Organ transplantation around the world

 

At present, about 180,000 people are waiting for a new organ throughout the world, of which only about 60,000 can expect, under current conditions, to actually receive a desired transplant [1]. The underlying factor behind this large difference in the number of expectant and likely recipients is that there is a substantial shortage of transplantable organs throughout the world. This is since the quantity of organs demanded by patients exceeds the number of organs supplied by living and dead donors, with any relative increase in annual organ collection being more than exceeded by the respective rate of increase in the demand for organs. As a result, vast delays have been encountered before patients could get a transplant, with one particularly unpleasant side-effect being that as transplants are often procedures of an emergency nature, where time is of critical value to their chances of survival, many patients will die before they can even receive an organ. 

 

In this section, we look at how transplantation has developed throughout the world, with our discussion drawing heavily on the arguments developed in the previous chapter on topics such as systems of altruistic organ procurement, systems of allocating organs, and ways of increasing the number of organs collected through the use of non-conventional methods. At the end of this section, a cross-country record of the number of organ transplants performed in several countries will be provided. This is done in order to enable us to gain a more meaningful impression of the efficiency with which countries operating in different circumstances and using varying policies have been able to fulfil their transplant obligations.

 

i) The United States

In the USA, the national Organ Procurement and Transplantation Network (OPTN) is managed by the United Network for Organ sharing (UNOS), a NGO initially contracted in 1986 to perform this function by the federal Department of Health and Human Services. Here, every hospital transplant centre, organ procurement organisation and tissue typing laboratory operating in the USA is an active member of UNOS. This occurs because even though membership is not mandatory, it is nonetheless financially advisable, for if these bodies wish to receive federal reimbursement under the Medicare and Medicaid programmes for any medical services rendered (not only for transplants), then they are required by law to belong to UNOS. For operational purposes, the USA is divided into 11 administrative regions, each of which contains a number of independent state and local organ procurement organisations and transplant centres operating under general UNOS guidelines. When solid organs are procured from a cadaveric donor, they are first offered to potential recipients within the region they are collected before being made available, through the co-ordinating services of UNOS, to patients in other regions. The rationale behind the use of this zoning system is that it apparently reduces the organ preservation time required before a transplant occurs, resulting in greater organ quality that improves the survival prospects of patients while reducing their expected financial costs. In addition, by giving local centres the first claim to an organ, it is thought that these bodies will have a greater incentive to attempt to acquire an organ, for which they receive federal compensation, than they would otherwise have if an acquired organ was placed automatically in the national pool.

 

The USA suffers from a problem that is familiar elsewhere, namely a shortage in organs where the total demand that exists, as expressed by waiting list numbers, greatly exceeds the annual number of transplant operations supplied, with the number of people being placed on waitlists exceeding the number of organs procured per annum. This growing rift has arisen mainly because the clinical success that has been achieved has substantially boosted the demand for transplants, with a large rise being reported in the number of American transplant centres (each of which need to handle a certain number of organs to be financially viable) accompanied by a concurrent relaxation in the eligibility criteria required to receive an organ (with older patients and those who were previously excluded due to predefined medical risk conditions now also vying for a chance at a transplant). While about 13,000 people were seeking a new organ in 1987, this number had increased to about 33,000 patients in 1993 [2], with current figures stating that at the end of 2000, there were about 75,000 potential organ recipients in the USA – almost 50,000 were awaiting a new kidney, about 17,000 required a new liver, and about 4,000 people each were looking for a heart, lung or other type of organ transplant respectively [3]. Furthermore, no respite in the growth rate of the number of potential recipients is in sight, with new individuals always being placed on the waiting lists for a transplant. In the case of kidney failure, for example, where the nationwide cost of dialysis is currently about $11 billion per annum [4], 25,000-35,000 Americans are diagnosed with ESRD each year, with at least 30% of these new patients having the potential to be rehabilitated through an organ transplant [5].

