A Desperate Economy:
Illegal Organ Trafficking

Charlie Zachariades

The medical community worried an unregulated market would make the rich the only ones who could afford organs. NOTA responded and banned human organ sales, and as with many commodities made illegal, the market went underground and abroad.


Every day in the United States, 18 people die while waiting to receive an organ transplant (1). Kidneys demonstrate the desperation and economics of this situation, for as the demand for kidneys has risen, the number of donors has remained stagnant in comparison (3). With over 100,000 patients on the waiting list in the United States each year, 70% of which are looking for a kidney, many have to wait years to receive a transplant (4). Additionally, costs are altogether prohibitive. The average cost for the first 90 days of care can be upwards of $100,000, but this is still cheaper in the long run than the $80,000 a year it costs to be on dialysis (2). In a life-or-death situation, sidestepping the legal process and turning to the underground organ trade is often the only option to survive.

History of Organ Transplants

The first successful kidney transplant on a human was performed in 1954 between two identical twins at Boston's Peter Bent Brigham Hospital, an operation which subsequently received the Nobel Prize in medicine (4). Since then, transplants have been performed with increasing success rates and with organs that previously would not have been suitable for transplantation, as with deceased donor organs. The Organ Procurement and Transplantation Network’s most recent study indicates success rates for deceased-donor kidney recipients of 94% for one year survival and 82% for five year survival. This is drastically higher than the success rates of less than 50% that transplant surgeries had in their infancy. Among living-donor transplants the prognosis is even more promising with 98% of patients living at least one year and 90% living at least five years after their surgeries (5).

Numerous pieces of legislation allow for these transplants to occur. In 1968 the Uniform Anatomical Gift Act allowed for organ donation after one’s death. The law has since been revised numerous times, first to conform to other laws which outlawed the trade of organs, and most recently in 2007 to make it easier to become a donor by simply checking a box at the DMV when getting your driver’s license (6). Previous to this legislative change, transplant surgeries were exceedingly rare due to the resources needed and risks involved. Yet as these transplants became more commonplace and demand for organs increased, a system was needed to organize the organ transplant network and eliminate the corresponding increases in illegal organ trade. Spearheaded by Al Gore, The National Organ Transplant Act of 1984 (NOTA) established the Task Force on Organ Transplantation and the Organ Procurement and Transplantation Network to increase organ availability from deceased individuals and to coordinate the donation process on a nationwide level (7). NOTA also specified how organ, bone marrow, and blood donors could and could not be compensated for their donations.

However, a new drug called Cyclosporine A came on the market the same time this act was passed. Cyclosporine A drastically decreases organ rejections by acting as a powerful immunosuppressant, and the increased assurance in transplant success that it provides was one of the most significant catalysts for doubling the number of organ transplants between 1988 and 2006 (4). This drastic growth in transplant success and availability, coupled with little regulation, proved to be an appealing investment opportunity, and the market for legal organ sales started to take shape.

At this time, the medical community, along with voicing ethical concerns about legally selling organs, worried that a relatively unregulated market would result in the rich being the only ones who could afford organs (3). NOTA answered these issues by banning the sale of human organs and making it illegal to compensate donors in other ways. Transplants must instead rely on donated organs and recipients are selected from a waitlist, the order of which is determined by a number of factors, including relative need, age, transplant prognosis, and length of time on the waitlist (8).

Desperate Times Call for Desperate Measures

As with many commodities that are made illegal, the market went underground and abroad. A 2005 World Health Organization study estimated that 1 in 10 kidneys are sold illegally. These kidneys can cost up to $200,000 out of pocket, double what a legal transplant can cost, yet for people without insurance, years of expensive dialysis plus the costs of a legal transplant can make a $200,000 kidney look like a decent financial decision. Additionally, an illegal kidney exchange bypasses the average 3-5 years on the waitlist (in some cases upwards of 10 years). Many even see it as the only option to avoid being one of the roughly 5,000 Americans who die each year waiting for a suitable kidney (9). The unfortunate result is that around the world, there is a growing need for transplant organs, and desperate people are enabling the illegal organ trade to thrive.

