Medical tourism has become a burgeoning industry (1,2). An estimated 500 000 Americans traveled abroad for treatment in 2005. In 2006, the medical tourism industry grossed about $60 billion worldwide, with the total expected to rise to $100 billion by 2012.
Transplant tourism is unlike other, more benign, forms of medical tourism (3,4). Replacing a hip or a knee, repairing a dysfunctional heart or enhancing one's appearance through cosmetic surgery, have little in common with transplanting an organ, particularly when the donor is unrelated and is recruited under questionable, if not objectionable, circumstances.
The worldwide shortage of donor organs has created global commercial opportunities in the international organ trade which, in turn, has become a significant, albeit controversial, international health care policy issue (5–9). It has prompted many countries to reevaluate the legal framework under which they have regulated, or more often, failed to regulate, organ transplant-related practices (10–12).
Many transplant professional associations have already, or are in the process of developing position statements concerning the commercialization of transplantation, including transplant tourism (13). This issue was first addressed by The Transplantation Society in 1985 (14). However, at that time, the full extent of economic globalization had not yet been realized. Today, in a diverse global economy, there are, in my opinion, many reasons why we should be cautious in declaring a position on international matters related to transplantation.
In considering the merits of my reflections, I offer as a broader frame of reference the following quotation attributed to Rudolph Virchow (15):
Medicine is a social science and politics is nothing else but medicine on a large scale. Medicine as a social science, as the science of human beings, has the obligation to point out problems and to attempt their theoretical solution; the politician, the practical anthropologist, must find the means for their actual solution.
As Virchow suggests, complex issues in medicine cannot be addressed in abstraction from the socio-political, cultural, religious, legal and ethical gestalt within which they have gestated.
The scope and economics of the commercial organ trade
According to the World Health Organization (WHO), 93 000 kidney, liver and heart transplants were performed globally in 2005 (12). As shown in Table 1, the majority of these procedures was performed outside the US (16).
|Type of transplant procedure||Total number of transplants performed worldwide||Location of transplants||US as a percentage of the total number of transplants|
|US only||All other countries|
|Kidney||66, 000||16, 500||49, 500||25%|
|Liver||21, 000||6400||14, 600||30%|
|Totals||93, 000||25, 000||68, 000||27%|
Shimazono reports that around 5% of all recipients in 2005 underwent commercial organ transplants (12).
The economics of transplant tourism, like that for medical tourism more generally, is as intriguing as it is appealing (1,2,10,11). The average billed charges for various organ transplants in the US are summarized in Table 2 (17). As shown, actual institutional accounting costs are much lower, with Medicare reimbursing transplant centers an amount that is insufficient to cover their costs (18). Private payer reimbursement is generally more favorable, permitting transplant centers to cover Medicare-incurred losses.
|Type of transplant procedure||Billed charges (in US dollars)||Accounting cost (in US dollars)||Medicare reimbursement (in US dollars)|
|Kidney||131, 400||73, 500||39, 800|
|Liver||268, 800||133, 100||82, 400|
|Pancreas only||186, 500||102, 200||50, 800|
|Kidney-pancreas||208, 900||106, 800||67, 700|
|Heart||349, 800||131, 800||115, 200|
|Single lung only||198, 500||96, 300||56, 700|
|Double lung only||364, 800||176, 500||105, 300|
|Heart-lung||503, 900||217, 200||159, 300|
Table 3 summarizes various estimates for all-inclusive ‘transplant packages’ in selected countries where commercial transplantation has been allowed (19). These figures are not directly comparable to those in Table 2, since the ‘transplant package’ often includes travel-related expenses for the recipient, payment for the donor organ, agent or broker fees, as well as reimbursement for all hospital and physician services. While US patients have typically paid out-of-pocket for transplant services received overseas, there are published reports by credible sources that health insurers in some countries have reimbursed patients for commercially provided organ transplants (10).
|Kidney transplant||Liver transplant|
|Country||Price (in US dollars)||Country||Price (in US dollars)|
|Pakistan||15, 000 to 40, 000||Egypt||25, 000|
|Iraq||20, 000||Pakistan||25, 000|
|Russia||25, 000||China||60, 000 to 130, 000|
|Philippines||35, 000 to 85, 000||Colombia||100, 000|
|China||65, 000||Philippines||100, 000|
|Colombia||80, 000||Singapore||290, 000|
|South Africa||120, 000||South Africa||290, 000|
|Turkey||145, 000||South Korea||290, 000|
|Pancreas transplant||Lung transplant|
|Country||Price (in US dollars)||Country||Price (in US dollars)|
|China||110, 000||China||150,000 to 170, 000|
|Singapore||140, 000||Singapore||290, 000|
|South Africa||140, 000||South Africa||290, 000|
|South Korea||140, 000||South Korea||290, 000|
|Taiwan||140, 000||Taiwan||290, 000|
|Country||Price (in US dollars)|
|China||130, 000 to 160, 000|
|South Africa||290, 000|
|South Korea||290, 000|
The concept and consequences of transplant tourism
The concept of transplant tourism is confusing. According to Shimazono, transplant tourism refers to ‘overseas transplantation in which a patient obtains an organ through the organ trade or other means that contravenes the regulatory framework of their countries of origin’ (12).
