The Use of Executed Prisoners as a Source of Organ Transplants in China Must Stop

Abstract

Internationally accepted ethical standards are unequivocal in their prohibition of the use of organs recovered from executed prisoners: yet this practice continues in China despite indications that Ministry of Health officials intend to end this abhorrent practice. Recently published articles on this topic emphasize the medical complications that result from liver transplantation from executed ‘donors’ but scant attention is given to the source of the organs, raising concern that the transplant community may be coming inured to unacceptable practice. Strategies to influence positive change in organ donation practice in China by the international transplant community are discussed. They include an absolutist policy whereby no clinical data from China is deemed acceptable until unacceptable donation practices end, and an incremental policy whereby clinical data is carefully evaluated for acceptability. The relative advantages and drawbacks of these strategies are discussed together with some practical suggestions for response available to individuals and the transplant community.

Abbreviations:

PRC

People's Republic of China

DCD

donation after cardiac death

The practice of obtaining organs for transplantation from executed prisoners is an unacceptable abrogation of human rights as made unequivocally clear for decades by established and internationally respected declarations and pronouncements including the Nuremberg code (http://ohsr.od.nih.gov/guidelines/nuremberg.html); the Helsinki Declaration (1); the Belmont report (http://ohsr.od.nih.gov/guidelines/belmont.html) and the International Conference on Harmonization of Clinical Practice (2). Yet this practice continues to this day in the People's Republic of China (PRC).

In this regard two related articles in the August 2010 issue of the American Journal of Transplantation deserve our attention. Allam et al. (3) report on the complications suffered by patients returning to Saudi Arabia and Egypt after liver transplantation in China. The authors comment that ‘the main growing concern with this choice (i.e. travel to China for liver transplantation) is the uncertainty regarding the outcome’. In an accompanying editorial, also concerned mainly with recipient complications (4), only passing reference is made to the actual source of the organs: executed prisoners who had suffered ‘severe brain injury in all cases’ followed by ‘donation after cardiac death (DCD)’ (3). Reference is made to the China Liver Transplant Registry (http://www.cltr.org.en), which reports 18 375 recipients in period between January 1993 and July 2010 (further details are password protected). The figure of greater than 18 000 was also reported by a representative of the Chinese Ministry of Health at the August 2010 meeting of The Transplantation Society in Vancouver where details of the working of the registry were presented in a invited lecture. Though concerns regarding the medical complications of such transplants are certainly appropriate, we are distressed and outraged by the fact that, despite uniform and consistent international condemnation, those euphemistically described as ‘donating’ their organs and dutifully recorded in a national registry were prisoners, whose ‘severe brain injury’ was most likely a result of execution by a gun‐shot to the head.

Representatives of the government of the PRC have officially and publicly acknowledged that since the 1980s executed prisoners have been the main source of organs and tissues in Chinese transplant programs (5). Recent changes in Chinese regulations prohibit transplant tourism and have added the ethically dubious requirement that consent for organ donation be obtained from prisoners prior to execution (6), but do not prohibit the practice. In recent years condemnations of the practice have also come from professional societies (7), human rights organizations (http://www.amnesty.ch.en) and the Declaration of Istanbul (8). The Chinese Medical Society itself, in agreement with the World Medical Association, has stated that the practice must cease (http://www.medicalnewstoday.com/articles/84754.php). Despite this, at the recent biennial meeting of The Transplantation Society in Vancouver over 30 abstracts were submitted, with data from several hundreds of transplants, where the donor source was likely executed prisoners (Paul Keown, personal communication). To their credit, some Chinese Ministry of Health officials have indicated their intention to end the practice (5) and pilot projects with the use of brain dead donors and conventional DCD donors are underway but currently contribute only 1% of the total donor pool (4). A national organ donation system has been launched in conjunction with the Chinese Red Cross, but when asked how long it would take for the system to cover the entire country, a senior official is reported to have responded, ‘the process took 20 years in the United States’ (http://www.chinadaily.com.cn/china/2009‐‐08/26/content_8616938.htm).

