Nauseous Nexus between the Organ Industry and the Risks of Illegal Organ Harvesting

Abstract

Organ transplantation saves lives and provides the best alternative for patients at the end-stage of their illness. Interestingly in some jurisdictions, a person who knowingly buys or sell organs for transplantation, could be penalized. However, there continues to be a lucrative global trade and a booming business in human organs as some companies prefer to remain as a private entity rather than undergo increase scrutiny by outside financiers. The common belief is that public health should be made to prevail over private wealth. Therefore, the troubling query is, why some health institutions that conduct organ and tissue transplantation are less transparent, and their work and processes shrouded in secrecy. The vulnerable, voiceless, and marginalized of society are more at risk with illegal organ harvesting activities. Donors’ rights are violated as they benefit little economically, and the lack of donor information could result in serious health and social risks. Law enforcement officers struggle to offer the relevant intelligence for swift action by policy decision -makers. This chapter gives attention to and increase awareness among researchers and community activists that this special gift of organ donation appropriately scheduled should be of a high quality and improve the lives of persons terminally ill.

1. Introduction

It is indisputable that Organ transplantation has saved lives and has provided the best alternative for patients who are at terminal stages of their illnesses and who would have experienced end - stage organ failure. Evidently this phenomenon is a medical miracle and milestone. It is part of the gripping advances in health in this twenty-first century in multi-ethnic societies and in populations with diverse cultures. However, this medical breakthrough abounds with complexities. The wide gap between organ supply and organ demand gives rise to prolong waiting times to receive organs as well as the increasing mortality among several vulnerable persons on waiting lists. This is the main contributing factors to this challenge. Additionally, organ donation remains an extremely sensitive and topical issue in extremely religious societies. In those societies the emphasis continues to be placed more on the body of deceased persons [1]. This is because there is the perception that there are several factors that mitigate a potential donor from consenting to the donation of an organ or tissue for transplantation during life or after death.

According to Ali et al. [2], the issues raised would include the lack of information, misinformation, and disinformation concerning the donation of an organ, suspicion of a healthcare system, the attitudes and views of family members and religious leaders, and a clear ruling and interpretation of the rulings of the clergy. Therefore, with such a mindset, for candidates waiting for transplantation owing to their irreversible medical conditions, the possibility of a delay in waiting time and unequal access of organ donation could be further compromised.

The sources of organs for transplantation include living donor (related and nonrelated), cadaveric donor, and brain-dead patients [3]. It is necessary to further distinguish the four categories: 1) Living Related Organ Donation “blood or emotional” which is a directed donation to a loved one [3, 4]; 2) Altruistic Organ Donation: non-directed donation, in which the donor gives an organ to the general pool to be transplanted into the recipient at the top of the waiting list [3, 4]; 3) Living Non-Related Organ Donation: directed donation to a stranger, whereby donors choose to give to a specific person with whom they have no prior emotional connection [3]; and 4) Cross donation where a living donor wants to donate to his blood or emotional relative an organ but blood groups does not match and there is a complete mismatch or cross matching is positive [3, 4].

According to Saleh [5], the kidneys are the most transplanted organ. The author further stated that in 2011, 11, 835 deceased -donor kidney transplants and 5, 772 living -donor transplants had occurred. [6] also reported that in the year 2021, there was more organ transplants ever in a single year and there was an eight percent increase in kidney transplant. Kidney transplant had moved from 22, 817 in 2020 to 24, 670 in 2021.

World Health Organization (WHO) [7] has reported that noncommunicable diseases (NCDs) is responsible for the deaths of 41 million people annually and 71 percent of the deaths globally. According to WHO [7], each year, 15 million people die from a NCD between the ages of 30 and 69 years, while 85 percent of these “premature” deaths occur in low- and middle-income countries accounting for seventy-seven percent of all NCD deaths. The increase of morbidity and mortality for NCDs has been attributed to the modifiable behaviors including unhealthy diets and a lack of physical activity, leading to severe hypertension and diabetes. According to WHO [8], globally, 422 million people live with diabetes whereas 62 million people in the Americas live with Diabetes Mellitus (DM) type II. WHO [8] further reported that Diabetes accounts for 244,084 deaths annually and in addition, 1.5 million cases of diabetes globally are directly attributed to diabetes each year thus accounting for 45 percent of new cases of chronic kidney disease diagnosed annually. Chen [9] has reported that over the past three decades, diabetes has become one of the most important public health challenges to all nations as the number of people with diabetes mellitus has more than doubled globally. In addition, medical expenditures have been 2.3 times higher than what expenditures would be in the absence of diabetes. According to American Diabetes Association [10], the indirect costs would include an increase in absenteeism ($3.3 billion) and reduced productivity while at work ($26.9 billion) for the employed population, reduced productivity for those not in the labor force ($2.3 billion), inability to work because of disease-related disability ($37.5 billion), and lost productivity due to 277,000 premature deaths attributed to diabetes ($19.9 billion). Cantrovich [11] had reported that shortage of organs could be a social, psychological, ethical, moral, and political problem, causing unjustifiable damage to public health.

