###Introduction about the authors
6 out of 10’000’000. This is the number of voluntary organ donations in China. Not only is this the lowest number world wide, but also one of the roots of china’s flourishing illegal organ harvesting from prisoners. China has been numerously covered in western media about this topic, mostly negative. Due to international pressure China attempted to ban illegal harvesting of organs after 1 January 2015. The following blog post will have a closer look at this opaque system. What are the key drivers for China’s low donation numbers? How was the situation before 2015? What did China change and was there a change at all? And finally, where is China heading to? These are the leading questions for this blog entry we try to give an answer to.
Situation before the statement
China has the weakest organ supply in the world whereas demand is roughly about 300’000 per year. The gap between the number of people needing organs and organs available for transplantation is therefore huge. The Chinese people do not want to list as donors because according to Confucianism it is required to have the body intact for the afterlife. Despite the decrease of this religious position as more and more Chinese become atheist, the culture of not wanting to be an organ donor is still strong. Additionally, people’s distrust of the Chinese waiting list system diminishes the number or voluntary donors as it is believed that people can pay their way to the top of the list.
China has tried to fight against the problem of low number of donors by various organ donation programs. For example in 2010, China piloted an organ donation program in Shanghai, Tianjin, Liaoning, Shandong, Zhejiang, Guangdong, Jiangxi, Fujian, Xiamen, Nanjing, Wuhan, and eventually in 19 provinces and cities. This program was jointly run by the Ministry of Health and China Red Cross. On 25 February 2013, the national organ donation working video meeting reported that only 659 donations had occurred in total nationwide since March 2010. Hence the campaign remained unsuccessful.
There has been international critisicm about China’s organ harvesting practice from executed prisoners. The organ harvesting is based on informal arrangements between hospitals and the local courts that supervise the penal system and for decades organ from executed prisoners were simply taken without consent. After the regulations of 1984 and 2007, written consent was officially required. However, this rule was largely ignored. Recently China has been paying attention to this issue but how serious are they about tackling this problem?
Change of law
What law is it? What’s illegal? (Catchier, from the intro: What did China change and was there a change at all?)
In this part of our blogpost we are going to further present you the announcement from 3 December 2014 made by Huang Jiefu, the director of the China Organ Donation Committee and former Vice-Minister of Health. Firstly, we will look at the changes China intends to implement in its legal system. Secondly, we are interested in the motivation behind this intention.
According to Jiefu’s announcement China decided to stop using organs from prisoners for transplantation after 1 January 2015. (Paul et al., 2017, p.1) Organs should only be voluntarily donated. (Allison et al., 2015, p.1) Nonetheless, it is to note that no regulatory changes in the Chinese organ donation laws accompanied this statement (Paul et al., 2017, p.1). No regulations regarding organ donation can be found on the homepage of the National Health and Family Planning Commission (http://en.nhfpc.gov.cn/regulations.html). Consequently critics make the point that this announcement is merely a “best statement of good intention but has no force of law”. (Allison et al., 2017, p.3) Yet, Jiefu comments that the legal framework is given by the old law in two regulations about human organ transplantation (from 2007) and procurement and allocation of donated human organs (from 2013) as well as the Criminal Law Amendment which criminalizes organ trading (from 2011). It is striking that these three laws require a voluntary and unpaid consent and an open, transparent and traceable procedure in the procurement and allocation of an organ. Even so, the organ procurement from prisoners is not exempted as long as there is informed consent. (Allison et al., 2015, p.4) As a matter of fact, Jiefu told reporters in 2014 that prisoners are still qualified organ donors. However, instead of using their organs for private trades they will be registered in the national organ donation database which will be the principal change in the future. (China Daily, 2014, retrieved from http://www.chinadaily.com.cn/china/2014-12/04/content_19025683.htm (accessed 29.4.17) According to Allison, Paul, Shapiro, Els and Li (2015) organs from “consenting” prisoners will now be redefined as organs from voluntary donors.
