The global growth of patients, health professionals as well as medical technology, capital funding, and administrative systems across national borders has given rise to new patterns of production within healthcare services over recent decades.[1] A component of a developing growing trade in health care involves the travel of patients across borders in the search of restorative treatment and wellbeing; a phenomenon commonly termed transplant tourism. According to The World Health Organization (WHO) transplant tourism occurs when patients travel across the borders to be transplanted elsewhere.[2] Patients from a more developed and financially stable tend to travel to more developed nations to get to these health services targeting the vulnerable, that have low employment opportunities making them more prone to corruption facilitating black market practices. As a result of international law’s ongoing failure to address the growing issue of transplant tourism, it is imperative that each country develops its own domestic legal framework for governing organ donations, while at the same time reducing the business of a black market.
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Firstly, the increasing demand for transplant organs on one hand and legal restrictions affecting the organ transplant process, on the other, people reside to developing nations in order to access transplant organs which is done through black market practices. With regards to this, “in Western Europe, approximately 40,000 patients are on waiting lists for kidney transplants; however, it is expected that only about 1 in 4 of these patients will be able to receive the organs that they need.” [3] The demand for organs has continued to grow all over the world due to an increase in the frequency of organ failure. Transplants are a life-saving opportunity for some people yet, access is often limited due to an imbalance of supply and demand. There are not enough organs available to meet the existing needs of patients. With the unreliable, but legal, organ transplant practices that currently exist, there are not enough organs for people who need them for the sole purpose of survival. Many of these individuals also do not have the time to wait for an organ to become available through legal practices. To demonstrate, in “the United States, the number of patients on the waiting list in the year 2006 had risen to over 95,000, while the number of patient deaths was over 6,300.”[4] Some patients whose immediate prospects of getting a transplant are not reachable navigate to other states where they can access organs is the most efficient to these patients who do not have the time to wait and are financially able to undergo these procedures. A transplant tourist from a developed nation bypasses the waiting list and receives an organ based not on need, probable success of transplantation, or other medical factors, but because of the individual’s ability to pay for these procedures. This is problematic both in terms of fairness to others on the waiting list and, on a global level, in terms of justice in the allocation of organs. Moreover, this creates an overall problem of not having enough organs to meet the needs of people that need them to survive. In addition, there is clear evidence that poor organ donors such as the illiterate and impoverished, are enormously underpaid in spite of the market value for their organs. As an illustration, “in Pakistan, many individuals donate kidneys to release themselves from bonded slavery but have insufficient capital to make a new life and often return to debt.” [5] Notably, commercial transplantation is made possible on the grounds that a high percentage of the population in developing nations is falling below the poverty line and many believe that transacting an organ can enormously impact the donors financial situations positively. Poverty is a leading cause for most criminal activities because when people are left with nothing to sell they sell their organs to pay off their debts or for basic necessities even if they are paid less than the actual value of the organ that the seller gets. Similarly, countries that have developed safe transplant services to lessen the dependability on black market practices. However, prolonged delays add to a greater risk for clinical declines, decreased quality of life, and a lot of the time, removal from the transplant list if the patients clinical depiction significantly declines. In a “review of transplant tourism in British Columbia [Canada] showed that ethnic minorities (90%) who traveled to their country of origin for transplantation after waiting a median of 2 years.”[6] This shows that with increased waiting times patients lose hope and are desperate and resort to the next best solution and in this case travelling to another country to obtain an organ would be the solution for some of these individuals. It was acknowledged that “according to the Korean Network for Organ Sharing, 7641 patients were on the waiting list for kidney transplantation by 2008 with only 481 (one in 15) receiving a deceased donor transplant.”[7] The amount of people on the waiting list always outnumbers the people actually donating organs and these patients have no choice and resort to black market practices because they are willing to do whatever it takes to survive. To emphasize, through the international problems contributed through the undetermined black market distributions needs to be addressed and handled in a sufficient way henceforth demolishing illegal practices.