2. Trends in illegal harvesting and benefits from the lucrative business

Surgical procedures like transplant of an organ would be morally acceptable with the consent of the donor and without excessive risks for the waiting patient. And that this noble act of organ donation must occur after death, where the real death of the donor must be fully ascertained. Interestingly, in Nigeria, organ trafficking is considered or rather is divided into three categories, namely firstly) the traffickers who would trick the victims into surrendering his organ at no cost; secondly, the “con -artist” who would convince gullible victims into selling their organs but somehow end up not paying them the agreed sum or not at all; and thirdly, this category would include the doctors who would treat patients for ailment that are non -existent and by extension remove the organs without the victims knowledge [12].

According to Cerón et al. [13], organ harvesting occurs to facilitate healthy and viable organs, primarily kidneys, to the wealthier individuals who require a transplant option and are unable to get it through more legal means and which may include the family and close friends. Cerón et al. [13] further reported that organs are usually either be sold or stolen from the “donor” owing to the economic supply and demand of the organ, and later are transferred to the purchaser for transplantation. Kar and Spanjers [14] noted that the illegal organ donation industry would generate $US840 million to 1.7 billion dollars annually. The common organs include kidney $US 8 million, liver $US 3 million, heart $ US700,000, lung $ US 500,000 and the pancreas $US 200, 000. The location of transplantation would have taken place in Asia, including countries like China, Kosovo, and Singapore, in South Africa, and in the United States of America and in Peru, South America. The Author reported that there has been gross disparity between the vendors and the recipients’ fees, as the vendors receive less than 10 percent of the recipient’s payment while the “middlemen” usually receive the lion’s share of the sum.

According to Tao [15], 10 percent of the 63,000 kidneys transplanted worldwide each year from living donors have been bought illegally. Tao [15] further reported that with kidney continuing to top the list of organ illegal trade with at least two hourly and that being 75 percent of the global illegal trade in organs. In 2014, 8000 illegal kidney transplants were performed although the prices varied according to nationality and location [14]. Kar & Spanjers [14] reported that while the price for a kidney transplant had cost $30,000, countries like Israel and Indonesia the cost of a kidney transplant had been $25, 000 and $23, 000 respectively; in Japan the cost was $16, 000, while there was a $4, 000 difference in China (12,000) for the said organ while for a similar organ in Peru was $12,000. According to Sharif et al. [16], the unethical nature of using organs from executed prisoners, due to its limitations on voluntary and informed consent in China has been unanimously stated in literature. Though this practice has been frowned and denounced by international declarations including the Nuremberg Code, the Helsinki Declaration, the Belmont report, Amnesty International, the World Health Organization, the World Medical Association (WMA), and of recent by the Declaration of Istanbul, but incarcerated inmates condemned to death may still not be in the position to make an autonomous and informed consent for organ donation in China [16].

According to Bruckmuller [17], the first official investigated case of illegal organ sale and trafficking was recorded in Bombay, India in 1993, however, the doctor in charge was only captured in 2008. Similarly, in the United States, after ten years, a physician- in -charge was eventually prosecuted for heading an illegal organ transplant ring. The Author further stressed that there have been other cases documented throughout the world owing to a well strategic operations with multiple individuals such as middlemen who constantly move various organ parts within the process of the transaction. In recent times, the Indian authorities claimed to have broken up a ring involving doctors, nurses, paramedics, and hospitals that had performed 500 illegal transplants of organs to rich Indians and foreigners. Most of the donors were poor laborers who were paid up to $2500 for a kidney.

World Health Organization [8] reported that in 2021, the authorities in India had broken up a ring involving doctors, nurses, paramedics, and hospitals that had performed 500 illegal transplants of organs to rich Indians and foreigners. Most of the donors were poor laborers who were paid up to $2500 for a kidney. Some were forced to give up organs at gunpoint. Bruckmuller [17] noted that the shortage of needed organs could lead to the patient’s willingness to pay high sums of money for body parts, especially organs. According to Bruckmuller [17], the Criminal organizations which have occurred in cooperation with staff members of the healthcare sector are very lucrative business with the trade of body parts, especially with the offense on human trafficking for organ (cells and tissue) removal.