Motivation behind the change
A reason for the above-mentioned announcement is given by Jiefu. Until 2014 it was a major issue that the laws regarding organ donation were largely ignored as well as that there were loopholes in law enforcement. Due to the anti-corruption campaign launched in 2013 (http://www.transparency.org/news/pressrelease/20130318_ti_welcomes_chinas_commitment_to_stop_those) and the “rule of law” slogan in 2014 (read more on: https://cpianalysis.org/2015/05/28/xi-jinpings-rule-of-law-with-chinese-characteristics/) Jiefu was confident that the laws would now be obeyed. (Allison et al., 2015, p.4)
Li (2017) believes that this at least official announcement also resulted from international pressure. (personal communication, 20.4.2017) Various international declarations such as the Nuremberg Code, the World Health Organization, the World Medical Association and the Declaration of Istanbul to name a few clearly denounce the organ procurement from prisoners as these cannot give a free consent. They are coerced by the prison environment and the prospect of execution. (Sharif, Fiatarone Singh, Trey & Lavee, 2014, p.1) Hence the Transplantation Society imposed an academic embargo on Chinese physicians engaging in these practices so that, for instance, these cannot attend international congresses or publish articles in the medical literature. (Delmonico et al., 2014, p.795)
As medical professionals and international journalist believed that the situation had changed (Allison et al., 2015, semantic trick article) the announcement seemingly had the effect the Chinese government wished for albeit it may only have been a semantic trick.
Change after the statement
Problems after the announcement – Why people believe there has been a change
After the announcement of Jiefu in December 2014, Chinese people think that the situation changed and the organ harvesting from prisoners is abolished. Still Jiefu did also state, that if the executed prisoners give their consent, organ donation it is still legal (China’s semantic trick with prisoner organs). It is problematic that one still can and will not control if the prisoners give their consent or not. After all, they will be dead anyway. Our interview partner, blabla expert Mr. Li, also enforces that “in such a system with no law, how can we guarantee that the consents are true”? He repeated that later in the interview, stating that the consent is obtained from the prisoners. (interview Mr. Li 20. April 2017 → maybe highlight quote/ put into a separate box?) Also concerning the prison environment, where coercion definitely is not rare.
Jiefu is still convinced that executed prisoners should have the possibility to atone for the crime they committed, that they should have a chance to repay the society (Historical development and current status). He agrees, though, that it should be done voluntarily. (China’s semantic trick with prisoner organs) Theoretically, if it worked the way Jiefu is claiming, the system would not be too bad. There should be a fair and transparent system in organ donation and if a prisoner actually agreed on donating his organs, why not use them legally instead of trading them on the black market. But such a situation is highly doubted and quite naïve to think of.
In another interview in January 2015, Jiefu disclosed – probably due to external pressure – that instead of including the prisoners in the legal system they want to completely abolish the practice of using organs from executed prisoners. (Historical development and current status) However, it is a given that there is still a big mismatch between supply and demand, so the government will continue using prisoners’ organs, also for economical reasons.
One other major change with the announcement is, that the organs are now classified as “voluntary donations by citizens” instead of organs from executed prisoners. Consequently the recipient cannot tell where the organ is actually coming from, making the system even less transparent than it was before. (China’s semantic trick with prisoner organs)
There was a conference on organ trafficking in the Vatican to which Jiefu also had been invited. He asserted there that the use of organs from prisoners is not allowed, nevertheless, in a country as big as China this law can easily be violated. (https://www.theguardian.com/world/2017/feb/07/china-still-using-executed-prisoners-organs-transplants-vatican)
Remaining supply and demand gap – Possible solutions
As mentioned above, China has always had a problem with the immense gap of supply and demand. The official data provided by the government often varies. For example, Jiefu stated in one interview, that there have been 2342 liver donations from 2011 to 2014, in another interview, one week later the number was 1910. (China’s Organ Transplant Problem) In March 2014 there were only 10’000 registered patients waiting for an organ transplant, although due to estimations there should be like 300’000 people needing an organ. Jiefu responded to that saying that people could not pay the costs for the transplantation, so they would rather “give up”. In March 2015 the number of people waiting for an organ was 22’000. (Historical development and current status of organ procurement in China) Although the numbers are quite inconsistent it is still easy to see that there is a big mismatch between demand and supply, meaning that the official system cannot provide the market with enough supply.
