Illegal Organ Trafficking
Every day 18 people die waiting to receive an organ transplant in the United States (1).
For patients lucky enough to receive a kidney transplant, the average cost for the first 90 days
of care can be upwards of $100,000. In the long run however, this is still cheaper than the
$80,000 a year it costs to be on dialysis (2). Since the beginning of transplant surgery the
demand for kidneys worldwide has been rising at an alarming rate. At the same time the
number of donors has remained stagnant in comparison (3). This discrepancy has created a
huge demand for kidneys. 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). As a result, sidestepping the legal process and turning to the underground organ
trade is often the only option to survive.
History of Organ Transplants
The illegal organ trade has its roots in the world of legal transplants. The first successful
kidney transplant on a human was performed in Boston between two identical twins at the
Peter Bent Brigham Hospital in 1954 and subsequently led to the awarding of a Nobel Prize in
medicine (4). Since then transplants have been performed with a steadily increasing success
rate and with organs that previously would not have been suitable for transplantation. The
largest advances have come with deceased donors. The most recent study in 2011 by the Organ
Procurement and Transplantation Network indicates success rates in 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 have been passed to allow for these transplants to occur.
In 1968 the Uniform Anatomical Gift Act allowed for the donation of organs 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). Up until this time transplant
surgeries were exceedingly rare due to the resources needed and risks involved. As these
transplants became more commonplace and demand for organs increased, a system was
needed to organize the organ transplant network and eliminate the organ trade that was
starting to spring up. This set the stage for the National Organ Transplant Act of 1984 (NOTA).
Spearheaded by Al Gore, this act established the Task Force on Organ Transplantation and the
Organ Procurement and Transplantation Network in order to make more organs available from
deceased individuals and coordinate the donation process on a nationwide level (7). It also
specified how organ, bone marrow, and blood donors could and could not be compensated for
their donations. At the time this act was passed a new drug called Cyclosporine A had come on
the market which drastically deceased organ rejections by acting as a powerful
immunosuppressant (4). This drug was one of the main reasons the number of organ
transplants doubled between 1988 and 2006. This drastic growth coupled with little regulation
proved to be an appealing investment opportunity, and the market for legal organ sales started
to take shape. However the questionable ethics of this caused great concern among the
medical community. Along with the issues of bribery and corruption, the main concern was that
an 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 how long they have been waiting (8).
Desperate Times Call for Desperate Measures
What this legislation failed to foresee however was that like many commodities that are
made illegal, the market would be driven 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. However for people without
insurance years of expensive dialysis along with the costs of a legal transplant can make the
proposition financially beneficial. This combined with an average time on the waitlist of 3-5
years and in some cases upwards of 10, makes bypassing the waitlist and circumventing years
of grueling and costly dialysis an understandable (albeit unethical) choice. 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 of this is that around the world there is a
growing need for transplant organs, and desperate people are enabling the illegal organ trade
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. This is especially a problem in
the third-world countries where many of these donors are recruited from. The limited access to
expensive antibiotics there results in many donors developing 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). All of these factors have caused the
waitlist for kidneys to increase 6 fold between 1988 and 2006, to over 100,000 people today,
while the number of donors has seen only a relatively marginal increase (4).
The Illegal Trade Worldwide
While the United States is often regarded as the most advanced and organized country
with regards to the legal transplant market, countries around the world face their own
problems with rising organ demand. Aside from the few developed countries with active organ
transplant systems, the majority of the world faces major challenges when people develop
renal failure. Although waitlist for organs in the U.S is overflowing with applicants, it is still one
of the most progressive in the world. Many poor countries do not have a waitlist, so people
searching for transplants resort to a largely unpoliced black market since travelling abroad is
costly and difficult. Increased international pressure from the human rights community has led
to most countries banning the organ trade. However while most governments condemn this
market on paper, most 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). In
the past one of the main providers of illegal kidneys to foreigners looking for organs was China,
where even though selling organs for profit is illegal, laws allowed government officials to
harvest and resell the organs of executed prisoners. With the vast majority of organs coming
from these prisoners, often before they died, and little effort to get healthy people to donate,
this practice was heavily opposed by the international community. Critics also pointed to the
fact that this system gave an incentive to officials to execute prisoners in order to harvest their
organs. This was reinforced by the numerous families of executed prisoners who claim they
were coerced into signing donor agreement forms or that there was never consent given at all.