3. What are the potential risks of illegal organ trafficking

Bos [18] has reported that the at-risk population namely the organ suppliers and victims can be classified into eight categories. These categories include but are not limited to 1) persons who have come from the less developed countries where the majority of persons are below the poverty line; 2) persons with the status of an immigrant or of a refugee; 3) persons who are very vulnerable; 4) persons who would have lacked knowledge in medical sciences and are unaware of what it means to have the removal of a kidney; 5) the victims are usually uneducated and illiterate; 6) the victims are usually young males within the 18 to 30 age group; 7) persons that could be easily coerced and deceived into obtaining the organ and 8) the victims who usually come from counties of origin where there is either a lack of a proper functioning legislative system that forbids such practice or countries which are unable to prosecute individuals owing to a high level of corruption. According to Bos [18], these victims and donors have been left to care for themselves following the removal of their organs and the final payments have been made. The Author further stated that the local recruiters are usually prevented from lodging complaints to the authorities owing to the lack of knowledge and awareness as to the importance of removing an organ and the punishment that might be available. Apart for the donor’s rights being violated most of the times, there has been limited economic benefits that are seen with the suppliers.

Illegal organ harvesting has been associated with complaints of asthenia, pain and health complications, the deterioration of the victim’s health usually because of inadequate post-operative care, and job loss [18]. Interestingly and frequently, it has been difficult to trace the whereabouts of the organ suppliers. When considering the potential risks of illegal organ trafficking, attention must also be paid to the health risks of the recipients. Bos [18] has noted that there could be serious health and social risks for the persons who are selling the organs as they are unable to give much clarity to the recipients of the commercial transplants. The Author further stated that when a comparison is made between the developed countries like the United States of America, the United Kingdom, Canada, Australia and Turkey and other less developed countries dealing with organ transplantation, there have been better outcomes from the type of transplant received from the developed when compared to the developing countries. There have been less surgical complications, post-operation hernia, infections from the wound or donor derived, less instances of infectious and sexually transmitted diseases, acute myocardial infarction, steroid diabetes, and inferior graft have been reported from recipients from the developed countries [19]. However, when compared to the developing countries, there were less patient survival and lack of data and information relating to donor information. According to UNODC [19], the grave effects of the illegal organ trade have been the increase in children mortality rate worldwide. The giving of impulsive donation by non-compensated donors without written consent and a stated waiting period. The Author further noted that the increasing network of criminality, especially the kidnapping of children and teenagers, who are murdered, and their organs harvested have been striking.

4. Challenges to enforcement

Despite stringent efforts by the European parliament and the United Nations making declaration and resolutions to “fight “against the trafficking of organs and putting rigorous measures in place to punish health care providers who condone and participate in the system of illegal trafficking of organs, the challenge to enforce appropriate laws to stop this illegal practice continues. According to Francis and Francis [20], the International Criminal Court (ICC) is not constructed to address transboundary crimes. However, the need to prosecute the offender and to address illegal organ trafficking is not without serious challenges, especially among states that are big on tourism. According to Adido [21], because of the illegal nature of the activities that are involved in the organ transplant tourism which includes secrecy under which some of the illegal activities are undertaken. With corrupt practices alleged to be occurring among the organ brokers, the enforcement officers, and regulatory bodies are all experiencing formidable challenges to enforcing appropriate laws. Ambagtsheer [22] reported that judges and prosecutors in Kosovo had refused to issue valid orders for a search and arrest on several individuals who were high members of the judiciary and who had refused to testify citing the case that they were off duty and that they were not paid for their duties after hours. However, the Author further noted that local factors such as poverty, corruption, poor regulation, weak enforcement methods, the inadequate local laws and cultural practices all help to mitigate the curtailing of this topical issue.

According to Ambagtsheer [22], the payment for organs should be banned because of the possible unfair treatment of the poor and vulnerable and even those persons who undermine altruistic donation of the organs. It has also been noted that the absence of measures of accountability and the inability of the lawmakers to identify the agencies that would be able to implement such laws could compromise any developing institutional structure and provide legal uncertainty [22]. Cerón et al. [13] reported that the main challenge to the enforcement of laws to illegal organ trafficking would be threat of the lack of resources, ineffectiveness of law enforcement, animosities between communities and the government, organs for donation through confidentiality agreements under the guise of law, and organ seizures from some category of medical practitioners. However, as there remains lucrative incentives for both the purchase and sales of organs in both affluent and impoverished areas of the world, efforts of prevention would be simply prescriptive but lack a regime of enforcement [20].