Furthermore, some smaller organisations have been making calculations, using utilization rates of beds from transplant wards in combination with the number of beds available. The number exceeds the official numbers by far. (China’s Organ Transplant Problem) That means, that a lot more transplantations are conducted as officially reported.
Our interview partner, Huige Li, MD, PhD, is convinced, that prisoners’ organs should not be used at all. In order to close the huge gap between demand and supply he sees possible solutions in structural changes. For instance corruption in the whole transplant system should be eliminated. This would consequently also lead to more fairness in the allocation process and everyone could get the same chance. (Personal communication, 20.04.2017) Additionally the Red Cross and the Chinese government should start working together closely in order to rise the awareness of people. The government should also consider to provide incentives to promote organ donation.
Nevertheless they are trying to find a solution: In December 2016 Jiefu introduced inscribing as a organ donor through Alipay – a Chinese online payment platform. (http://english.cctv.com/2017/03/09/ARTIXpkGZ6Y3IY7dq4AnoaZl170309.shtml) Instead of filling out loads of different forms, people can now subscribe easily as a organ donor within less than a minute. Since it was introduced in December 2016, already more than 80’000 people registered as a organ donor, which is the same amount of people that registered since the system was introduced in 2010. (http://www.chinadaily.com.cn/china/2016-12/23/content_27751049.htm) → find more about organ donation promotion through social media, also see effects in other countries, other sources: (http://news.xinhuanet.com/english/2016-12/22/c_135926024.htm)(http://www.sixthtone.com/news/1729/alipay-organ-donation-just-few-taps-away)
Current organ donation system
The official national donation system in China started in 2014 (Bloody Harvest/ The Slaughter, p. 402) but until today it is not very successful. According to Jiefu the rate is 0.6 voluntary donors per million people. The World Health Organisation speaks of a much lower number of 0.03 donors per million. Still Jiefu would declare the transformation after the introduction of the system as successful. (Bloody Harvest/ The Slaughter, p. 403) This is not the case, since a lot of people still are backing off donating their organs when there is no blood-relation or something similar to the recipient.
One example to illustrate how low the numbers actually are, is Shanghai. There were only five organ donations made in 2015, although the infrastructure would give the possibility to carry out many more. Another problem is that if someone dies, one would have to remove their organs immediately due to the short ischemia time – the time slot after someone’s death in which one’s organs can be removed. It lasts mostly only for several minutes. Hence the convenience of harvesting organs from executed prisoners: One knows the exact time of death and everything for the transplantation can be set up beforehand.
However, it takes some time to contact the family and ask for their permission. Therefore this process should be sped up in order to be more efficient. Other problems that can occur are that the requirements for the organ donation are not met or that the organs are not transplantable. (Bloody Harvest/ The Slaughter)
What are the key drivers for China’s low donation numbers? How was the situation before 2015? What did China change and was there a change at all? And finally, where is China heading to?
All in all, one can say that the key drivers for the bottommost organ donation rate and thus resulting in a gargantuan supply and demand gap emerge from two sources. Firstly, the role of religion and cultural understanding in China, such as the confucian rule that the body has to be kept pristine after death. Secondly, it is all about trust and transparency, e.g. that in chinese hospitals you mostly do not know where the organs are sourced from.
→ Add own opinion?
Taking this and international pressure into account, China’s government saw the urgency to act. The shift of China not to use prisoner’s organs started with Jiefu’s announcement to stop using organs from prisoners. During our research, we perceived that Jiefu’s announcements are confusing and contradictory. According Jiefu’s first statement China wanted to stop organ harvesting from prisoners generally. This was also one crucial argument by Li: No organs from prisoners (which is also the international standard). In another interview, Jiefu stated that China will only accept organs donated voluntairly by prisoners. Which is indeed not adapted to international standards. In our view this is neither consistent nor effective because the organs can easily be labeled as voluntarily donated and bothers the idea of a necessary transparent system.
→ Add some more information?