The primary cause of this increased demand and consequential black market growth is twofold. Better anti-rejection medications have the unintended consequence of increasing illegal transplants. By decreasing the risk of rejection and recovery time, organ transplants are easier to perform, aren’t as risky, and allow for more doctors to take on the risks of an illegal transplant. Furthermore, these medications enable people to donate to recipients who in the past would have been incompatible. This not only allows more patients to be on the waitlist, driving up demand, but also makes it easier for black market brokers to find suitable donors. However, since these drugs inhibit the entire immune system, they also leave patients much more vulnerable to complications and infections after surgery. Especially in the third-world countries where many of these donors are recruited from, limited access to antibiotics causes many donors to develop health complications (9).

The second reason for the increase in demand is the dramatically increased rates of obesity and diabetes, both of which are closely tied to renal failure. Between 1980 and 2011 the number of Americans diagnosed with diabetes has more than tripled (from 5.6 million to 20.9 million) (10). In addition, life expectancy has increased over the years. This has led not only to more elderly people with failing kidneys, but also to more young recipients needing another kidney later in life. This is because transplant kidneys usually only last for around 25 years if they come from living donors and 15 years from deceased donors (4, 11). Thus the kidney waitlist increased 6-fold between 1988 and 2006 to over 100,000 people (4).

The Illegal Trade Worldwide

Aside from the few developed countries with active organ transplant systems, the majority of the world has developed a robust black market to respond to organ need. Increased international pressure from the human rights community has led to most countries technically banning the organ trade, but most governments do little to actively combat it. Currently Iran is the only country where it is legal to sell organs, but even there it is restricted to Iranian citizens and highly corrupt (12).

China was historically one of the main providers of illegal kidneys for foreigners. Even though selling organs for profit is illegal, laws allowed government officials to harvest and resell the organs of executed prisoners. International backlash became significant, as China’s practices involved organ harvesting before prisoners actually died and insignificant efforts to elicit donations from healthy persons. The system gave an incentive to execute prisoners in order to harvest their organs, and numerous families of executed prisoners claimed they were coerced into signing donor agreement forms. In 2007, China passed the Human Transplantation Act, banning this practice and standardizing the organ collection process, and in 2011, China changed its laws to specifically ban the forced removal of organs.

With the increased regulations in China, brokers for illegal organs moved to other developing countries with little to no enforcement of transplant laws. Brazil, Pakistan, India, Israel, and Turkey have all seen increases in organ trafficking, and Moldova, a small eastern European country, became particularly notorious as a hub for the illegal kidney trade. There, the black market is a thriving enterprise run by organized crime which takes advantage of the Moldovan citizens’ willingness to sell one of their kidneys. The organ brokers entice the impoverished, offering them a few hundred to a few thousand dollars to donate their kidney (9). Most of these people are not made aware of the actual risks involved, including the fact that people who have donated a kidney on the black market are at a much higher risk for kidney failure later in life. In addition to voluntary donation, men are often tricked into donating by brokers who offer them work in Istanbul. With the high unemployment rate, many people accept this offer, only to be told once there that that they must donate a kidney (15). For those that decline the offer for work and do not want to voluntarily donate, walking away is not simple. Brokers will come back numerous times trying to recruit people and will often turn to intimidation and threats to get people to donate. Although little is known about these statistics, it is thought that large portions of the Maldovans who donate are coerced into doing so (9).

Finding a Solution

In 2008, the Transplantation Society and the International Society for Nephrology held the first International Summit on Transplant Tourism and Organ Trafficking in Turkey. The landmark conference involved organizations from over 70 countries to specifically address the commercialism of the organ trade and the exploitation of poor populations for the purpose of harvesting organs for sale. In result, the conference produced the Declaration of Istanbul, which condemns “victimizing the world’s poor as the source of organs for the rich” and seeks to “preserve the nobility of organ donation” by combating the threat to “the legacy of transplantation…by the organ trafficking and transplant tourism” (16). The Declaration also suggested a ban on advertising for illegal organ donors, called for legal repercussions for illegal organ trade brokers and solicitors, asked developing countries to establish organ donor registries, and asked countries with long waitlists for organs to create incentives for organ donation.