Transplant tourism involves not only the purchase and sales of organs, but also other elements relating to the commercialization of organ transplantation (12). Shimazono notes that intermediaries, including agents and health care providers, often arrange the travel and recruit donors.
The organ trade may take other forms as well. For example, Shimazono reports that live donors have been brought from the Republic of Moldova to the United States or from Nepal to India (12). In other cases, both recipients and donors from different countries move to a third country.
There is evidence that the medical practices surrounding commercial organ transplantation are sub-standard (12,21,22). Medical complications are common, as is the transmission of infectious diseases, including HIV and hepatitis B and C (12).
A last issue surrounding commercial organ transplantation and transplant tourism concerns the future of paid organ donors (25–27). In this regard, the routine follow-up of paid organ donors is essentially nonexistent, but the evidence suggests that there is little lasting economic benefit for the donor (26,27). Based on self-report, many donors are unable to work due to poor health, and they often experience depression, regret and discrimination (25).
Based on many of the foregoing issues and experiences, several countries, including China, India and Pakistan, have independently taken steps to curtail commercial organ transplantation (10–12,27). Appropriate laws have been passed, and enforcement has ensued.
Unfortunately, despite these favorable actions to deal with objectionable circumstances, there is cause for concern. Transplantation has moved from the realm of clinical practice to international affairs, encompassing foreign relations and, ultimately, diplomacy. It is these collateral issues that I would now like to address. My rationale is straightforward: in a global economy, we must be cautious in imposing our beliefs and values on others, given our unique cultural and socio-political circumstances (28,29). While acculturation is possible, it is best achieved by offering guidance and encouragement, not by dictating culturally insensitive conditions of participation (30,31). The process of social change is evolutionary and, as history has shown, divisive and often violent. Too frequently, in the realm of foreign relations, ethnocentrism has been an issue (32–34).
Reflections on position statements concerning transplant tourism
International policies concerning the commercial aspects of transplantation are a concern, increasingly reflected in position statements issued by professional associations. For many reasons, I have trouble accepting what are, more often than not, relatively superficial assessments of an exceedingly complex issue. From a multi-cultural perspective, their content, tone and intent are often questionable.
Let me explain why we, as individuals, should be hesitant to take a definitive position on transplant tourism specifically, and commercialization more generally.
First, language and concepts are critical to our understanding. Unfortunately, based on negative associations, the concept of transplant tourism has become emotionally charged. For example, ‘organ brokers’, ‘agents’ and ‘organ trafficking’ are frequently mentioned in the same breath as transplant tourism, even though it has long been an established practice (35,36). Such language narrows the debate, and biases the process of argumentation (37).
Transplant tourism, which, for the remainder of this discussion is defined as receiving an organ transplant in a foreign country, is legal in countries as diverse as the US, the UK, India, China, Thailand and the Philippines (38,39). In other words, foreign nationals, or nonresident aliens, are transplanted, in some cases with restrictions. In the US, the United Network for Organ Sharing (UNOS) has established what is functionally equivalent to a quota system (38). Tourists are expected to pay for their transplants, with the donor organ billed to whoever is the responsible party.
Second, more often than not, the primary issues to which position statements on transplant tourism are directed concern the source and circumstances surrounding the procurement of donor organs. Thus, most of the statements I have reviewed are conceptually flawed. They essentially confuse the donor organ acquisition process with the receipt of a transplant surgical procedure in a foreign country. For example, if, for economic reasons, a US citizen chose to have a living-related donor kidney transplant in China, it would be no more objectionable than having it performed in the UK, Canada or Australia.
Third, the situation in China directly and indirectly raises myriad questions about the role of capital punishment, religion, informed consent, financial incentives and valuable considerations in relationship to organ donation. In the US, both the ethical justification and the legal basis for capital punishment remain open to debate (40,41), where it is legally sanctioned in 37 of 50 states. Meanwhile, it has been abolished in the European Union, Australia, New Zealand and Canada (41). In general, the use of executed prisoners as a source of donor organs has been challenged, and found repulsive in the West (42,43). The actual circumstances in China, however, may be misunderstood.