In 2007, amidst external pressure from the human rights community, China passed the Human
Transplantation Act, banning this practice and standardizing the organ collection process.
Health officials in China still fail to acknowledge the ethical problems this practice had however,
saying that the reason that it was discontinued was because the organs of prisoners were often
diseased or infected. In addition, it was only in 2011 that China changed its laws to specifically
ban the forced removal of organs. While these laws show that China is improving its practices, it
also indicates that the black market is still thriving in a country that is often very secretive about
these transplants (13, 14).
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 are all countries which have seen increases in organ trafficking. The mecca of
this practice in Europe is thought to be Moldova, a small eastern European country which
became notorious as a hub for the illegal kidney trade. Here 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. Living in a poor country with a high unemployment rate, many of
these people are struggling to survive. The organ brokers entice these impoverished people by
offering them between a few hundred and a few thousand dollars to donate their kidney (9).
This combined with their assurance that it is a safe procedure that will save someone’s life is
often enough to get many of these desperate people to agree in order to feed their families. In
reality most of these people are not aware of the actual risks involved. There are numerous
consequences and complications to kidney donation that often lead to health problems later in
life, especially in countries that do not have the medical resources to deal with any
complications that may arise. In fact people who have donated a kidney on the black market
are at a much higher risk for kidney failure later in life. This leads to an even higher demand for
kidneys compounding the problem further. 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 or be stuck with no money in a foreign country (15). For those that decline the offer for
work and do not want to voluntarily donate, walking away may still not be an option. 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 the statistics of this, it is thought
that large portions of the people who donate are coerced into doing so (9).
Both voluntary and coerced donors are then taken to Turkey. Here doctors and
hospitals are paid off to either assist with the transplantation or turn a blind eye to it. The
doctors themselves justify these surgeries not just by the large paycheck they receive, but by
claiming that that they are doing it for patients who would die otherwise and ignoring the
corruption and extortion that occurs. Recipients of these kidneys are usually wealthy Europeans
or Americans who find the brokers online or through middle men. The surgery itself is
performed in an unsanitary environment and rushed to avoid detection. There is usually very
little testing that takes place to ensure that the kidney and donor are healthy and the recipient
runs the risk of getting HIV or hepatitis from a diseased kidney or unsterilized medical
equipment. In addition, paying off nurses and assistants is costly and corners are often cut to
maximize profit. This inevitably leads to increased risks of complications, especially when the
donor is often transported back home just hours after the surgery. While the recipient may pay
up to $200,000, the donor gets pennies in comparison as most of the money goes into the
pockets of the broker, doctor, and middle men. Popular culture and movies like Touristas has
portrayed these organ harvesting rings as stealing organs from kidnaped foreigners. In reality
this is exceedingly rare as most of the time it is easier to find poor people to donate or extort.
However, these groups have been known to participate in human trafficking of poor
populations for the sole purpose of harvesting organs (4, 9).
Finding a Solution
While coercing the poor to sell their organs is illegal in most of these developing
countries, it usually goes unpunished since crime rings often have a strong hand in local
governments. In addition, due to the global nature of the market, investigating these groups is
exceedingly difficult without international cooperation. Unfortunately there has been very little
regulation of these practices on an international level, and crime syndicates can simply move
from country to country to avoid detection. In the past decade however there have been
encouraging calls for action on the international level. 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. From this
conference the Declaration of Istanbul was produced which condemned “victimizing the
world’s poor as the source of organs for the rich” and sought to “preserve the nobility of organ
donation” by combatting the threat to “the legacy of transplantation… by the organ trafficking
and transplant tourism” (16). Calling on countries to act, it suggested a ban on advertising for
illegal organ donors and called for legal repercussions for the brokers and solicitors of the organ
trade worldwide. It also addressed the fact that the organ marketplace naturally exploits the
world’s poor for the benefit of the rich and suggested measures that governments should take
to protect these people. Regarding the legal transplant market, it acknowledged the growing
demand for organs and called for countries to encourage organ donation in order to become
nationally self-sufficient with regards to transplantation. Developing countries were
encouraged to establish organ donor registries and countries with long waitlists for organs were
advised to create incentives for organ donation before and after death. Based on these
recommendations over 100 countries have reformed their legislation on organ trafficking.
