FRESH ORGANS, MOULDY SOURCE?

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Illegal! Prisoners! Corruption! China?

6 out of 10’000’000. This is the number of voluntary organ donations in China. Not only is this the lowest number worldwide, but also one of the root causes of China’s flourishing illegal organ harvesting from prisoners. This has been covered to a great extent in Western media, mostly negatively. Due to significant international pressure, China attempted to ban illegal harvesting of organs on January 1st 2015. Thus the following blog post will have a closer look at this opaque system. What are the key drivers for China’s low voluntary donation numbers? How did the situation look like before 2015? Was there a change in China and, if so, what has changed? And, finally, where is China heading to? These are the leading questions we try to give an answer to in this blog entry.

The following illustration shows the answers submitted to a question we asked during a presentation given to the fellow students. The bigger the word, the more students mentioned it. As one can obviously notice, many negative words were associated with China regarding organ transplantation. The four keywords this blog post is aiming at discussing further are prisoners, corruption, and government.

MentiStatsQuestionnaire Menti.com, 04.05.2017, (Source: Own Illustration).

How did the situation look like before the regulatory announcement in 2015?

In order to set a proper context, we are going analyze at the situation in China before 2015 and are going to illustrate the main drivers for the low number of voluntary organ donations.

While China has the lowest organ supply in the world,  the demand stands roughly at 300’000 per year. The gap between the number of people needing organs, and organs available for transplantation is therefore huge – as the following graph depicts. Chinese people do not want to enlist as donors, mostly because according to Confucianism it is required to keep the body intact after death to pass on to the afterlife. Despite the decrease of this religious practice as more and more Chinese become atheists, the culture of not wanting to be an organ donor is still strong and thriving.
TheGap        The gap between organ supply and demand (Source: Own Illustration).

Additionally, people’s distrust in the Chinese waiting list system diminishes the number of voluntary donors, since it is believed that people can pay their way to the top of the list (Gutmann, Kilgour & Matas, 2016, p. 400–405). This has been made possible through the marketization of organs over the past few decades. During the course of this marketization process, a shift from organs as inalienable parts, embedded in our bodies, to commodities, which can be traded for a surplus, has occured. (Parry Bronwyn, 2012, p. 214) In our interview with Huige Li, a doctor from China, working for Doctors Against Forced Organ Harvesting (DAFOH), he confirms that corruption is a major flaw of the current waiting list system. In 2013, a famous court case proved the existence of corruption in the allocation process. A woman in need of a kidney paid the doctors in order to get a new organ sooner than those above her in the list. This turns out to be an accepted practice, as the state also indirectly benefits from such a business, as costs of keeping the hospitals running are lower. (personal communication, 20.04.2017) Therefore, this court case clearly shows how a market value gets assigned to organs as they move into the commodity state. One particular boost for this business was the shift from bodily parts as proxies, belonging solely to an individual, which could hardly be transferred into other bodies. With the technical and medical enhancement in China, this paradigm has been softened. According to Parry Bronwyn (2012), the whole human body and its proxies became hypermobile, or, to put it in other words: “Capable of being circulated with great ease at a high speed.” (p. 217)

China’s organ harvesting practice from executed prisoners received heated international criticism. The organ harvesting is based on informal arrangements between hospitals and the local courts, supervising the penal system. For decades, organs from executed prisoners were taken without the consent of the prisoners in question (cf. European Parliament: Directorate General for International Policies, 2016). For instance, the 1984 regulation allows the organ procurement from executed prisoners, if the body is not claimed, or if the consent of the prisoner or his family has been granted. Only in 2007, a further regulation on human organ transplantation ruled that a written consent has to be obtained prior to removing someone’s organs. However, this rule was largely ignored (Allison, Caplan, Shapiro, Els, Paul & Li, 2015a, p. 2–4). This dealing with the executed prisoners shows that a process of dehumanization is taking place (cf. Phillips, 2013, p. 24). The prisoners are not treated as human beings, but merely as things. Recently, China has started paying attention to this issue, but how serious are they about tackling this problem?