 

The end result is that there has been a substantial increase in the median waiting time before a transplant can be performed for all organ types: for kidneys, from 444 days in 1989 against 938 days in 1996; for hearts, 139 days in 1989 against 209 days in 1998; for livers, 39 days in 1989 against 515 days in 1998; and in the case of lungs, from 320 days in 1989 to 643 days in 1997 [6]. What these figures do not reveal is that substantial numbers of patients die while listed before they can even receive a transplant – in 1990, about 1,900 patients died while registered on the waiting lists, with the numbers steadily increasing since then to stand at about 6,100 waiting list deaths in 2000 [7]. Various steps have been taken to alleviate these problems and increase the number of organs that are collected. First, almost all states have, in varying forms, replaced their informed consent policies with required request laws that made medical requests for organs from possible donors mandatory. However, due to poor enforcement of these laws and a large number of refusals to donate, the number of organs collected per annum, although greater than which was previously obtained, still remains low relative to the needs that have been expressed. As a result, calls have been made, barely a decade after its introduction, for required request to be replaced with an even more pro-active organ procurement policy. While presumed consent has been considered as a policy option, it has been deemed too controversial to implement, with various influential lobby groups, such as the American Medical Association, favouring instead the introduction of mandated choice laws as being more in line with concepts of individual autonomy [8]. Secondly, increased efforts have been made to increase the size of the human donor pool through the exploitation of non-conventional organ sources. For example, in 1999, about 40% of the donors used in the USA were living donors (providing mainly single kidneys), while slightly over 1% of cadaver donors were asystolic donors, with an additional number (albeit small) being brainstem dead marginal donors who would previously not have been considered suitable for use [9]. Finally, all alternative methods of providing organs examined in a previous section have been considered for exploitation, with the USA being by far the largest contributor in terms of financial and human resources to research aimed at developing organ substitutes such as cloning, xenografting and artificial organs.

 

One of the most divisive issues in the American transplant sector in the past decade, brought about in part by the shortage of organs, concerns the manner in which organs are allocated, with critics claiming that various groups, including ethnic minorities, females, the aged, and the disabled, all do not receive organs in proportion to their representation on waiting lists. Of particular interest to South Africans is the acrimonious and emotional debate that has erupted over whether African-Americans, who constitute about 13% of the national population but around 34% of those with ESRD, are fairly treated when it comes to the allocation of cadaveric kidneys for transplantation. In 1988, while white patients made up 61% of the kidney waiting list, they received 74% of cadaveric kidneys as against the 22.3% that were allocated to black recipients, which appeared to be a discriminatory measure as this meant that blacks would wait almost twice as long as whites to receive their first organ transplant – 13.9 months against 7.6 months respectively [10].

 

The underlying cause of this problem relates to the points system used to allocate kidneys, where higher scores that suggest a good antigen match increase the chance a patient has of receiving a kidney, with 6-antigen match (or 0-antigen mismatch) recipients being almost guaranteed such a kidney if it is donated. From a genetic perspective, people of a particular racial group are more likely to share similar antigen (and blood) types with people of their own group than with people from other races [11], which means that African-Americans were less likely to receive kidneys as timeously or with as good an antigen match as white recipients (as most cadaver organs were provided by whites). This, critics felt, was unfair, as an equitable allocation system would require that kidneys be allocated to individuals from each racial group in direct proportion to their waiting list representation regardless of antigen considerations, especially since the introduction of drugs such as cyclosporine had largely nullified the clinical advantages of antigen matching. Thus, to rectify the alleged historical bias in kidney allocation, it was proposed that the incumbent points based system be restructured in order to “recognise more explicitly the racial implications of HLA-based allocation and award points to blacks … to compensate for points accumulated by whites on the basis of antigen matching” [12].

 