Although reports are mixed and uncertain, Chinese prisoners are apparently informed about organ donation prior to their execution and consent can be given or denied. Duress and coercion are clearly cause for concern but, according to knowledgeable persons, in the Buddhist tradition, consent may actually make amends for wrongdoing through reincarnation and, in all cases, compensation is permissible, with the prisoner's family being eligible for multiple benefits, including no-cost health insurance, complimentary education up to high school for all children and/or subsidized housing (for more on Buddhism see reference 44).
It is noteworthy that no religion is legally practiced or recognized by the government in China. Nonetheless, Buddhist precepts and the belief in reincarnation are critical considerations (44). It is believed that human beings, like all other living creatures, live not just one life, but come back into this world again and again in a continuous process of life and death. According to the law of karma, good actions bring a good rebirth in a future life, and bad actions bring a bad rebirth (44). Rebirth can generally take place in one of six realms: as a god, demigod, human being, ghost, animal or spirit in hell. Thus, when facing execution, a person who has already committed a bad action may consent for organ donation—a good action—in hopes of achieving a better life through rebirth.
Clearly, Buddhism can be a great challenge to people who have grown up in the Western world and think that religion has to do with the worship of a single, almighty God (44). Some people think that Buddhism is so different from all we know as religion in the Western world that it should be called a philosophy of life rather than a religion (44). Buddhist religious precepts, including reincarnation, have obviously been neglected in the development of position statements concerning transplantation in China.
Fourth, virtually all of the position statements I have reviewed, as the foregoing comments imply, are unapologetically ethnocentric (28,32–34). Anthropologists and sociologists alike define ethnocentrism as follows: the tendency to look at the world primarily from the perspective of one's own culture. Ethnocentrism often entails the belief that one's own race, ethnic group or nationality is the most important and/or that some or all aspects of its culture are superior to those of other groups. As a result, individuals often judge other groups in relation to their own particular ethnic group, culture or nationality; especially with regard to language, behavior, customs, ethics and religion (33).
The association between ethics and ethnocentrism in relationship to transplant position statements is cause for concern. The problem is familiar. For example, when it comes to research ethics, the Declaration of Helsinki has been an extremely influential document (45–47). However, revisions to the Declaration of Helsinki have underscored the difficulties associated with the promulgation of ethical standards, the prospects of universal ethics and the problem of ‘ethical imperialism’ (46,48). Since 1996, a division has emerged between developed and developing countries concerning the Declaration of Helsinki, with overt claims of American ethical imperialism, accompanied by criticism that ethical standards ‘reflect the American context in which they have been formulated’ (46).
Fifth, in evaluating position statements and similar documents, we need to be cognizant of the relationships among religion, science, politics, ethics, law and international health care policy. Increasingly, position statements are issued with a religious fervor, and a missionary zeal. In reality, different religions have varying perspectives on the same ‘ethical’ issues.
This leads me to offer what is surely a controversial proposal. The authors of position statements should be obligated to declare any major sources of bias, which may have more to do with their religion than their science. By analogy, we routinely have to disclose industry relationships in presenting our research. In issuing position statements based on political-religious-ethical precepts, the authors should be required to do similarly. Atheists and agnostics are encouraged to do likewise.
Sixth, transplant position statements essentially qualify as foreign policy and eventually serve as the basis for international relations and a means to promote social change. In many respects, they represent well-intended attempts on behalf of the transplant community to be diplomatic. Unfortunately, in this regard, the West is increasingly finding it fashionable to impose itself on the East with paternalistic and often self-serving policies (49). In other words, consistent with ethnocentrism, it is felt the East should conform with the West, which, in turn, has become increasingly intolerant, overtly imperialistic and unacceptably antagonistic.
There are clearly socio-political matters at stake, including the interplay among communism, freedom and democracy, and these must not be ignored. In this regard, the Falun Gong has assumed a major role in criticizing transplant policies and practices in China (50,51). Many Westerners are sympathetic, as is apparent from the favorable reception of recent reports by Matas and Gilmour (52,53). Unfortunately, there is more to this picture than meets the eye.
The Falan Gong, formerly Falun Dafa, is essentially a social movement religiously aligned with Buddhism intent on political change in China (50,51). According to a recent Wall Street Journal report, ‘Falun Gong follows in a long tradition of sects in China that have challenged the state. Falun Gong started in 1992 as a spiritual movement intended partly to improve practitioners’ health. While a government crackdown has largely contained Falun Gong in China, the group has flourished overseas, driven by well-educated practitioners who volunteer time, money and technological expertise to push their cause, to what some experts describe as a near-fanatical degree' (51).
