• ethics

For decades The People’s Republic of China has been expanding its capacity to perform organ transplants, primarily kidneys and livers but also hearts, lungs and multiorgan transplants. The annual number of organ transplants performed is estimated to be over 30 000. The number is expected to grow with a projected market for immunosuppressants expected to be over ¥30 billion/$4.3 billion by 2024.1

China is second only to the USA and is expected to become the country with the largest number of organ transplants by 2021 or 2022. Many transplants are performed on Chinese citizens but an active market in transplants for ‘tourists’ is ongoing.2

The source of the supply of organs to fuel this rapid growth has long been suspect.3 China had no system for obtaining organs for many years from cadaver sources making it impossible to credit claims that gifts from the newly dead were the sole or even majority source of transplantable organs. Critics, including myself, have long alleged that the only possible source of organs for both Chinese citizens and transplant tourists are executed prisoners. Many accounts, commissions and investigations have confirmed an immoral reliance on this vulnerable population.3–6

The Chinese government, in response to a steady stream of complaints, denunciations and boycotts announced the suspension of using the organs of executed condemned prisoners for organ transplantation in 2015. Organ donation from either those consenting before death or family members after death became, according to Chinese law, the only legal source of supply.7

Despite efforts by some in the transplant community and the pharmaceutical industry, which supplies necessary immunosuppression, drugs and equipment to the enormous and profitable Chinese market, to accept the avowed ban on the use of prisoners, the reliance on vulnerable prisoners still is ongoing. This is obvious from the poor performance to date of cadaver organ procurement among the general population, the reluctance of many families to serve as cadaver organ donors due to cultural and religious concerns on the part of many Chinese citizens and ever-increasing numbers of transplants performed. While there may be less reliance on executed prisoners post the 2015 legislation than was true in years past, it is impossible that this source of organs has been completely abandoned.8 9

The procurement situation is further complicated by the fact that Chinese authorities insist that when prisoners do donate organs they do so voluntarily and without coercion. The fact is that some minorities are treated as prisoners solely due to their ethnicity or religion or both. For example, an August 2018 United Nations human rights panel stated that it had received many credible reports that one million ethnic Uyghurs in China are being held in ‘re-education camps’. And many followers of the spiritual movement Falun Gong have, since 1999, been subject to arrest and imprisonment. This mistreatment of innocent persons as prisoners makes it likely that ‘prisoners’ may have been used as ‘donors’ when their consent to organ donation is dubious and their status as prisoners who are facing execution constitutes a basic violation of human rights.8 9 More generally it is unclear whether any prisoner sentenced to death, particularly to supply the lucrative transplant tourism market, which requires timed executions, can be said to be a volunteer providing freely chosen consent.10

Given the ongoing abuse of prisoners for obtaining their parts the question continues to face the biomedical community as to whether data describing transplant outcomes, immune regimens, the management of high-risk recipients, the use of anti-infective agents, and many other practices associated with transplantation ought be accepted for presentation at conferences, meetings or symposia or published in any scientific or medical journal, textbook or anthology. On 1 October 2011, I and four other prominent transplant physicians argued in a highly cited paper in The Lancet that the answer to these questions ought to be a resounding ‘no’.11

We insisted that,

The time has come to bring normal scientific and medical interchange with China concerning transplantation to a halt. We call for a boycott on accepting papers at meetings, publishing papers in journals, and cooperating on research related to transplantation unless it can be verified that the organ source is not an executed prisoner.11

I see no reason to change that boycott today.

The publication of information about transplantation from a nation with great experience and sophistication on the subject undoubtedly brings benefits to both patients and practitioners. But, without being able to certify the moral soundness of organ sources for which data are being generated based on transplants, possibly the result of deliberate murder, the moral price of acquiring that data is complicity with a barbaric practice that ought not be accepted by the biomedical community or, for that matter, industry who may sponsor or assist in the creation of transplant data.12 13

The only way to establish the provenance of organs used in transplants about which data are being recorded is to insist on full transparency in the consent of subjects with written and video evidence, the attestation of proper consent from non-coerced people by researchers responsible for certifying that this is true and the openness of transplant centres to visits and audits by independent experts to affirm that decades of abuse have been corrected. To do otherwise is to ignore basic protections for those involved as subjects in the creation of data for dissemination and citation as well as to tolerate and perhaps even encourage the continuation of practices in procuring organs that are morally illicit, repugnant and heinous.9 12 13