This suggestion that the antigen matching approach to kidney allocation was undesirable and ought to be replaced has been controversial, with several flaws being pointed out that nullify or reduce the validity of these “affirmative action” proposals. First, despite the major value of anti-rejection drugs in reducing graft failure rates, the quality of the antigen match continues to serve as an important indicator of how well a patient will fare with a new organ – consequently, whether critics like it or not, the manner in which patients are genetically constituted continues to be an important clinical factor in the clinical success, and thus the allocation, of kidneys. Second, while the number of African-American donors has slowly been rising, this ethnic group still does not donate the same number of cadaver organs in relative terms as whites do, which raises another issue of whether it is appropriate to accuse whites of receiving an excessive number of organs when they also donate organs in numbers that are disproportionate to their national representation. This lower donation rate has a direct impact on the quantity of organs allocated to blacks, for if the number of black donors were to increase, then the probability of black recipients finding kidneys with the same rare antigens as their own would also increase, which would decrease both their expected waiting time before receiving a transplant as well as their total numbers on the transplant waiting lists. Finally, while African-Americans complain about receiving poorly matched kidneys, Asian-Americans have not complained despite being even worse off in this respect, for although “Caucasians were the best HLA-matched renal allograft recipients … Asians were the most poorly matched … [which] resulted in an average number of HLA mismatches of 3.9 for Asians as compared with 3.0 for Caucasians, 3.7 for African-Americans and 3.4 for Hispanics” [13]. Despite their poor matching, Asian-Americans needed less immunosuppression and had higher graft survival rates than their black counterparts. Thus, it can not be implied that blacks were specifically discriminated against, as other factors, including poverty, lifestyle risks, a lack of adherence to medical instructions, and greater unavailability when called to receive an organ may also be held partly responsible for their longer waiting times and poorer consequent acceptance of transplants [14].

 

Despite the increased time spent waiting for organs, no reports have yet emerged in the USA of organs actually being given by donors to recipients in return for payment. However, on a couple of occasions in recent years, kidneys have been offered for sale on Internet auction sites such as e-Bay, although it is possible that these offers were merely pranks rather than real attempts at trade, with all such offers being eliminated before they could be fulfilled. Interestingly, in the late 1960s and early 1970s, a few states in the USA allowed for sales of organs to be carried out by decedents or their next of kin, although no record exist of any trades taking place. With the passage of the law that led to the creation of UNOS, any possibility of inter-state commerce in organs was turned into a criminal offence, although it is possible, in theory, for trade to take place within a state [15], with citizens of Mississippi still being technically allowed to sell their organs due to a loophole in state legislation [16]. 

 

ii) Europe

Organ transplantation is widely performed throughout Europe, which is not surprising given that much of the initial research into this field was conducted here. Now, while European states have worked hard at forging close economic and political links, when it comes to the collection and transplantation of organs they are not as intricately linked, with no single pan-European agency similar in structure and function to UNOS being in operation. Rather, there are an assortment of cross-national procurement networks, such as Eurotransplant (covering Germany, the Benelux states, Austria and Slovenia) [17]; UK Transplant (operating in the UK and Ireland) [18]; Scandiatransplant (serving Denmark, Finland, Iceland, Norway and Sweden); as well as a number of independent national networks, such as the ones that are run in France, Spain and Portugal [19]. There are also significant differences in the organisation and reporting structures of these networks, with the national transplant programmes generally being managed by state governments while the multinational networks are either indirectly run by the state through NGOs (as occurs in the UK and Eire) or having no government involvement in the management of their affairs whatsoever (as happens in the Eurotransplant region) [20].

 

A steadily growing number of European countries have switched from using informed consent to presumed consent as the official method for procuring organs from cadavers, although in some of these states, only the weak form of presumed consent, where a family veto exists, is used. The justification for this general change in procurement policy has been that insufficient organs have been procured for use despite the widely perceived public approval of transplantation, with state agencies arguing that organ collection would rise if networks assumed that all people wanted to give organs unless they opted out. Due to the lead taken by these countries, pressure has been mounting in those countries that still retain informed consent to change their mode of operation to conform with the systems of neighbouring states and improve organ collection rates. In the Netherlands, for example, even though over 25% of the Dutch population carry donor cards, the waiting time for a renal transplant stands at about 4.5 years, which has led to calls for the present system of informed consent to be changed [21]. However, due to a high emphasis on individual autonomy and opposition to presumed consent, a compromise solution had to be reached, with one proposed approach being to create a register where both opt-in and opt-out choices could be registered, although the feasibility of such an option has yet to be fully determined.