5. Recommendations

Untiring efforts have been made by countries in the Caribbean, Asia, and in the Metropolitan to stem the tide of illegal organ harvesting. In fact, several principles have been established and advanced from the Asian Task force on Organ Trafficking to the Declaration of Istanbul 2018 to strengthen lack of donation records, the inadequate regulation for donation of deceased donors, and limited human resources with the correct expertise has contributed to the inequitable access to organ transplants and organ trafficking [23]. According to WHO [8], health is not just the absence of disease but that there must be the consideration of the total well-being of the individual: Family physicians and primary care physicians (PCPs) should play a key role in health promotion and in disease prevention.

According to Kao [24], the physicians should be compelled to act in a way that promotes equity and enhances the chances of all persons to live a healthy life especially when considering the social determinants of health. The Author further stated that physicians should guard against the “Pittsburg protocol” of practicing the retrieval of organs for donation from non-heart- beating rather than from brain-dead donors. It behooves the family members to ask about donation before the life support is removed to prevent valuable time being lost, and the organs become unsuitable for transplantation.

The physician can be of great help to the patients by discussing the significance of organ donation. The importance of disseminating such information could benefit the patients in four reasons. Firstly, the PCPs would have an established relationship of trust with patients, being more aware of the patient’s cultural and moral preferences and hence would be able to better tailor information and engage in shared decision making [25], Secondly, according to Thornton et al. [25], the ambulatory setting may be particularly well suited for discussions about organ donation because people under the age of 50, who comprise over a third of deceased organ donors, utilize ambulatory services at disproportionately high rates. Thirdly, PCPs have successfully engaged in difficult conversations about end-of-life care that have increased the number of patients who completed in advance [26]; and fourth and finally, for patients, designating donor status would allow them to preserve their autonomy, give them piece of mind, and permit them to feel confident that they have contributed to their end-of-life care and treatment by documenting and communicating their wishes in case situations arise in which they would be unable to do so ([27]; National Survey of Organ Donation Attitudes and Behaviors. Rockville, MD: [27]).

To decrease the risk of illegal organ harvesting and to bring a halt to this booming and lucrative industry, there must be the combined effort of government and non-government institutions to prevent such crimes, to protect the vulnerable and marginalized donors, and to prosecute the agencies or persons engaged in corrupt practices.

The recommendations for consideration include but not limited to the following suggestions:

6. Prevention

1. To increase the supply of organs donated through media which would guard against exploitation by donors who are willing and able to donate their organ [28].

2. To enhance the donor pool in well-resourced countries to meet their own needs and,

3. To upgrade facilities and standardize medical care [28].

7. Protection

1. To have regulated, standardized, and ethical system for organ procurement [28].

2. To have Presumed Consent Policies on Organ Trade- According to Bamgbose [12], presumed consent policies could curb organ trafficking while simultaneously, increase the numbers of legal organ donations globally, land thus lessening the need for organ tourism.

3. To have an opt-in and an opt -out policy system of organ donation as is seen in countries successfully implemented like Brazil, the United States of America, and several European Nations where an individual may decide to donate his/her organ while still living. In addition, Bamgbose [12], also reported that an opt-out organ donation policy system would be needed as such policy would suggest that organ donation is done after death.

4. To have accountability measures with sanctions attached should be made which will make doctors liable if found associated in illegal organ transplantation.

5. To create awareness in the physicians and the public by ensuring that there is integrity in the pursuit of self-sufficiency [28],

6. To enforce legislation for transplantation- meaning that regulations, legislations, and agencies should be set up and put in place, adequately equipped with appropriate measures and sanctions to quell this disturbance of organ trade which is rising globally at a phenomenal pace Bamgbose [12].

7. To approve systems that will foster accountability, safety in surgical practices, employ vendor registries, provide donors with lifetime care, and include benefits or compensations, especially for volunteer donors as a means of appreciating and encouraging legal organ donation, whilst also reducing black market operations Bamgbose [12].

