With a population of more than 1.3 billion people and a carrier rate of chronic hepatitis B estimated to be somewhere between 20%-30%, complications from liver disease are one of the leading causes of death in the People's Republic of China (PRC). In this issue of Liver Transplantation, Professor Jie-fu Huang, Vice-Minister of Health of the PRC, provides an informative and detailed description of the history and current status of liver transplantation in the PRC. From an inauspicious start in 1978, the early experiences in the PRC mirrored that of the early efforts in Europe and North America; however, liver transplantation activities have evolved such that the unofficial tally now numbers in excess of 3500 liver transplants in 2005. There are 10 well-established transplant centers that perform more than 100 cases annually and at least 200 more centers that have an interest in or have performed this procedure. With recent improvements in outcomes, the 1-year and 5-year post–liver transplantation patient survival in these experienced centers are 85% and 70%, respectively, and the demand for liver transplantation is increasing. However, unlike their Asian counterparts who have relied on living donor liver transplantation in the development of liver transplantation, deceased donors account for more than 95% of allografts for liver transplantation in the PRC.
The remarkable achievements in liver transplantation in the PRC are tainted by 2 practices, which have been harshly criticized by the international transplant community: the commercialization of liver transplantation that has benefited wealthy patients from the PRC and from abroad, and the use of executed prisoners as a source of deceased donor organs. Professor Huang acknowledges these “growing pains” and the presence of questionable practices that have appeared along with the explosive growth of organ transplantation in China. At a national forum convened by the Ministry of Health on November 13, 2006, in Guangzhou, he also describes the steps that China is taking to bring this important health care activity up to the standards that prevail in Europe, the United States, and the rest of Asia. These efforts include implementation of brain death criteria, outlawing transplant tourism, and providing more government oversight. He acknowledged that the majority of deceased donors are from executed prisoners. However the claim that “only prisoners who are subject to capital punishment in the PRC are convicted criminals”, the reported judicial reforms in capital punishment, and the opaque consent process fall short in convincing the international community of the legitimacy of liver transplantation in the PRC. These shortcomings will continue to marginalize Chinese liver transplantation centers in the transplant community until this practice ends
Nevertheless, the Editors of Liver Transplantation applaud the admission of the internal problems that face liver transplant programs in the PRC. Although the process of liver transplantation in the PRC is not transparent to the degree of standards in Europe and North America, the creation of a national registry, implementation of the laws which are outlined in this document, and continued discourse within the international community will certainly help evolve their practices toward international norms. Unlike the situation within the PRC, the bulk of transplantation outside the PRC is seen in other countries accused of transplant tourism involving paid living donors and which falls outside sponsored government oversight. The effect of international condemnation of paid living donor transplantation and subsequent outlawing of such practices in countries such as India, Philippines, Pakistan, South Africa, and elsewhere have driven these activities underground, where governmental agencies cannot or will not enforce such laws. In this murky world of human trade, shoddy donor procurement, swindling of donors and recipients, and substandard surgical and posttransplant care are the norm; outcomes cannot be collected and the impact on donor safety is unknown. This situation should be avoided in the PRC. The possibility for further growth in the future dictate that the international community has a role in helping to influence the potentially largest transplant arena in the world.
The Editors remain optimistic that liver transplantation in the PRC will continue its progress and will soon adopt some, if not all, of the ethical principles that are recognized by the international community. Application of brain death criteria has already taken hold, and the expansion of living donor liver transplantation has been seen at a number of centers in the PRC. These principles that reflect the distillation of years of experiences and learning from objectionable practices that at times have also occurred in the world's collective transplant history. However, several international and professional organizations, including the AASLD and ILTS, have taken positions against exploitation of donors and are opposed to the recovery of organs from executed prisoners or paid living donors. In light of these concerns, the Editors and Associate Editors of Liver Transplantation have decided that original publications dealing with clinical liver transplantation outcomes submitted to this journal should explicitly exclude the use of executed prisoners or paid donors as a source of donor organs. The Editorial Team will adjudicate all manuscripts on the basis of scientific and ethical merits.