 

Of greater interest though is the debate that has taken place in the UK, which, given its vocal advocacy of the virtues of altruistic blood donation over paid donation, could reasonably be expected to have high organ donation rates under the voluntary principles of informed consent. Here, various lobby groups, particularly associations representing patients with end-stage organ failure, have pressed for presumed consent to be adopted, citing widespread public support as expressed in various polls as reason for the introduction of opting-out mechanisms [22]. However, these results should be viewed with scepticism, as opposing polls have demonstrated that presumed consent is disliked not only by most British subjects, but also by organ procurement co-ordinators and ICU staff, both of whom play a major role in organ procurement [23]. In addition, another sign that the British are unlikely to support presumed consent has been illustrated by the uproar that greeted news that since the 1950s, thousands of organs had been removed by British doctors, often without parental consent, from dead infants. While these organs were not transplanted but were rather used for research purposes, the underlying principle of presuming consent without fully knowing private wishes remains the same – thus, given the outcry that arose, it seems unlikely that the British public has an appetite for presumed consent, even if it is applied in the weak form.

 

Throughout Europe, a general shortage of organs exists, with several cases being reported of organs being acquired from donors in return for remuneration, in contravention of national laws banning such activities. In addition, a phenomenon known as “organ tourism” has developed, where patients from these developed states, who are unlikely to receive a kidney at home, will travel to medical centres in the developing world, where they are guaranteed immediate access to a kidney provided by a paid donor that allows them to circumvent their time on a waiting list. 

 

In the late 1980s, the British public was shocked to learn that several Turks flown into the country had each sold a kidney to a doctor at a prominent private London hospital in return for a fee of about ₤2,000-3,360 [24]. While several individuals were suspended from further medical practice, in the commission of inquiry that was subsequently undertaken, it was discovered that the doctors concerned had initiated several measures to ensure that the organ sellers knew precisely what they were engaged in at this hospital. This is since they “did not appear to be under any duress and willingly and freely signed a consent form for the operation to donate a kidney. The nursing staff did not detect any irregularities and an interpreter was present” [25]. To prevent further irregularities from taking place, stricter measures were introduced to ensure that living donation could only take place involving carefully monitored related and non-related donors, although it now seems that the effectiveness of these safeguards has been limited, as new ways of acquiring organs from paid donors have developed. Here, it recently emerged that Indian doctors based in the UK, with links to transplant centres in India, were offering to refer British kidney patients to India so that they could immediately receive a transplant using an organ bought from a local donor [26].

 

In France, confidence in the national transplant system has been severely eroded by several disputes concerning irregularities in the acquisition and allocation of organs. In one incident, corneas were said to have been taken from at least one corpse without the required family consent [27], while in another case, public dissatisfaction was reported over the fact that private clinics could purchase donated corneas from eye banks at a price of FFR3,000-5,000 each for grafting into foreign patients, even though there was a pressing need for them among national patients who could not afford these prices [28]. In addition, it was alleged by a self-proclaimed organ broker that a Dutch donor had provided a kidney for transplantation into a recipient from the Persian Gulf at a private French clinic. Here, the recipient was believed to have paid ₤160,000 for an all-inclusive package that covered a ₤25,000 payment to the donor, tissue testing, surgery, hospital fees, post-transplant care and a residual profit margin of ₤10,000-20,000 to the broker [29]. While it was claimed by the broker that hundreds of similar potential recipients and donors existed, this story was later dismissed as being a possible hoax, although by this time, substantial damage had been caused, with a major drop being recorded in the consent rate to organ extraction in France for several years thereafter.

 

Germany has also suffered from scandals regarding paid organ donation, with doctors estimating that by 1996, at least 50 German patients had travelled to India for a paid kidney transplant in a popular form of organ tourism [30]. Medical opposition to such activities was rife, since, in many cases, patients never received a kidney that had a good antigen match nor were their surgical operations performed in conditions that met suitable standards of clinical safety and efficacy. In most cases, patients were given large doses of immunosuppression before being discharged after a couple of days, whereupon they would then be likely to fall sick and reject the organ once they had returned home. Consequently, mortality in the first year after a transplant for recipients of these third-world kidneys was about 10 times higher than the respective European rate, with 10-20% of all these patients dying due to the onset of complications. Closer to home, organ tourism involving journeys to neighbouring East European states also appears to take place, despite the passage of a law in 1997 banning such activities. For example, a German count publicly offered to arrange kidney transplant deals similar in structure to the aforementioned French package. Here, in return for DM150,000, a patient would receive a kidney transplant, with DM80,000 going to the donor, DM50,000 being spent on the operation and associated medical expense, and the remaining DM20,000 serving as a brokerage fee [31]. 