China has tried to fight against the problem of low numbers of donors through various donation programs and schemes. For example, in 2010, China piloted an organ donation program in Shanghai, and eventually in 26 provinces and cities throughout the country. This program was jointly run by the Ministry of Health and China Red Cross (Wu, 2012). On 25 February 2013, the national organ donation working video meeting reported that only 659 donations had occurred nationwide since March 2010 (Red Cross Society of China Sichuan Branch, 2013). Hence, the campaign remained unsuccessful, despite having invested a lot into the improved public image of organ donation.

The announcement: What is it?

In this part, 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. We will first find out what changes China intends to implement in its legal system and then consider the motivation behind the change.

According to Huang’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., 2015a, 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. Consequently, critics make the point that this announcement is merely a “statement of good intention but has no force of law”. (Allison et al., 2017a, p. 3) Yet, Huang 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 criminalises 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., 2015a, p. 4) As a matter of fact, Huang 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, accessed 29.04.17) 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

According to Huang the main reason for this announcement is the following: 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 and the “rule of law” slogan in 2014 Huang was confident that the laws would now be obeyed. (Allison et al., 2015a, p. 4)

Li believes that this announcement was also a result of increasing international pressure. (personal communication, 20.04.2017) Various international declarations, such as the Nuremberg Code, the World Health Organization, the World Medical Association, and the Declaration of Istanbul, clearly denounce the organ procurement from prisoners, as these cannot give a free consent. The prison environment, as well as the prospect of execution, coerces them. (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 academics cannot attend international congresses or publish articles in the medical literature.  (Delmonico et al., 2014, p. 795)

But while the medical professionals and international journalist believed that the situation had changed (Allison, Shapiro, Els, Paul & Li, 2015b), the announcement seemingly had the effect that the Chinese government wished for, albeit it may have been no more than a mere semantic trick.

Real change or only a cover-up?

Many of the Chinese think that the situation has changed since the announcement of Huang in December 2014, and that organ harvesting from prisoners is abolished. But is this really the case, or was the announcement just a hoax by the government to appease the public?

In the following video, we put different pieces of interviews together to demonstrate how varying the official statements of the Chinese officials (i.e. Huang Jiefu) are.

The main problem is that organ donation from prisoners is still legal, as long as they give their voluntary consent. Huang remains convinced that executed prisoners should have the possibility to atone for the crime they have committed, and to repay their debt to the society (Allison et al., 2015a, p. 5). Theoretically, if the system would be working the way Huang is claiming, it would not be too bad. There should be a fair and transparent system of organ donation, and, if prisoners agree on donating their organs, why not use them legally instead of trading them on the black market. But such a situation is highly arguable, as prisoners are not able to make a free and informed decision about donating their organs, while the prison environment is generally one of coercion. Moreover, there is no system in place that would make sure that the prisoners’ consents really are given voluntarily.

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So the major change after the announcement has not been the abolishment of using prisoners’ organs, but rather that they are now classified as “voluntary donations by citizens”. This makes the organ donation system even more intransparent, since the recipient cannot tell where the organ he receives is actually coming from. (Allison et al., 2015b) There are, however, also some statements by Huang that, instead of including the prisoners in the legal system, they want to completely abolish the practice of using organs from executed prisoners. (Allison et al., 2015a, p.4–5) But these statements are driven by the external pressure, and have to be taken with a grain of salt as there is still a big mismatch between supply and demand, which has to somehow be closed. At a conference on organ trafficking in the Vatican, Huang also asserted that the use of organs from prisoners is not allowed in China anymore. But he added that in a country as big as China this law can easily be violated without any tangible consequences. (Kirchgaessner, 2017)

Remaining supply and demand gap – Possible solutions

As mentioned above, China has always had a problem with the immense gap between supply and demand, where the official system cannot provide enough organs to meet the demand. Even though the official data, provided by the government, often varies, in the end, a gap can always be observed. There is a number of organizations that have been making calculations by using utilization rates of beds from transplant wards, in combination with the number of beds available. These numbers by far exceed the official numbers, meaning that a lot more transplantations are conducted than officially reported. (Lavee, J. & Robertson, M., 2017)

