade may still thrive. Another possibility is that the organ trade will be opened to classes in the donor country; relatively wealthy residents in a poor country may be able to buy organs from those who would have previously sold organs to foreigners. There is an increased international awareness of the epidemic of the organ trade, and legislation of both vendors and recipients is becoming tougher. However, if the international response is to be truly successful in ceasing the exploitation of such desperate people, all nations must look inwards to solve the problems of inescapable poverty and inadequate healthcare systems.