18.104.22.168 Tourism, transplantation and ethics
Marie-Chantal Fortin, MD, PhD, FRCPC, Nephrologist
- Raise awareness of organ shortages and their repercussions.
- Reflect on the sale of organs and transplant tourism.
- Reflect on whether transplantation is a right or a privilege.
Mr. J.A. is a patient on hemodialysis. He consulted the transplant clinic upon arrival in Montreal after having spent the last month in Pakistan, where he underwent a kidney transplant. Presently, he is not feeling very well. He is running a fever and his blood work shows pronounced leukocytosis.
Mr. J.A. is well known to the transplant team at the hospital centre. He has suffered from end-stage renal disease for a number of years. He received a cadaveric transplant eight years ago. Unfortunately, following numerous rejections and chronic dysfunction of the transplant, he was put back on dialysis three years ago. Recently, having never been called for a transplant and feeling very tired of dialysis, he considered all his options. Doing research on the Web, he found foreign hospitals offering transplantation from paid, living donors. Well aware of the risks of such a venture, Mr. J.A. decided to go for broke. For him, staying on dialysis and waiting here for a transplant meant a slow, painful death, while living-donor transplantation in a developing country, despite the inherent medical risks, represented a return to a normal, healthy life. Moreover, this transplantation seemed to be a win-win situation for all parties: the living donor received a sum of money, enabling him to improve his situation, while Mr. J.A. received an organ.
Throughout the discussion, we will examine the case of renal transplantation. We favour this type of transplantation as the context is not a tragic one, and because there are methods of replacing renal function. Moreover, at the current time, transplant tourism mainly involves renal transplants. While liver transplants do in fact occur in connection with this type of tourism, they nonetheless remain a marginal occurrence.
It is true that transplant tourism is currently not a very common phenomenon. However, it is likely to increase in the next few years in response to the ever-growing demand for organs, rising wait times for transplantation, and increasingly multicultural populations who maintain ties with their countries of origin where this transplant tourism occurs. Therefore, it seems important for future physicians training in nephrology and surgery to study this question.
Moreover, certain comparisons could be drawn between transplant tourism and general medical tourism. Both cases involve patients who are unsatisfied with the necessary wait times for a procedure and who decide to bypass the system by going abroad. True, a person who undergoes orthopaedic or ophthalmic surgery abroad is not compromising the health of a third party, as in the case of transplant tourism. However, both situations raise questions with regard to social justice, and call into question the obligations of the health system to meet the health needs and demands of its citizens.
The benefits of transplants performed in Western countries
Transplantation is the treatment of choice for patients with end-stage renal disease. Transplantation improves both patient survival and quality of life.1 Moreover, time spent in dialysis has deleterious consequences for the survival of the renal transplant and the transplanted patient.2
Moreover, the success rates of renal transplants performed from living donors exceed those performed from deceased ("brain-dead") donors.3
Lastly, in addition to benefiting uremic patients, renal transplantation also benefits society. In fact, the societal burden of treating a transplant patient is less than for a dialysis patient. In 2001, the cost of a renal transplant was estimated at $20,000 for the first year and $6,000 for subsequent years. By comparison, a dialysis patient cost approximately $50,000 per annum.4 A different study, conducted by Canadian researchers in 1996, showed that the costs associated with the first year of transplantation ($66,290) were similar to those associated with dialysis ($66,782). From the second year post-transplantation, this method of replacing renal function seemed to be much less expensive than dialysis ($27,785).5
In Canada and the rest of the Western world, the main problem associated with organ transplantation is the lack of organs. On the one hand, the number of patients waiting for a transplant continues to increase because of an aging population, broadened eligibility criteria for transplantation, major incidences of diseases like hypertension or diabetes and the need to perform a second, third or even fourth transplant following the failure of a transplant. On the other hand, the number of potential donors has remained essentially consistent over the years. At the same time as the gap widens between organ supply and demand, the wait times for an organ have risen constantly. In 2005, the average wait time for a renal transplant in Quebec was 21 months.6 In some areas of Canada, like Toronto, the wait time for a renal transplant can reach up to seven years.7
Certain methods have been implemented in an attempt to compensate for this organ shortage: harvesting from non-heart-beating donors and accepting new living donors, such as living donors who are not genetically or emotionally related. Methods such as assumed consent or organ conscription have also been discussed.
The Canadian legal context
In Quebec, section 25 of the Civil Code prohibits the sale of organs or tissues.8 However, this law does not have any force outside the territory. It only applies if the transaction occurs in Quebec.
In November 2005, the Canadian parliament adopted bill C-49, which amended the Criminal Code. This Act criminalized the trafficking of persons. Included under this designation is any situation where a person is displaced and compelled to provide work, services, organs or tissues. How this law is interpreted and applied in relation to organ trafficking will need to be monitored over the next few years.9
Organ sales worldwide
The legislative frameworks. The laws regulating the sale of organs vary by country. Most Western countries, such as the United States and France, have enacted laws prohibiting the sale of organs or tissue.
