Organ transplantation organisations face perpetual problems of matching supply and demand and some patients opt to purchase organs (mainly kidneys but also livers), which is an illegal practice worldwide with the exception of Iran. Organ transplantation in a foreign country is legal, whereas the purchase of the organ is illicit. The movement of body parts within and across national borders has a long history. For example, in Europe human organs are legally circulated amongst some countries through not-for profit institutions like Eurotransplant and Scandiatransplant but trade for profit within private individuals is illegal. Illegal transplants still occur and they tend to be disguised as altruistic donations. Outsourcing organ transplantation abroad is not normally driven by cost-containment like other transnational healthcare activities (i.e. elective and cosmetic surgery). It is organ availability and regulatory permissibility that drives the demand for organ trade and transplantation abroad. Consumers of healthcare evade local medical legalities in search of transnational ‘permitted or permissible’ health treatments with varied contested moralities like in reproductive technologies (i.e. surrogacy, ova providers) or stem cell therapies.
Purchasing human organs from living seller encounters several moral dilemmas:
- Medical harm. Sellers may not have medical insurance for follow-up treatment; or they may develop chronic or life threatening health conditions as a consequence of the surgery.
- Social harm. Sellers may not be able to do hard manual work during a prolonged period post-transplantation; and worsening of the economic status is a common long-term outcome of trading organs.
- Moral harm. Stigma is a well-document consequence of selling organs; coercion, uninformed consent and exploitation of the poor are also ethical issues to consider.
The invisible issue of organ laundering, published in Transplantation in September 2014, identifies the practice of organ laundering where the illegal purchase of human organs takes on the veneer of a legal transaction once integrated in other healthcare systems. A life supply of immune suppressors, to stop the body from rejecting the new organ is always needed. Most probably, another life supply of medication to reduce the side-effects of the immune suppressors will also be required. Therefore all transplanted organs need to be reintegrated into the health services (public or private) of the organ buyers.
There are certain factors that allow for ‘laundering’ organs in the purchasers’ countries. These are:
1. A reluctance by those who give away their organs to talk, because of fear of prosecution.
2. No agreement between countries about what penalties should be in place for those who buy organs, and little consistency in enforcing laws.
3. The high status of the medical professionals. Some surgeons perform illegal transplants knowing that they will only be caught if they are reported to regulatory bodies by colleagues.
4. The nature of organ trafficking offences means they can span several countries, making tracing organs difficult.
5. Insurers play a part in the proliferation of organ trafficking by paying for follow-up treatment to transplant patients.
How determined the multiple professionals along the healthcare pathways are to understand the true nature of the donor-recipient relationship is a key issue. This can be clearly seen in the first organ trafficking case uncovered in Spain in March 2014. A Lebanese citizen recruited and paid for nine people to have organ compatibility tests in a private clinic in Alicante. These were very specific tests like abdominal and liver CT scans, costing a total of 12,000 €. However, it was the living donor transplant coordinator in a private clinic in Barcelona who rejected the Romanian ‘donor’ having no guarantee of the altruistic relationship between him and the Lebanese recipient.
In this case, all the prospective sellers but one were migrants, all had low economic status. A migrant from Morocco was also the seller in another case uncovered in Spain in May 2015. It seems that he had initially agreed to sell his kidney to a criminal gang but during the process of medical tests, previous to the transplantation, he changed his mind. He was then kidnapped, beaten, and threatened with death to force him to proceed with the sale. Spain is one of the few countries that criminalised buyers and also where clinicians must report the recipient to authorities if follow-up care for an organ purchased abroad is requested. This is now changing since, in March 2015, 14 European nations signed the first ever international treaty to fight human organ trafficking.