However the empty rhetoric of the document was often little more than suggestion. There is
much room for more progress to be made as international organizations start to take up and
enforce laws regarding the black market (17).
One of these bodies was a 2009 joint UN and Council of Europe task force created to
develop a comprehensive examination of organ trafficking since its origins. As a result of this
study they 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. It also points out 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 deceased donation would collaterally strike a blow to the
illegal organ trade. A special emphasis was put on the value of deceased donation due to the
lack of complication risk that living donors hold. This study lead to numerous resolutions,
notably the introduction of criminal penalties against complicit doctors, the effects of which are
still seen in how the EU and UN fight organ trafficking (4).
In the U.S. the main problem regarding the organ trade involves “transplant tourism,” in
which the wealthy travel abroad, typically to poor countries where trafficking is rampant, in
order to receive a transplant. While this practice is acknowledged as a major problem, many
people do not realize that it is possible to receive an illegal organ within the U.S. Although
American hospitals are seen as highly reputable institutions that screen donors well for
potential fraud, there have been numerous accusations of illegal operations taking place
domestically. One of the main people to call attention to these crimes has been Nancy Scheper-
Hughes, a UC Berkeley anthropologist who has been a vocal opponent of the illegal organ trade
for decades. Hughes’s investigations led to the exposure of an international ring of organ sellers
led by Isaac Rosenbaum. An Israeli citizen living in Brooklyn, N.Y, Rosenbaum’s case made
headlines in 2011 when he 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 traffickers in the U.S. and Israel, a growing nexus of the organ trade,
recruited Israeli sellers and brought them to the U.S. Here Rosenbaum used his connections in
prestigious hospitals including Mount Sinai, John Hopkins, and Albert Einstein to bypass the
screening process that organs usually go through and pay off doctors and administrators to
perform the surgeries (9, 18).
With convictions like Rosenbaum’s becoming increasingly common, there have been
numerous propositions to fix the problem. Many have pushed for greater support for social
altruism. Volunteer Firefighters receive numerous benefits for helping their community, but
organ donors take on the medical risks to save someone’s life without any help or reward.
Some have argued 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.
Without delving too far into the philosophy of natural rights, 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). While I
acknowledge the logic behind this argument, I believe it is too simplistic and idealistic a view. I
also take issue with the idea that people can be viewed as just a collection of parts to be sold.
Furthermore, as seen in Iran, regulating the organ trade would lead to corruption and
exploitation. The poor would inevitably end up being the sellers and the rich the buyers. There
is precedent for this in the U.S in blood transfusions. In the early days of transfusions hospitals
bought blood from people regularly. However 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. Compensation for blood plasma is
still a common practice, and there have been increasing reports of corruption in this area as
well. Some investigations have reported that donation centers misrepresent the risks of plasma
donation (20). 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.
Although a free market on organs has a number of drawbacks, it does not mean that
organ donation should remain a purely altruistic endeavor. When Al Gore spearheaded the
NOTA he intended to test out if voluntary donation would be viable. If it was not, “a voucher
system or a tax credit to a donor’s estate” may need to 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.
A great examination of this systems effectiveness is in looking at Germany and Austria, two
countries with very similar cultures and medical systems, but the former with an opt-out
system and the later with an opt-in system. Studies have shown that in these countries and
others, an opt-out system 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 something needs
to be done. As the waitlist continues to grow and black market brokers both domestic and
abroad 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 die each year waiting for
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