Secondly, it is important to realize that most of the world’s nations have laws implemented nationally as well as domestically that prohibit the buying and selling of human organs because transplant tourism is subjected to the infringement of human rights and morality while undergoing transplant procedures degrading vulnerable donors. The Declaration of Istanbul on Organ Trafficking and Transplant Tourism initiatives are a step in the right direction to prevent exploitation, yet, they are insufficient. This is evident when “the Istanbul participants emphasized that organ trafficking and transplant tourism should be prohibited because they violate the principles of equity, justice, and respect for human dignity.”[8] The Declaration was derived from a direction by the World Health Assembly and was created to protect the vulnerable and poorest from transplant tourism and getting taken advantage of. Clear consequences have also been established regarding the consequences of transplant commercialism, but since transplant commercialism targets impoverished and otherwise susceptible donors, it leads to this declaration to having insufficient meaning to people that continue to undergo illegal practices and go against the declaration for their own purposeful purposes risking the lives of inclined donors. To be effective, “these prohibitions must include bans on all types of advertising (electronic and print), soliciting or brokering for the purpose of transplant commercialism.”[9] In the event that the worldwide population is really serious about ceasing transplant tourism, such action is going to take more than overlooking transplant practices and sharing information about the issue. For whatever time span that the interest for organs overpowers supply, punitive measures will be lacking: transplant tourism will fundamentally go further underground. In addition, to address this urgent and growing problem of transplant tourism and the global shortage of organs, the Declaration of Istanbul on Organ Trafficking and Transplant Tourism was created, however, it still contains legal loopholes motivating the travellers to carry on illegal activities without hesitation. This was demonstrated in the year of “2017 [when] the DICG formed an international working group to draft a new edition of the Declaration, updating the principles in the light of clinical, legal, and social developments in the field throughout the last decade. Since 2008, more than 135 professional societies have formally endorsed the Declaration.”[10]The treaty is not implemented adequately to generate information about the organ transplants taking place and charge every one of the general population engaged in the crime. In this way, it does not alleviate direction to prevent exploitation and transactions of transplants. For the purpose of international health care systems, meeting the needs of patients with applicable educational programs for the public and hospital staff regarding the need and benefits of organ donation need to be reviewed. According to The Declaration of Istanbul on Organ Trafficking and Transplant Tourism, “educational programs are useful in addressing the barriers, misconceptions, and mistrust that currently impede the development of sufficient deceased donor transplantation; successful transplant programs also depend on the existence of the relevant health system infrastructure.”[11] Key components of effective programs include public education and awareness, health professional education and training, and defined responsibilities for all stakeholders internationally. Through sufficient analysis, useful programs can be used to serve their actual purpose rather than be unacknowledged and not thought about. Educational programs are a progressive sector to develop and support changes with increased knowledge of the issue and have continued to fail because there is no infrastructure in place to serve as important sources of information for patients considering transplantation. By failing to provide beneficial data that can be used to gain a greater understanding of illegal and unsafe transplant tourism procedures causes unsafe practices to continue to increase. Furthermore, through implementing and enforcing educational programs there will be a clear limitation of hindrance and interpretations of undergoing a procedure that is unlawful but rather practiced in a safe manner guaranteeing the wellbeing of the recipient and the security of the donor. In summary, although there have been approaches to address issues about transplant tourism they have failed to uphold their purpose continuing the cycle of transplant tourism through illegal markets.
Finally, to address the ongoing issue of transplant tourism, the international transplant community must convey a joint message that organ markets that manipulate the poor and vulnerable is not tolerable, but rather programs must be developed that guarantee donor security. Firstly, the importance of international collaboration and a global consensus is needed to improve donation and transplantation practices. Clare Nullis-Kapp, writing in the Bulletin of the World Health Organization, has claimed that “the illegal trade is based on the coercion of vulnerable Third World donors who are “frequently impoverished and ill-educated”. What is needed is a critical and thorough analysis of the different proposals that have been made particularly with regard to expanding the use of living donors, by providing incentives and/or removing disincentives.”[12] Dr. Biller-Andorno said. Under those circumstances, the lack of adequate laws and enforcement mechanism to regulate the practice calls for countries to step up and aim at the drastic problems that target the impoverished and individuals in poverty. Through collective agreements within states, they can challenge policy tensions to help establish legal and ethical obligations for patients. In addition, each country must have a clear transplantation practice that is accountable to the health authorities and whose authority is derivative from national legislation. The international organ trade has been recognized as a significant health policy issue in the international community. This was demonstrated in “a World Health Assembly resolution [which was] adopted in 2004 (WHA57.18) [it] urged member states to take measures to protect the poorest and vulnerable groups from ‘transplant tourism’ and the sale of tissues and organs.”[13]The Ministry of Health being able to oversight transplant practices is an essential component to improve the global situation of transplant tourism. Without a clear agreement, there tends to be a lack of knowledge in the sense that many individuals do not realize that there are legitimate consequences of transplant tourism that must be addressed in each country and lawfully authorized by national legislation and guided by the World Health Assembly resolution. Lastly, countries in which the buying and selling of organs is illegal must not permit their citizens to travel to destination countries and return for insured health care in their home country. To illustrate, “the Israeli Ministry of Health has recently developed a more practical approach: if it is illegal to undergo transplantation in a foreign country (for example, now in the Philippines), then insurance companies should not condone or provide support for such illegal activity.”[14] Essentially, insurance companies should not support illegal practices as they are doing so in some countries. This is required in order to restrain the global injustice of using a vulnerable division of a country or population as a source of organs. In brief, instead of depending on strict measures, plans to restrain and punish transplant tourism it is more powerful to center around a base up system that handles the main driver of the issue, specifically, the interest for organ transplantation.
In conclusion, transplant tourism is a dire and progressively prevalent response to a worldwide shortage of organs with a continuous lack of international legislation. As attempts have been made to oversee this issue this international imbalance of domestic legal framework, it has been universally unsuccessful and transplant tourism is continued to grow, and alternative options are required. Several alternatives need to be considered and sought in order for nations to drive to national self-sufficiency in transplantation and limiting the intervention of black markets. A pivotal intervention would devise a viable method for changing universally recognized goals, guidelines, and conventions into restricting national laws. Overall, the international states ought new binding mechanisms that uniformly put an end to transplant tourism while simultaneously urging domestic legislation to undertake and demolish black market affairs.
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[1] Neil Lunt, Richard Smith, Mark Exworthy, Stephen T. Green, Daniel Horsfall, Russell Mannion, “Medical Tourism: Treatments, Markets and Health System Implications: A scoping review,” OECD, accessed November 14,2018, https://www.oecd.org/els/health-systems/48723982.pdf
[2] “New Definition of Transplant Tourism,” National Library of Medicine National Institutes of Health, last modified Feb 1 2017, https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5347406/#B4
[3] Greg Knoll, Sandra Cockfield, Tom Blydt-Hansen, Dana Baran, Bryce Kiberd, David Landsberg, David Rush, Edward Cole, “Canadian Society of Transplantation: consensus guidelines on eligibility for kidney transplantation,” National Library of Medicine National Institutes of Health, last modified Nov 8 2005, https://www.ncbi.nlm.nih.gov/pmc/articles/PMC1330435/.
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