Is there more that can be done by the international community or are we helpless in the face of what John Fung appropriately describes as an ‘awakening sleeping giant’ (4)? Specific guidelines addressing interactions with China have been developed (9) yet appear to have had little impact. We are faced with a difficult dilemma: how do we support those Chinese transplant professionals who want to see their country develop organ transplant practice according to international standards, while continuing our efforts to end ‘donation by execution’. Arguments can be made for different approaches: an absolutist approach requires that the Chinese government must bring the practice of using executed prisoners as a source of organs to an end before any clinical transplant data is presented at meetings and published in journals; before pharmaceutical companies engage in clinical trials in China; before Chinese professionals are trained at international centers and return home to practice; and before the international community visits China to teach and advise. An incremental approach requires that Chinese clinical transplant data is carefully filtered; transplant professionals are questioned regarding their attitude; and the international community are selective about their travels, so as to attempt to separate the acceptable from the unacceptable while the use of executed prisoners continues; yet in the fervent hope that by fostering the acceptable the unacceptable will wither away.

It is hard to know which of these approaches will be more effective or if we have any leverage at all. Yet, if our approach is a passive one—continuing as we are doing—we will certainly send a message to Chinese authorities that ‘business as usual’ is an acceptable outcome. The absolutist approach may be more morally gratifying, but does it risk stifling the efforts of those who want to see change? The approach bears some similarity to the embargoes used in international affairs to change the political behavior of rogue states: a broad degree of consensus, not easy to achieve, is required for the approach to be effective. The incremental approach may encourage the development of organ donation practice according to international standards, yet might well permit donation by execution to continue unhindered. It would also require assurances from Chinese transplant professionals that they may not be in a position to make or reject. Having acceptable and unacceptable donation practice continue side by side might be a convenient way for the Chinese authorities to avoid making the tough but inescapable decisions necessary to effect real change.

As individual concerned transplant professionals we are frustrated by the apparent failure of the efforts of the international community to date. We believe that following immediate steps could achieve broad acceptance and would, at the very least, indicate to Chinese authorities the extent of our community's resolve, and the price to be paid for their continued failure to adhere to international standards.

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  International and national professional medical societies and journals should not accept abstracts, publications or presentations from Chinese transplant centers unless the authors clearly indicate that the data presented is in concordance with the most recent Chinese government regulations regarding transplant tourism and that executed prisoners were not the source of organs.

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  Membership of international professional societies by Chinese transplant professionals must be conditioned by acceptance of ethics policies that specifically express the unacceptability of executed prisoners as a source of organs.

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  Pharmaceutical companies must ensure that no executed prisoners are the source of organs used in their studies and that Chinese government regulations regarding transplant tourism are adhered to rigorously.

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  Training of Chinese transplant professionals by the international community must be conditioned on commitments that trainees will not engage, directly or indirectly, in the use of organs from executed prisoners.

These proposals would be greatly strengthened, and considerable trust engendered, by on‐site inspections of Chinese transplant centers by internationally respected organ transplant professionals. Acceptance of these proposals by the major international professional transplant organizations, editorial boards of major transplant journals and relevant pharmaceutical manufacturers would send a clear message to the Chinese authorities and provide succor to those in China who struggle for progress.

It is to be fervently hoped that progressive Chinese transplant professionals and government officials will gain sway and that China will take its rightful place in the international organ transplant community as a respected member to be welcomed, unequivocally, with open arms. In the meantime however, we cannot merely give lip service to our repugnance or become inured to unacceptable practice cloaked in banal euphemism. As history has painfully taught us, in face of a self‐admitted crime against humanity, it is our moral obligation as individuals and a community to raise our voice and do our utmost to bring the process to a complete halt. If another 18 000 executed prisoners with ‘severe brain injury in all cases’ become organ donors in China, and we have not done our utmost to put an end to this practice, we will all have blood on our hands.

Disclosure

The authors of this manuscript have no conflicts of interest to disclose as described by the American Journal of Transplantation.