 

Due in part to their Communist legacy, few East European states have laws governing all aspects of organ donation and transplantation, with those laws that do exist being rarely enforced by the authorities. As a result, the trafficking of organs has been alleged to take place on a wide scale, with organised crime being considered a vector linking wealthy Western patients desperate for an organ with Eastern donors desperate for cash or an opportunity to enter a wealthy state. In the Czech Republic, for example, organisations have been accused of soliciting German patients with promises of receiving an immediate kidney transplant [32], while in Russia, reports have emerged that in addition to the voluntary selling of organs by people, individuals have been kidnapped and offered for sale as entire repositories of transplantable organs [33].

 

iii) Latin America 

Transplantation is practised in most Latin American states, although it is not viewed as a priority medical procedure by most governments, who prefer to allocate their financial resources to more pressing social and medical issues. Due to this limited government involvement, unregulated private parties play an important role in this sector, which has led to allegations of some irregularities involving the purchase or outright theft of kidneys and corneas, although no conclusive proof has ever been found that could officially substantiate these reports [34]. As elsewhere, there are variations in organ procurement systems, with some countries, such as Peru and Brazil, having presumed consent policies while others retain informed consent laws. In addition, networks of organ sharing between some countries in this region have been introduced to make better use of collected organs, although these have had only limited success, as poor infrastructure and low donation rates mean that very few organs have actually been made available for use [35]. Due to these restrictions, many individuals will, if they have the funds, attempt to have a transplant outside of their home country, with the USA being seen as a particularly desirable destination for receiving a new organ.

 

iv) Middle East

Since the late 1970s, transplants have been performed in most Middle Eastern countries. However, while financial wealth has enabled many states to set up well equipped medical facilities and employ qualified expatriates and foreign trained local doctors, a general shortage of donated organs means that this infrastructure has not always been employed to optimum capacity.

 

In general, it appears that inhabitants of this region have a widespread aversion towards cadaveric organ donation, even though senior authorities of key local religions, including the Ayatollah Khomeini and the chief rabbinate of Israel, ruled that post-death organ donation was permitted. Given this popular resistance to organ donation, presumed consent is obviously not used, with informed consent serving as the standard policy that is applied in the collection of organs from both living donors as well as from the small number of individuals that may be willing to give organs after death. Due to the limited number of organs collected and the presence of legal and administrative barriers, organ sharing between states is not widely practised, with collected organs being jealously guarded for domestic use even when they could be better employed in more suitable recipients elsewhere in the region.

 

Various methods of overcoming the local shortage of transplantable organs have been proposed and implemented. Attempts have been made, where possible, to actively recruit the relatives of a potential recipient as organ donors, although cultural traditions may hamper the donation of organs from certain family members, with this activity being practised relatively infrequently in this region. Alternatively, indirect financial incentives have been offered for organs, with the Omanis, for example, proposing to pay for the expatriation costs of migrant workers that die in their country if their organs can be removed locally for transplantation [36]. In spite of these measures, it is perhaps inevitable that many potential recipients would resort to acquiring organs from paid donors, with such an option being seen by some commentators as being the main reason for the low rate of live related donation in the region [37]. While India has been the favoured destination for getting transplants using organs from paid donors, incidents of organ selling have also been recorded in other countries, including Israel [38], Iran and Iraq [39].

  

v) Asia

Most Asian countries operate organ transplant programmes, although social, religious and medical barriers regarding the handling of dead donors have often limited their success and scope of activity. In particular, the general lack of acceptance of brain death has meant that certain organs, such as hearts and lungs, have rarely been transplanted locally.

 

With the notable exception of Singapore, presumed consent is not used to collect organs from cadaveric donors in Asia [40]. This state of affairs arises either because governments believe that there is only limited support for organ donation in their countries, and therefore rely on informed consent mechanisms, or, as may happen in Indonesia and Pakistan, no use is made of dead donors at all (in which case the debate over the merits of presumed versus informed consent is deemed irrelevant) [41]. Furthermore, no systems of organ sharing between existing national procurement networks are formally used, with organs being transplanted in the same areas as where they are collected. 