Based on these recommendations over 100 countries have reformed their legislation on organ trafficking, but there is still much room for more progress. Currently, the strongest action has developed out of international organizations (17). The 2009 joint UN and Council of Europe task force created a comprehensive examination of organ trafficking since its origins and called for the creation of new laws to combat the black market. In particular they suggested numerous changes to the organization of government bodies in order to resolve discrepancies between pieces of legislature. This would increase the efficiency of the international community by standardizing practices.  The task force also discovered that tackling the organ trade head on may not be the best approach. Instead, addressing the demand for more donors through efforts to incentivize living and deceased donation would collaterally strike a blow to the illegal organ trade (4).

In the U.S. the main problem regarding the organ trade is “transplant tourism,” in which the wealthy travel abroad, typically to poor countries where trafficking is rampant, in order to receive a transplant. But there have also been numerous accusations of illegal operations taking place domestically. In 2011, Nancy Scheper-Hughes, a UC Berkeley anthropologist, was the first to investigate and expose of an international ring of organ sellers led by Isaac Rosenbaum. An Israeli citizen living in Brooklyn, N.Y, Rosenbaum became the first person convicted of brokering an organ transplant in the U.S under the aforementioned National Organ Transplant Act. For over a decade, Rosenbaum’s network of organ traffickers in the U.S. and Israel recruited Israeli sellers and brought them to the U.S. Rosenbaum used his connections in prestigious hospitals including Mount Sinai, John Hopkins, and Albert Einstein to bypass the typical organ screening process and pay off doctors to perform the surgeries (9, 18).

Following further convictions like Rosenbaum’s, many have pushed for a regulated organ trade like that of Iran. Proponents of this idea believe that commercializing the organ market will not only instantly eliminate the black market for organs, but will also drive the price of organs down and nearly eliminate the waiting list. One of the primary arguments of this view is that as an autonomous being you own your organs, and it should therefore be your human right to do with them what your want as long as it does not harm others (19). The primary issue is that as seen in Iran, regulating the organ trade would lead to corruption and exploitation, where the poor would inevitably end up being the sellers and the rich the buyers. And there is precedent for this in the U.S in blood transfusions. In the early days of transfusions, hospitals bought blood from people regularly, but with increased demand the government turned to a population eager to give blood in exchange for money, prisoners. Coercion and corruption was soon rampant as donors would often lie about diseases they had in order to donate while officials accepted tainted supplies to increase sales. While purchased blood is still technically legal today, hospitals almost exclusively use donated blood. Additionally, organ donation has many more complications than giving blood or plasma. A legal organ trade would incentivize the downplaying of these risks and cause people to donate when they are not healthy enough to live on one kidney, exchanging one person’s medical problems for another’s.

However, there are possibilities for other incentives. When Al Gore spearheaded NOTA he suggested “a voucher system or a tax credit to a donor’s estate” could be instituted if “efforts to improve voluntary donation are unsuccessful” (18). This could be instituted with deceased donors similar to how a life insurance policy works, providing a major incentive to donate with much less risk of corruption. Another policy that has recently been gaining ground due to its success in Europe is a change from the opt-in structure the U.S. has today to an opt-out one. In this system the health care providers relinquish the burden of recruiting donors and gives implied consent to harvest organs. If individuals do not consent they simply go through the process to opt-out of donating. Studies have shown that an opt-out system, as in Germany, has led to an increase in organ donation by as much as 30% (3).

In addition to policy changes, advances in medical technology seek to bypass the donor process altogether. Although still experimental, xenotransplantation is a promising practice that may eliminate the need for donors entirely. By transplanting organs obtained from another animal or grown ex vivo through the implantation of human genes into animal tissue via stem cells, petri dish organs can be grown for everyone in need of an organ (21).

However we address the problem of organ transplants, it is clear that there is an urgent need. As the waitlist continues to grow and black market brokers thrive, experts agree that the best way to combat the illegal organ trade is to fix the legal system regulating it. Cooperation from the international community along with incentives for social altruism, tax breaks, opt-out systems, xenotransplantation, or a combination therein seem to provide the best hope to save the thousands of people who will die each year waiting for an organ.

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