Our interview partner, Huige Li, is convinced that prisoners’ organs should not be used at all. In order to close the huge gap between demand and supply, he sees the only possible solutions in structural changes. For instance, corruption in the whole transplant system should be eliminated. This would also lead to a fairer allocation process, and everyone would have the same chances of receiving an organ. (Personal communication, 20.04.2017) Additionally, the Red Cross and the Chinese government should start working together more closely in order to raise awareness of the general public to become organ donors. The government should also consider providing incentives to promote organ donation. Here, according to Sandel, it has to be taken into account that market incentives may not be an ideal solution due to the shift of a market economy, which is a tool for organizing productive activity, to a market society, where market values and market thinking are in every sphere of life, and where almost everything is for sale. Subsequently, there would be a tendency that market thinking erodes market values worth caring about. In our case, we have to ask ourselves which goods were at stake if economic mechanisms were applied. We find that human dignity, as well as personal bodily integrity, was at odds. Even though the choice to donate one’s organs might be made voluntarily, it might still be degrading, as organ donation is not consistent with one’s bodily integrity. In the end, selling organs for money would drive out and devalue the altruism of giving.

The official national donation system in China started in 2013 (Gutmann et al. 2016, p. 402), but until today it is not very successful. Only very few people actually signed up as organ donors, nevertheless, Huang declares that the transformation after the introduction of the system was a success. (Gutmann et al., 2016, p. 403) To show you how low the numbers of voluntary organ donations really are, let us look at the example of Shanghai. In 2015, there were only five organ transplantations performed, although the infrastructure would have given the possibility to carry out much more.

The government of China is aware of this problem, and they are trying to find a solution as well. In December 2016, Huang’s foundation introduced the possibility of inscribing as an organ donor through Alipay – a Chinese online payment platform that has over 450 million users. (He, 2016) Instead of filling out many of different forms and undergoing a rather complicated process, people can now register as organ donors in less than ten seconds. Since it was introduced in December 2016, more than 100’000 people have already registered. This figure counts to more than the total number of people who have registered at the Red Cross since the official organ donation system was introduced in 2014. (Deng, 2017) The success of this new sign-up method lies in its convenience, and easiness to handle.

Alipay
Organ donation on Alipay. (Source:http://www.sixthtone.com/news/1729/alipay-organ-donation-just-few-taps-away)

Besides the problem that not many people register as organ donors in the official national donation system, another issue is the short ischemia time – the time slot after someone’s death, in which their organs can be removed. Doctors usually only have a few minutes after someone’s death to transplant the organs. This makes harvesting organs from executed prisoners very convenient: one knows the exact time of death, and everything for the transplantation can be set up in advance. In all the other cases, it takes time to contact the family and ask for their permission, which often means that organs will not be transplantable anymore despite the consent being given. (Gutmann et al., 2016, p. 405) This problem can be partially counteracted through the new possibility of registering ahead as an organ donor through Alipay. In this case, the doctors do not have to wait for the family’s consent. With more people being officially registered as organ donors, the process could become significantly faster, and more organs can be transplanted within the ischemia time.

One of our Chinese friends, living in Beijing, recently decided to become an organ donor. So we asked him for his reasons to become a donor. He is convinced that his organs would enter the official system, and then go to the people that need it most. His biggest motivation in registering as an organ donor is being able to help other people after his death.

Quote3.pngSince he is a doctor and has been working in the hospital for quite some time already, he is well aware of the low organ supply. He registered through the Alipay-link, which he found extremely easy and self-explanatory even for the most inexperienced person. (personal communication, 06.05.2017)

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In a Nutshell

In our opinion, the two key drivers for the bottommost voluntary organ donation rate in China are the role of religion and cultural understanding, as well as the lack of trust and transparency in the official organ donation system. This results in a gargantuan supply and demand gap, which the Chinese Government tries to close with the use of prisoners’ organs. Ethically this practice is strongly criticized internationally, which led to Huang’s announcement in 2014 to stop using organs from prisoners.

At first sight, the announcement of 2014 seemed to us like a change for the better. However, we came to the conclusion that this has to be profoundly questioned due to a great number of Huang’s contradictory statements. We believe that the Chinese government is still using prisoners’ organs – the only difference being that they are now labeled as voluntarily donated organs. Instead of closing the gap this way, we suggest that the focus should be set on acquiring more voluntary donors in society in general. In our view, the only ethically correct way is to establish a trustworthy and transparent organ donation system. The Chinese governments’ approach with the help of Alipay seems very mostly due to its convenience, accessibility and easiness to use.