 

In Australia and New Zealand, transplantation using organs from both living and brain dead donors is performed, with nationals of smaller neighbouring states occasionally being permitted to receive transplants in these two countries due to a lack of appropriate domestic facilities [42]. In Australia itself, most states run their own separate organ procurement networks for internal transplant purposes, although the sharing of collected organs does take place between these state networks, the New Zealand programme and the medical systems of smaller neighbours that lack formal collection networks. Despite this sharing of organs, donation rates are relatively low, which has consequently led to a major strain being exerted on the size of the organ waiting lists. In an effort to overcome this problem, proposals have been made in some states to switch to presumed consent laws or copy the transplant systems of other countries, most notably that of Spain. 

 

In Japan, the non-acceptance of brain death criteria meant that for a long time, only organs acquired from live donors could normally be used [43], with innovative ways being developed of acquiring and transplanting body parts that could only be provided by dead patients. While a few extremely sick Japanese patients received transplants in Europe and the USA, usable organs were also flown into Japan or were, when possible, obtained from the sovereign hospitals serving the large American military contingent based there. It was only in 1997, following several aborted legislative efforts, that a law was passed that finally accepted brain death as being grounds for the removal of organs for transplant purposes. As the same time, the Japanese organ transplant system was remodelled to work in compliance within the framework set out by the new law, with the previous organ procurement network being reconfigured into a new organisation known as the Japan Network for Organ Sharing (JNOS) [44]. While these moves to modernise the national system appear promising in theory, in practise, it is still to early to ascertain how effective this new system will be, for a couple of features in this new law have raised disapproval – first, the concept of brain death that is used is deemed to be too restrictive to have much value, and second, there is unhappiness at the fact that family members can still veto a donation decision. 

 

Similar problems to those of Japan have been found in South Korea, where the lack of brain death laws once again meant that only living donation could be used as a reliable means of organ procurement. Due to the large waiting list that exists for kidneys, one innovative method of easing the current shortage that has steadily gained acceptance has been the concept of organ swapping [45]. Here, potential recipients who have relatives that are willing to be donors but who are unsuitable for this task due to a lack of compatible antigens might be able to exchange kidneys with other individuals facing the same predicament. In other words, if we have two related donor-recipient pairs, A and B, then donor A can provide a kidney to recipient B while donor B provides a kidney to recipient A, provided there is an equally good blood and antigen match in both exchanges.

 

In India, “unrelated paid organ donation has become prevalent … because long term dialysis is not possible, there is virtually nonexistent cadaver programme, and there is also no serious cultural / religious conflict to paid organ donation” (sic) [46]. As a result, kidneys and corneas have, for many years, been sold at prices that range from ₤200-2,000 to wealthy recipients from throughout the world in a system of organ tourism that is worth millions of dollars annually. 

 

Traditionally, organ sales took place in India because there was no legal definition of brain death, with the only body parts available for transplanting from cadavers being corneas, skin and bones. At the same time, there were no effective laws governing the collection of kidneys from living donors, which meant that a void was created that made the selling of these organs possible [47]. After lobbying by the medical community and other interest groups, this situation was rectified when a law was passed in 1995 that permitted cadaveric organ donation to take place while simultaneously prohibiting living unrelated donation and the transplantation of organs into foreigners. 

 

Despite the introduction of this new law, it is unlikely that much of an impact will be registered on the number of Indians waiting for an organ, with a couple of factors suggesting that organ selling is to continue for a long time to come. First, there is a vast discrepancy between supply and demand for organs that is unlikely to be resolved solely through cadaveric donation. Each year, about 80,000 people are diagnosed with ESRD in India, although financial constraints mean that only about 10% of these patients, who are generally derived from the wealthy and educated classes [48], will actually qualify for dialysis, which is the preliminary stage to having a transplant. In contrast, the number of donated kidneys has been much lower than this figure, even though it has been estimated that about 70% of the kidneys derived from living donors, the major source of kidneys in India, were provided by unrelated donors in return for payment [49], with about 3,000 kidneys probably being provided per annum at present from all sources [50]. Second, in a country where the per capita income is at most ₤300 per annum, the money that is offered to potential donors, usually young peasant males starting a family, can literally seem like a ticket to a new life out of poverty. Thus, even though the law may state that organ sales are prohibited, the incentive of easily earning a large sum of money for no apparent effort may lead to the development of ingenious ways of selling an organ, either directly or indirectly. For example, some donors may sign legal affidavits or issue declarations on video stating that they are voluntarily donating organs without compensation even though they receive covert payments. Alternatively, marriages of convenience might be entered into, where an apparently sudden discovery will be made that one of the spouses has an altruistic family member who would be willing to freely give an organ to the other, ailing spouse, with the link now being that of (non-biological) related living donation rather than that of unrelated paid living donation. 