8. To adopt creative approaches by utilizing technological advancement set up to help expose misconducts and aid whistle blowing. Examples of these methods include: —Tor‖ which is an anonymity network used globally by whistleblowers; Securedrop‖ and —Global Leaks‖ which have been adopted to enhance secure whistle blowing; and Open Board‖ which is another security service used in whistle blowing internationally [12]. Whistle Blowing policy has taken several forms such as Internal, External, Third Party, Private Sector, and Public Sector; however, Internal Whistle Blowing is considered a good type to mitigating corruption and enhancing sustainable development as in Nigeria [12]

8. Prosecution

Another recommendation to assist in the prohibition of the illegal harvesting of Human Organ is to be able to prosecute the culprits. According to Gawronska et al. [29], there are two main conditions rather indications where prosecution should be meted out, namely, 1) if there was no consent to remove the human organ from a living donor and 2) if there were monetary benefits included in the arrangement without violating the principle of ne bis in idem as developed by the European Court of Human Rights (ECHR) and the Court of Justice of the European Union (CJEU).

However, Gawronska et al. [29] further reported that members of the judiciary and law enforcement should receive the proper training. The Author noted that there could be double prosecution of illicit organ removal as organ trafficking and the possibility to prosecute illicit organ removal under the human trafficking and organ trafficking frameworks, hence awareness must be raised of this overlap to avoid double prosecution and punishment. Gawronska et al. [29] noted that there could be a case, though, hypothetically, where the physician to whom a patient is transferred, proceeds to remove an organ in exchange for money. According to Gawronska et al. [29], such a case could involve not only a single act, but a plurality of acts: on the one hand, ‘taking control over the victim’ (which constitutes human trafficking within the meaning of Article 433quinquies, §1, of the Criminal Code) and, on the other, ‘illicit organ removal’ (penalized under Article 433novies/2 of the Criminal Code). Thus, there is therefore the possibility of a criminal court judge ruling that these punishable acts are interrelated through a common intention, objective, and execution and that they should therefore still be regarded as a single act [29].

Finally, to be able to prosecute effectively and to have successful organ trafficking case outcomes, there must be trained medical and forensic experts to assist with such investigation and to establish national reporting codes for identifying and disclosures of trafficking networks [30] Insurance companies must not support illegal practices [31]; a transparency of transplantation practice that is accountable to health authorities should be in place; and proper bilateral agreements should be established to permit the enhanced transfer of organs across countries and to address transboundary crimes [22].

9. Conclusion

In conclusion, this topical issue of Illegal Organ Harvesting continues to leave a destructive medical footprint owing to the exploitation of the poor and vulnerable in the low-income countries with serious health consequences while contributing significantly to the wealthy in the first world metropolitan. According to Zimik [32], because of poverty, ethnic conflicts, unemployment, gender inequality, inadequate legislation and law enforcement have enabled such trafficking of the illegal human organs to thrive. Importantly, the private sector and the financial industry have acted in concert and unknowingly have been a conduit for its facilitation [31]. The growing demand of human organs especially for the kidneys and livers by unscrupulous traffickers and the unhealthy lifestyles of some citizens have contributed to this global shortage of supply. It is the wish that where there are lax laws to encourage and support human organs being transferred via transboundary crossing or going directly to recipients in wealthier countries, be identified and fixed. The training of anti-money laundering professionals and law enforcement agents to detect related financial activity is imperative. In addition, epidemiological data and global transparency should be obtainable and visible to assist the living donors and recipients manage their long-term health, psychological and socio-economic consequences.

With the engagement of the right public-private partnerships, the meticulous international efforts of all stakeholders to identify illegal transplant activities, to investigate and disrupt and prosecute trafficking networks, I am optimistic that this age-old illegal and unlawful practice and booming business could be reduced significantly if not abolished. According to Okere & Emedolu [33], the Immanuel Kant’s End formulation which elucidates that man should not be used to satisfy or serve another end as he would make the former a means to the latter as man’s creative body is already an end this.

Acknowledgments

The Author is grateful to an anonymous reviewer for his assistance for thoughtful comments on an earlier draft of this chapter which helped to improve its quality. I also thank the funders for their monetary contributions toward this project.

Conflict of interest

“The author declares no conflict of interest.”

Acronyms and abbreviations

AMA

American Diabetes Association

CJEU

Court of Justice of the European Union

DM

Diabetes Mellitus

ECHR

European Court of Human Rights

ICC

International Criminal Court

NCDS

Non-communicable diseases

PCP

Primary care physician

UNOC

United Nations on drugs and crime

UNODC

United Nations Office on Drug and Crime

UNOS

United Network for Organ Network

WMA

World Medical Association

WHO

World Health Organization