The Falun Gong has seized upon commercial transplantation in China as one of many means to advance a political agenda. For Westerners, the pursuit of freedom and democracy, and the quest for human rights, rings a familiar and sympathetic socio-political cord. However, in the tradition of Virchow, from both a clinical and a health policy perspective, the transplant community should have reservations in joining the band (15).
Seventh, I have concerns about what might be called a ‘social desirability’ bias in relationship to position statements concerning the commercialization of transplantation (54,55). There is every reason to believe that the majority of position statements is the product of like minds, meaning there is little tolerance for dissenting opinion, even when differences exist. Based on conversations I have had with transplant colleagues from abroad, it is clear that some, while supporting the commercialization of transplantation, are reluctant to voice their opinions out of fear that they will be ostracized by the transplant community for coming out in favor of policies the American majority appears to reject. Thus, the tendency is for them to express a position consistent with the majority, or to not state their position at all (hence, a social desirability bias).
Eighth, in a diverse world rife with conflict, I find it increasingly difficult to establish what truly qualifies as ‘ethics’ in relationship to transplant policy. It seems as if everyone has become an ‘armchair ethicist’, which is to say that anyone can qualify as an ethicist in much the same way that, based on a person's ability to converse, anyone can qualify as a behavioral scientist (56). In reality, so-called card carrying ethicists learn their craft in one of two ways: they are usually trained in religious studies or, alternatively, secular philosophy. Thus, if credentials are a consideration, much of what is passed off as biomedical ethics in medical and scientific journals is suspect, including transplant policy position statements concerning the commercialization of transplantation.
Lastly, to put this all in context, I suggest that we look no further than the war in Iraq, where a gallant effort is being made to implement social change, with what appears to be a growing appreciation of cultural differences. By analogy, I would argue that transplant position statements have similar objectives with respect to social change, and are similarly shackled with many of the same problems.
Depending upon the conditions of what I will refer to as ‘socio-political readiness’, significant social change can take decades, if not centuries. In the case of Iraq, it was assumed that democracy would serve as the salve to heal a nation's wounds. However, Iraq is clearly a country struggling with tribal differences. While the Iraqis may eventually come to terms with freedom, it is clear they were culturally unprepared to adopt democracy as a political means to what many world leaders felt was a better end.
Surprisingly, even as a mature democracy, when advancing its political agenda to the far reaches of the world, the US often fails to reflect on its own historical experience. The Revolutionary War (1775–1783) was instrumental in establishing what became the framework for a democratic society. The Civil War (1861–1865) questioned the integrity of that framework, as well as our commitment to the basic principles underlying democracy. Slavery, and the exploitation it entailed, was ultimately responsible for more than 600 000 deaths. Clearly, as American history has revealed, even a democratic society can occasionally question its commitment to its foundation, including freedom, human rights and respect for human dignity, with the ultimate price reflected in the senseless loss of human lives.
Slavery and exploitation are terms often used to describe organ donors who are the alleged victims in commercial transplantation (12). As noted above, transplant position statements are effectively implements of social change. Realistically, despite their laudable intent and noble purpose, the full and lasting impact of transplant position statements will not be fully felt for years, if not decades. And, as has been the case in Iraq, cultural sensitivity, free of ethnocentrism, can produce favorable results, with diplomatic integrity (57). In this regard, anthropologists are increasingly being deployed as a nonmilitary option in Iraq, as well as Afghanistan (58). Clearly, the lessons of war should not be confined to the military.
In conclusion, for all of the foregoing reasons, I find it difficult to personally endorse any international transplant policy position statement that prematurely dictates the terms of participation for what has become a global transplant community. Additionally, I would advise international professional associations to avoid impulsively weighing in on ethical issues with socio-political and cultural consequences, which, based on the current stage of political readiness for social change, I consider to be personal and individual matters. I remain open to discussion, and the free exchange of ideas, but I must draw a firm line between signing on and listening in. I find the fundamental inter-relationships among science, religion, politics, ethics, law and international health care policy to be minefield deserving of impartial diplomatic efforts and unprejudiced foreign relations. Unfortunately, in the end, given the current level of myopia, and the attendant predispositions toward cultural superiority, I believe the underlying metaphysics will prove difficult, if not impossible, to negotiate. In other words, in the absence of a universal code of ethics, and within the context of cultural and ethical relativity, what's wrong is often no more obvious than what's right (28,29,31–34).