[MUSIC] When faced with needing an organ transplant, patients do not only explore legal avenues but sometimes illegal ones. Organ trafficking is a very real concern. It may feel remote, but it does happen. Although primarily a problem with living, unrelated kidney donation, the negative effects tarnish our entire profession and all of transplantation. How real is the problem? It was estimated by the WHO that up to 10% of all transplants in the world in 2006 were as a result of organ trafficking or transplant tourism. South Africa was unfortunately a site for such activity for a period of time from 2000 to 2003, before it was stopped and our systems improved to prevent it from happening again. What occurred was that renal transplants were arranged between reportedly related donors and recipients. This was not the case, the donor and recipient were not related and there was money changing hands. Now some may argue that both parties had consented to their operation and understood the risk. And that with informed consent it is ethically permissible to proceed. This is not the case. There were obviously attempts to deceive the systems in place, and by adding money into the process with people profiting along the way, there was undoubtedly exploitation of the weak and vulnerable. This is something we must actively guard against by ensuring the correct systems and practices are in place. Living donors must consent freely, be screened properly, and have long-term follow up and support for complications related to the donor operation. To offer anything less than that is automatically exploitation, and meets the definition of organ trafficking. Deceased organ donation can also be abused. If organs are not allocated transparently and fairly, then a national resource is being misused. If the Dead Donor Rule and informed consent principles are respected, then organ donations must not take place. In 2004, the World Health Organization called on member states to take measures to protect the poorest and most vulnerable groups from transplant tourism and the sale of tissues and organs. The Declaration of Istanbul, formulated by the Transplantation Society and the International Society of Nephrology in 2008, was published to help countries do just that. It has been endorsed by over 100 countries and 150 professional associations, and has led to law changes in China, the Philippines, Israel, and Pakistan. Ultimately, the document boils stand to the fact that all countries need a legal and professional framework to govern organ donation and transplantation activities. As well as a transparent regulatory oversight system that ensures donor and recipient's safety and the enforcement of standards and prohibitions on unethical practices. Countries must take active measures to put in place legislation that will support ethical transplantation practices and equitable allocation. The declaration goes on to state that in order to eliminate organ trafficking, interventions need to be on multiple levels, and it provides a framework for countries on how to achieve this. Firstly, it states that national governments should develop comprehensive programs for screening, prevention, and treatment of organ failure. Secondly, that each country should have legislation to govern the recovery of organs from both deceased and living donors consistent with international standards. There should be a national registry of deceased and living donors and oversight and accountability by health authorities is required to ensure transparency and safety. Finally, that organs must be allocated within countries to suitable recipients without regard to gender, ethnicity, religion, social, or financial status. One of the countries to change their laws after the Declaration of Istanbul was China. China had a law enabling executed prisoners to be used as a source of donated organs from 1984 until January 2015. The law stated that the bodies of executed prisoners could be used for transplantation if the body was uncollected or is donated by the prisoner or their family. This unconscionable practice has officially been stopped due to widespread international pressure. The condemnation of such a practice is absolute. Prisoners are vulnerable persons, and the ethical concerns are insurmountable. In consultation with international professional bodies, China has given up this practice, changing the law to outlaw organ procurement from executed prisoners and putting in place a voluntary deceased organ donation program. If you read on the internet about transplantation in China, it is difficult to verify that executed prisoners are not still being used. There are many contradictory reports based on very limited evidence. One of the major reasons that are ongoing concerns about China is that there is limited transparency of their transplant system by Western standards. It is important that all transplant systems make information available in order to show that the system is accountable. Recipients of trafficked organs have worse outcomes compared to regulated transplants. The chance of being transplanted an organ with a pre-existing malignancy or infection is much higher, because donor workup is often inadequate. We know this because patients return to their home country after traveling for their operation, no longer needing an organ transplant, but requiring ongoing immunosuppression. There is a concerted effort by countries to stamp out such practices. Some countries have made traveling abroad for an unsanctioned transplant illegal with financial penalties and prison sentences for recipients. Other countries have directed their focus towards the prosecution of brokers and ethically corrupt transplant teams. It is a reality that organ trafficking is driven by the need outstripping the supply and by gross inequalities in wealth. If all countries had organ transplantation services which might fair access to and good oversight of transplantation, then organ trafficking will become far less pervasive. Improving deceased donation helps to achieve this, and this is mentioned specifically in the Declaration of Istanbul. The therapeutic potential of deceased organ donation should be maximized. Efforts to initiate or enhance deceased donor transplantation are essential to minimize the burden on living donors. Education programs are useful in addressing the barriers, misconceptions, and mistrust that currently impede the development of sufficient deceased donor transplantation and successful transplant infrastructure. To recap, organ trafficking does take place. It is driven by a demand for organs that outstrips supply and by major wealth inequality. Measures have been put in place to stamp out this practice across the world. These include legislative changes to facilitate aggressive prosecution of guilty parties, improving deceased donation and access to transplantation across the world is an effective way to decrease the demand for trafficked organs. [MUSIC]