Instead of closing the gap this way we suggest the focus should be more on acquiring more voluntary donors in society in general. In our view, the only ethically correct way is to establish a trustworthy and transparent organ donation system. The Chinese governments’ approach through Alipay seems very promising because it is conveniently accessible and easy-to-use.

The question remains if the government succeeds in implementing this system – what do you think? Comment below!

Our research methods:
– Collecting, analysing and interpreting mostly qualitative data from news articles, videos and academic articles.
– Interview with Huige Li (studied medicine in China, currently researching in Germany) and Page Peng (medicine student at Beijing University).
– Contact via email with Yu-Tao Xiang (Psychiatrist at Bejing Hospital) and Torsten Trey (executive director of Doctors Against Forced Organ Harvesting).
– Critical approach to the data due to the research difficulties.

Research difficulties:
– As it is a highly controversial topic we encountered different information from Chinese officials and the media, for instance regarding the number of prisoners executed for their organs or the number of transplantations made in China.
– We had to pay attention to biases in Western media as well as in Chinese sources which may not be as critical as sources from outside of China.
– Yu-Tao Xiang was very helpful at first, later on he did not agree on an interview anymore and referred us to Huang Jiefu.

Sources:

Allison, K., Caplan, A., Shapiro, M., Els, C., Paul, N., & Li, H. (2015a). Historical development and current status of organ procurement from death-row prisoners in China. BMC Medical Ethics. doi:10.1186/s12910-015-0074-0.

Allison, K., Shapiro, M., Els, C., Paul, N., & Li, H. (2015b). China’s semantic trick with prisoners organs. Retrieved from http://blogs.bmj.com/bmj/2015/10/08/chinas-semantic-trick-with-prisoner-organs/

China Daily. (2014). China to scrap organ harvesting from executed prisoners. China Daily. Retrieved from http://www.chinadaily.com.cn/china/2014-12/04/content_19025683.htm.

Delmonico, F., Chapman, J., Fung, J., Danovitch, G., Levin, A., Capron, A. & O’Connell, P. (2014). Open Letter to Xi Jinping, President of the People’s Republic of China. Transplantation, 97(8), 795-796. doi:10.1097/tp.0000000000000150.

Deng, J. (2017). Internet helps promote organ donation in China. Retrieved from https://news.cgtn.com/news/3d55444f31676a4d/share_p.html?t=1488774312122.

European Parliament: Directorate General for International Policies. (2016). Proceedings of the Workshop on Organ Harvesting in China.

Gutmann, E., Kilgour, D. & Matas, D. (2016). Bloody Harvest/ The Slaughter – an Update. Retrieved from http://endorganpillaging.org/an-update/.

He, W. (2016). Alipay lets organ donors register online. China Daily. Retrieved from http://www.chinadaily.com.cn/china/2016-12/23/content_27751049.htm.

Kirchgaessner, S. (2017). China may still be using executed prisoners’ organs, official admits. The Guardian. Retrieved from https://www.theguardian.com/world/2017/feb/07/china-still-using-executed-prisoners-organs-transplants-vatican.

Lavee, J. & Robertson, M. (2017). China’s Organ Transplant Problem. The Diplomat. Retrieved from http://thediplomat.com/2017/03/chinas-organ-transplant-problem/.

Parry, B. (2012). Economies of Bodily Commodification. John Wiley and Sons. doi:10.1002/9781118384497.ch13.

Paul, N., Caplan, A., Shapiro, M., Els, C., Allison, K. & Li, H. (2015). Human rights violations in organ procurement practice in China. BMC Medical Ethics. doi:10.1186/s12910-017-0169-x.

Red Cross Society of China Sichuan Branch. (2013). National Human Body Donation Work Video Conference held. Retrieved from http://2010.scredcross.org.cn/html/detail.asp?ID=5151.

Sharif, A., Fiatarone Singh, M., Trey, T. & Lavee, J. (2014). Organ Procurement From Executed Prisoners in China. American Journal of Transplantation, 14, 2246-2252. doi:10.1111/ajt.12871.

Wu, P. (2012). China ’s organ donation pilot two years not broken supply and demand disparity. Retrieved from http://news.sciencenet.cn/htmlnews/2012/3/261753.shtm.

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