 

While it has no laws regarding the performance of transplants, no legal acceptance of brain death as the criterion for declaring death, and no entrenched organ procurement and distribution system, transplantation is nonetheless practised throughout China [51]. Here, a wide range of organs, including hearts and livers, are obtained exclusively from asystolic donors. Despite this good use of a rarely used source of organ donor, organ donation is an infrequent practise relative to the size of the Chinese population, with possible factors for these low rates being a popular dislike of donation due to cultural reasons, a poorly developed transport and medical infrastructure, a general lack of awareness of the benefits of donation, and the obvious lack of brain death laws that would permit the collection of more organs [52].

  

There is, however, international concern over a hidden aspect to Chinese transplantation where, according to some reports, large numbers of organs extracted from executed prisoners are transplanted into wealthy patients who have literally ordered a well-matched organ suitable for use in them [53]. In the highly sophisticated industry that has developed, the convicts and their families are not asked to consent to donation nor do they receive any compensation, with the main financial beneficiaries being the foreign doctors who refer clients to these transplant centres as well as the state and military organisations that run these centres. Depending on the organs required by recipients, prisoners could either be shot through the head or the heart, with executions sometimes taking place adjacent to a hospital where a patient had already undergone pre-operative preparation to receive a transplant, with the purpose of such proximity being that it was almost as good as a live donation in reducing ischaemia time [54]. Transplanting cadaver organs obtained from executed prisoners is not restricted to mainland China though, with similar activities being performed in Taiwan, although in this country, there was no trade, as all such organs were placed in the national pool for allocation to all suitable recipients. In the period October 1990-December 1991, out of 51 executed Taiwanese prisoners, 22 “voluntarily” donated organs at death, with donors being shot through the head rather than through the heart, as was the standard operating procedure when executing convicts, in order to retrieve organs [55]. 

 

vi) Africa

In Africa, transplantation most commonly takes place in those countries that are situated along the Mediterranean Sea. There are variety of problems that prevent this form of surgery from being widely performed in these areas, with the lack of suitable organs once again being cited as the main reported obstacle to further activity in this field. As a result, organ selling has once again been reported, with paid living donation being said to take place in, amongst other places, Egypt and Algeria [56]. Meanwhile, in sub-Saharan Africa, transplantation is not reported to have taken place with the notable exception of South Africa, as few countries in this part of the continent have sufficient resources and skills with which to set up and maintain the infrastructure required for their own transplant programmes. In cases where patients do fall ill from end stage organ failure, very little can be done, with most usually dying in their home countries, with the only exception being a few cases when patients receive transplants in Europe or the USA. 

 

Before concluding this section on global transplantation and moving on to examine how organ donation is organised in South Africa, we can first view, in Table 9, a cross-country comparison of the type and number of organs transplanted in 1999 in a select group of countries that employ different organ procurement policies. Here, a standardised measure that is often used to determine how efficient a country is in this field is shown, where we evaluate how many donors were recruited and organs transplanted per million people (pmp) in the population (with a higher value always being seen as indicative of a more efficient system than a lower rate) [57]. As we can see, there is a substantial variance in national transplantation rates, with vast differences being experienced between countries even when they share the same system of organ procurement. For example, while Spain and Greece both have presumed consent laws in theory but informed consent policies in practise, their organ collection rates differ greatly, with the Spanish being, in a rough manner, 8 times more effective than the Greeks in collecting organs from cadaver donors after population differences are accounted for.  