Even though some countries have enacted laws prohibiting the sale or purchase of organs, an illicit market persists. This is the situation in India and China, among other countries. Iran is the only country to authorize the sale of organs. Their market is state-controlled, centralized and available exclusively to Iranians. Transplant tourism is therefore not possible.10, 11
Impacts on the sellers. Little data exists in the literature on the fate of the kidney sellers. Contrary to unpaid living donors, there are no cohort studies assessing mortality and morbidity among sellers on a short- or long-term basis. The only available data discusses the impact of selling among Indian, Iranian and Pakistani sellers. The first study conducted with former kidney sellers in India showed that the involvement of an intermediary in the sale was very widespread, that the main reason for selling a kidney was to pay down debts, that sellers received less money than they were promised, that their economic status did not improve at all and, lastly, that 79% of these sellers would never advise a relative to sell a kidney.12 The second study, conducted in Iran with former sellers, once again showed that the main reason for selling a kidney was to pay down debts, that the amount sellers received did not improve their situation, and that 76% of these sellers supported a ban on the sale of organs13. Lastly, Naqvi and his team conducted a study with former kidney sellers in Pakistan. The kidney sellers were young men with limited education. The main reason for selling a kidney was to pay down debts. After the transaction, most of the sellers were not able to successfully repay their debts. They also indicated that their health did not allow them to work as much as before.14 In a second study, the same authors compared the medical conditions of the kidney sellers with those of unpaid living donors. This study revealed that the kidney sellers were more likely to be infected with Hepatitis C, suffer from hypertension, and have a glomerular filtration rate below 60 ml/min after harvest than unpaid kidney donors.15
Impacts on the recipients. In 2006, a Toronto team published a study comparing the results of transplants performed from living donors overseas with those performed in their Toronto hospital. The cohort consisted of 20 patients who had undergone a total of 22 transplantations. Most of these transplants were performed in Asia, and 52% of these patients suffered a serious infectious complication (CMV, tuberculosis or invasive fungal infection). Moreover, the survival rates of both the transplants and the patients were significantly lower than those of patients who underwent transplants in Canada from living donors.16 In 2006, a Minnesota team also published the medical results of their cohort of 10 patients who underwent transplantation overseas. In this cohort, patient and transplant survival were identical to those of patients who underwent transplantation in the United States. However, the team also observed an abnormally-high rate of infectious complication among these patients.17
A physician called to care for the patient described in the above-mentioned case may feel uncomfortable. Indeed, the physician may be troubled by the possible fate of the kidney seller overseas. On the one hand, he might not want to encourage this type of market. On the other hand, he feels torn by his duty to treat the patient before him who is now suffering from the repercussions of his actions. The transplant physician's discomfort may also derive from being well aware that transplantation is not a panacea and from wondering to what lengths we should go to perform transplants. Conversely, the physician understands the suffering of uremic patients awaiting transplantation. The physician might even wonder what he himself might do, including purchasing a kidney overseas, if he or a relative needed a transplant.
In Quebec, the acts and actions of the medical body are regulated by the Code of Ethics of the College of Physicians, which has the force of law. It stipulates that the physician cannot refuse to treat a patient based on discrimination. However, if the physician cannot ensure adequate treatment and follow-up of the patient because of the physician's personal convictions, then he or she must advise the patient of said convictions and help the patient find another physician who could assume care. In an emergency, the physician must treat the patient.18
That said, the physician described in the case above could, if personal convictions oppose the idea of buying organs overseas, advise the patient of these convictions and help the patient find another physician to perform post-transplant follow-up. However, the number of professionals specializing in transplants is small and we must wonder what would happen if all transplant physicians refused to follow up with these patients. Moreover, in the case described, the patient presented with symptoms of infection that could be considered an emergency (fever, pronounced leukocytosis), which would require the physician to treat the patient. When does a situation cease to be urgent? What do we consider an emergency: a CVA? Acute rejection? Septicemia?
To help address these issues, some could attempt to draw an analogy between the treatment of a murderer and the treatment of this patient. A physician cannot refuse to treat a murderer, as that could be considered discrimination. Is the situation the same for a patient who has purchased a kidney overseas? It is hard to tell if these two situations are identical. In the case of the murderer, the physician has no involvement in the act committed. Yet, in the case of the patient who purchased a kidney overseas, the physician might feel that he is participating in a morally reprehensible activity, as the physician cannot care for and ensure the well-being of the organ seller.
As we can see, even though ethics offer some guideposts for addressing these questions, it can also raise numerous other questions that do not currently have answers.
That said, despite all of these questions, the physician must provide care to a patient who has travelled overseas for a transplant. However, in a transplant department where the members hold different positions on this issue, it could be acceptable for those physicians who are most uncomfortable with transplant tourism to refuse to see patients who have voluntarily purchased a kidney overseas, provided that the physicians' colleagues agree to see such patients. However, during on-call hours in the evenings or on weekends, as well as emergencies, a physician could not refuse to see or treat these patients.19 Lastly, we can wonder whether the transplant physician does not have a moral duty to inform all of his patients on the waiting list of the medical, legal and social consequences of purchasing a kidney overseas. Presently, there is no data to demonstrate whether patients purchasing a kidney are aware of the Canadian legal provisions or the health risks that they face.
