Tuesday, November 29, 2005

should people from developing countries be allowed to sell their organs ?

Excerpt from " The Ethics and Efficacy of Banning Human Kidney Sales" By Joseph Shapiro , Stanford University : May 2003

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It is 106 degrees in Chennai and I am in the palm hut of a 38 year old named Parvi. Nine months ago, Parvi sold a kidney to a dying man from North India. I asked Parvi why she gave a kidney. “We were so poor that my children were about to drink poison,” she said. “We had no income and many debts. I had no choice. “Several years earlier, Parvi accepted government payment for a sterilization surgery; she felt that her experience with the “family planning operation” made her more comfortable agreeing to sell a kidney. For the kidney she received US$800, enough to repay her debts. Parvi has no formal education and no knowledge of the kidney’s function. Until her first conversation with the doctor, she was unaware that there existed body organs named kidneys. Parvi’s daughter, who is sitting next to us, interjects. “We’re content. We repaid our debts and saved a life.”

Now I am having coffee in the apartment of Dev, an educated Indian accountant. At a young age, Dev was diagnosed with kidney failure. After ten weeks of dialysis, Dev had a kidney transplant; his mother was the donor. That kidney was soon rejected, so Dev received a kidney from his father. Now that kidney has been rejected and Dev has no other relatives who can donate. On dialysis Dev would lose his job and income. So Dev flew to Chennai and told a broker that he needed to buy a kidney. A day later, the broker offered him “matching donor and authorization committee approval” for US$2000. Dev asks me whether kidney sales should be legal, and I tell him that I am unsure. “Look at me,” he says. “I have a wife and a child who is seven years old. I need to live. What should I do?”

Kidney sellers and buyers are not statistics; they are mothers and uncles with daughters, homes, friends, frustrations, and dreams. Facts about the thousands of people who sell a kidney should not obscure the reality that for each seller, nephrectomy is a life-defining event.

Nonetheless, many individuals share Parvi’s desire to sell a kidney. A leading Indian NGO estimates that at least 2000 Indians sell a kidney every year. The United Network for Organ Sharing estimates that 200-300 Americans and a tenth as many Canadians by an organ in a developing country each year. By 1993, at least 960 Arabian Gulf residents had received kidneys from donors in India, Egypt, Iraq, the Philippines, and elsewhere.

Trade in kidneys is truly global. David Rothman, chair of a research group on organ sales, wrote in 1998 in the New York Review of Books:

The routes that would-be organ recipients follow are well known to both doctors and patients. Italians (who have the lowest rate of organ donation in Europe) travel to Belgium to obtain their transplants: so do Israelis, who lately have also been going to rural Turkey and bringing their surgeon along with them. Residents of the Gulf States, Egyptians, Malaysians, and Bangladeshis mainly go to India for organs. In the Pacific, Koreans, Japanese and Taiwanese, along with the residents of Hong Kong and Singapore, fly to China. Less frequently, South Americans go to Cuba and citizens of the former Soviet Union go to Russia.

Over 8400 Iranians have sold a kidney since Iran began regulating kidney sales in 1988, and most of those sales have occurred recently. The Bangkok Post has written extensively on hospitals accused of purchasing kidneys in violation of Thai law. Journalism Marina Jimenez and Stewart Bell report that the Philippines allows residents to sell a kidney to a Filipino if no broker is involved. But many Manila slum dwellers have sold a kidney to foreigners for US$2000. Michael Finkel interviewed a Turkish donor who claimed to have received $10,000 for a kidney. Jimenez reports that Istanbul surgeons now operate on Moldovans who receive $3,000 for undergoing nephrectomy in Turkey. At least until 2001, the foreigners could by a Chinese kidney – often from an executed prisoner – for $6,000. Michael Friedlander wrote in Lancet in 2002 that surgeons at Tel Aviv’s Rabin Medical Center often go with their Israeli patients to Estonia, Bulgaria, Egypt, Turkey, Georgia, Russia, and Romania to perform surgery on local donors from whom the Israeli’s purchase a kidney. In 1991, Abouna et al. called the Al Khayal Hospital in Iraq the most active private hospital in the Middle East for paid kidney transplantation; Frishberg et al. Finkel, and Friedlander emphasize the high volume of paid transplants in that program. Abouna et. Al interviewed 21 Kuwaiti patients who purchased kidneys in Iraq and found that their average payment fro transplant and kidney was US$ 15,000, which equaled the total earnings of an average Iraqi physician in eight years. Friedlander wrote in 2002 that Iraqi donors typically received US$500 for a kidney.