 

In general, it appears that countries that work according to presumed consent guidelines do seem to collect slightly more organs than do countries using informed consent, although the link is not definitive. This can be seen by considering that the Spanish have what is considered to be arguably the best and most admired organ procurement system in the world even though they use informed consent to procure organs. This success can be attributed to a couple of simple factors. First, there has been substantial investment in this sector by the government, with a thorough support structure being erected to help a large number of well-trained doctors, who serve as organ procurement coordinators, request, remove, transport and transplant organs across this country. Here, it seems that there has been no need to rely on the provisions of the law to presume consent, as the Spanish public appears to be supportive of transplantation in general, which makes the task of these doctors much easier [58]. Second, a factor that is largely overlooked by commentators on this topic is that the Spanish have made better use of older, supposedly marginal organ donors than surgeons in other countries. While 10% of Spanish donors in 1992 were older than 60, by 1998, people in this age group made up 27.3% of the total donor pool, which clearly indicates that a substantial portion of the marginal increase in new donors recruited in the intervening years was attributable to the recruitment of old people who would otherwise have been overlooked [59]. Now, even if marginal donors provide slightly lower survival rates than more conventional donors, it is still possible to treat more patients who would otherwise have died due to a lack of organs, with the increased quantity of organs collected allowing for a much greater chance of a retransplant even if graft failure does take place.

 

Table 9: Cross country comparison of organ transplantation rates (1999) [60]

	Population	Cadaver
Country	(in million)	donors	Cadaver kidney	Living kidney	Total Kidney	Liver	Heart	Heart-Lung	Lung
Austria Presco-Presco	8.1	202 (25.0)	382 (47.3)	35 (4.3)	417 (51.6)	140 (17.3)	95 (11.8)	1 (0.1)	70 (8.7)
Australia Inco-Inco	19	164 (8.6)	286 (15.1)	167 (8.8)	453 (23.9)	124 (6.5)	68 (3.6)	2 (0.1)	69 (3.6)
Canada Inco-Inco	30.5	430 (14.1)	647 (21.2)	378 (12.4)	1025 (33.6)	383 (12.6)	172 (5.6)	5 (0.2)	91 (3)
Cyprus Inco-Inco	0.6	6 (10)	12 (20)	29 (48.3)	41 (68.3)	0	0	0	0
Eurotransplant Mixed	114.5	1578 (13.8)	3054 (26.7)	572 (5.0)	3626 (31.7)	1136 (9.9)	736 (6.4)	28 (0.2)	264 (2.3)
France Presco-Inco	59.9	970 (16.2)	1760 (29.4)	77 (1.3)	1837 (30.7)	699 (11.7)	349 (5.8)	28 (0.5)	99 (1.7)
Germany Inco-Inco	82.1	1039 (12.7)	1895 (23.1)	380 (4.6)	2275 (27.7)	757 (9.2)	500 (6.1)	20 (0.2)	146 (1.8)
Greece Presco-Inco	10	45 (4.5)	69 (6.9)	85 (8.5)	154 (15.4)	12 (1.2)	7 (0.7)	0	0
Portugal Presco-Presco	10	190 (19.1)	358 (35.9)	9 (0.9)	367 (36.8)	159 (16)	12 (1.2)	0	0
Scandiatransplant Mixed	24.1	338 (14.0)	603 (25)	233 (9.7)	836 (34.7)	183 (7.6)	110 (4.6)	5 (0.2)	83 (3.4)
South Africa Inco-Inco	40	N.A.	N.A.	N.A.	319 (8.0)	4 (0.1)	37 (0.9)	8 (0.2)	1 (0.03)
Spain Presco-Inco	39.7	1334 (33.6)	2006 (50.6)	17 (0.4)	2023 (51.0)	960 (24.2)	336 (8.5)	4 (0.1)	135 (3.4)
Transplant UK Inco-Inco	62.9	816 (13.0)	1432 (22.8)	269 (4.3)	1701 (27.1)	703 (11.2)	289 (4.6)	50 (0.8)	110 (1.7)
USA Reqres-Inco	280	5848 (20.9)	8026 (28.7)	4457 (15.9)	12483 (44.6)	4698  (16.8)	2185 (7.8)	49 ((0.2)	885 (3.2)