The clinical case described above brings into play several ethical principles. First, the autonomy of the patient who knowingly decides to go purchase a kidney. Second, the physician's desire to act in the best interests of the patient and the kidney seller. Third, this clinical case appeals to the principle of justice. Transplant tourism essentially involves rich buyers from Western countries and poor sellers from developing countries. Some insist that authorizing the sale of organs enables people in need to obtain money to help overcome the alienation of poverty.20 However, current studies on the subject do not support this claim. 12, 13 Lastly, this clinical case also highlights the principle of dignity of the human body, according to which it cannot be subject to trade nor reified. This principle is present throughout the Quebec and Canadian context of transplantation, which holds altruism and free access as fundamental values.
There is no simple answer to this complex question. The situation described in our fictitious scenario affects not only the transplant physician faced with a similar situation, but all citizens. Specifically, this case raises questions about whether transplantation is a right or a privilege, and to what lengths we can go to find organs. These questions cannot be answered solely by physicians; rather, they must be debated on a larger scale and engage all parties involved (politicians, patients, hospital administrators, etc.). The answers that result will guide choices in matters involving transplantation and health.
How do you react toward this patient?
Do you feel uncomfortable in light of the situation described?
What are your obligations toward this patient?
What do Quebec and Canadian law specify about the sale of organs and medical tourism?
Is transplantation a right or a privilege?
- Wolfe RA, Asby VB, Milford EL, Ojo AO, Ettenger RE, Agodoa LYC, et al. Comparison of mortality in all patients on dialysis, patients on dialysis awaiting transplantation, and recipients of a first cadaveric transplant. New England Journal of Medicine. 1999; 341 (23): 1725�30 (02 Dec 1999).
- Okechukwu CN, Lopes AA, Stack AG, Feng S, Wolfe RA, Port FK. Impact of years of dialysis therapy on mortality risks and the characteristics of longer term dialysis survivors. American Journal of Kidney Disease. 2002; 39 (3): 533�8.
- Terasaki PI, Cecka JM, Gjertson DW, Takemoto S. High survival rates of kidney transplants from spousal and living unrelated donors. New England Journal of Medicine [Original articles]. 1995; 333 (6): 333�6 (10 Aug 1995).
- Sant� Canada. Le don d'organes au Canada. 2001. Accessible at http://www.hc-sc.gc.ca/ahc-asc/media/advisories-avis/2001/index_f.html.
- Laupacis A, Keown P, Pus N, Krueger H, Ferguson B, Wong C, et al. A study of the quality of life and cost-utility of renal transplantation. Kidney International. 1996; 50(1): 235�42.
- Qu�bec-Transplant. Missions de Qu�bec-Transplant. 2006. Accessible at http://www.transplantquebec.ca/en.
- Trillium Gift of Life. Kidney waiting list and transplantation. 2006.
- Code civil du Qu�bec. 1991.
- An Act to amend the Criminal Code (trafficking of persons), Parliament of Canada. 2005.
- Ghods AJ. Renal transplantation in Iran. Nephrology, Dialysis and Transplantation. 2002; 17 (2): 222�8.
- Ghods AJ. Without legalized living unrelated donor renal transplantation many patients die or suffer - Is it ethical? In Ethical, legal, and social issues in organ transplantation edited by Gutmann T, Daar A, Sells R, Land W. Lengerich: Pabst. 2004; 337�41.
- Goyal M, Metha RL, Schneiderman LJ, Sehgal AR. Economic and health consequences of selling a kidney in India. Journal of the American Medical Association. 2002; 288 (13): 1589�93 (02 Oct 2002).
- Zargooshi J. Iranian kidney donors: motivations and relations with recipient. JouRnal of Urology. 2001; 165 (2): 386�92.
- Naqvi SAA, Ali B, Mazhar F, Zafar MN, Rizvi SAH. A Socioeconimic Survey of Kidney Vendors in Pakistan. Transplant International. 2007; 20: 934�9.
- Naqvi SAA, Rizvi SAH, Zafar MN, Ahmed E, Mehmood K, Awan MJ, et al. Health status and renal function evaluation of kidney vendors: a report from Pakistan. American Journal of Transplantation. 2008; 8.
- Prasad RGV, Shukla A, Huang M, D'A Honey J, Zaltzman JS. Outcomes of commercial renal transplantation: a Canadian experience. Transplantation. 2006; 82 (9): 1130�5.
- Canales MT, Kasiske BL, Rosenberg ME. Transplant tourism: outcomes of United States residents who undergo kidney transplantation overseas. Transplantation. 2006; 82 (12): 1658�61.
- Code de d�ontologie des m�decins. 2001.
- Fortin M-C, Roigt D, Doucet H. What should we do with patients who buy a kidney overseas? The Journal of Clinical Ethics. 2007; 18 (1): 23�34.
- Radcliffe-Richards J, Daar AS, Guttmann RD, Hoffenberg R, Kennedy I, Lock M, et al. The case for allowing kidney sales. Lancet. 1998; 351: 1950�2 (27 June 1998).