We have the most information about kidney sales in Iran and India. Iran’s government began a paid donor program in 1985 at the Heshmi-Nejad Hospital, By 2000, Iranian surgeons had performed nearly 11,000 kidney transplants with 23% related donors, 77% unrelated (usually paid) donors, and 1% cadaver donors. In 2002 alone, 23 centers in Iran performed about 1500 transplants. Iran’s Dialysis and Transplant Patients Association (DTPA) coordinated recipients and donors, DTPA pays all transplant expenses, and donors receive payment both from the government and from the recipient. Iran prohibits foreigners from undergoing renal transplantation with an Iranian kidney donor.

Kidney sales in India have become more famous. Throughout the 1980’s, wealthy Arabs visited Bombay to purchase kidneys in backstreet transplant centers. In 1991, India Today published a story on the now-famous Bharati Nagar slum of the Villivakkam locality of Chennai, where on average one person in every family sold a kidney – about 500 people total. Villivakkam has since earned the nickname “Kidneyvakkam.” India outlawed kidney sales in 1995, but kidney sales continue there.

Desperation fills kidney markets with strange stories. One Indian nephrologist received an email from “the first would-be emotionally-related donor.”

I want to become a donor of a kidney if a girl is suitable for me. I shall not take any money to donate a kidney if is [sic] used for a girl who are [sic] between 20 to 25 years old and if she wants to marry me she is more preferable and I shall not take money to donate a kidney to that girl. If the girl does not like to marry me then I shall take money of I donate a kidney. So please let me know or you direct the family member of the girl for whom kidney is required for [sic].

Iranian nephrologists B. Broumand recounts a person who “wanted to sell his kidney” to be able to buy drugs, and asked if he could sell both of his kidneys and start on maintenance dialysis, as dialysis is anyhow was free.” Another husband donor in Bromound’s hospital, “Just discharged from the hospital after donating his kidney, brought his wife to donate her kidney as well because the payment for his kidney was not enough for them to repay their debts.” Although rumors of kidney left often circulate on email and in newspapers, many investigated cases appear to be false.

These statistics and stories show the supply of kidneys – the people who, like Parvi, seek income from selling an organ. But many people, like Dev, demand a kidney for transplant. Every year, 3,000 renal disease patients in the U.S. die while awaiting a kidney for transplant. Transplant waiting lists are growing; today over 40,000 Americans are waiting for a kidney, while in 1993 the waiting list was half that size. The waiting list has grown in part because improvements in transplantation technology allow a single patient to survive through four or more transplanted kidneys. Also, the increasing number of elderly Americans relative to young Americans means that more Americans are at risk of renal failure.

America is not alone. England’s waiting list has grown from 3,800 to 4,900 people over the last ten years. Last year in Germany, 9500 people were waiting for a kidney and 117 people died while waiting. Chugh and Jha estimate that 64,000 Chinese, 4,000 Saudis, and 1,200 Singaporeans are awaiting kidney transplants.
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My impressions : This paper does bring a thought provoking subject if Kidney selling could be consider as a morally acceptable approach to alleviate poverty, starvation and basic needs. Would such a concept not tantamount to exploitation and cruelty ? But if one were to accept such a permise, can Government not involve in monitoring such a exercise than letting unscrupulous elements in the society to take over. Iranian model does go along this line . Today, there is no waiting renal transplant patient in Iran, this is despite having free Hemodialysis program. How did they do it ?? It will be another topic by itself !!!

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