Journal of the Royal Society of Medicine March 2007 edition
By Tom Treasure
The numbers of organ transplants
performed in China and the speed with which organs become available has raised
international concern about the source of organs. It is publicly declared that
organs come from executed criminals and that consent is given but there are
allegations of an even more macabre scenario – that prisoners are systematically
subjected to surgery specifically to remove their organs for transplantation. In
this essay I explore the plausibility of this claim against our knowledge of
doctors’ complicity with the events leading to the holocaust and the
practicalities of contemporary organ transplantation.
Organ transplantation
has increased in China at a remarkable rate. One institution reported 647 liver
transplant operations in about a year. The waiting times are between one and two
weeks according to Chinese Hospital web pages. Price lists are available with
dollar sums well below others in a global health market and under a tenth of
those in the USA. To become organ donors people have to die young, and under
particular circumstances, so organs are generally scarce and waiting times can
be long. In China there is a numerical gap between the likely number of donors
and the number of organs evidently available in spite of that fact that organ
donation has met resistance in Chinese culture. From May 2006 organ
transplantation came under regulation for the first time2 but the question still
arises, how have these transplant teams achieved such rapid expansion and such
short waiting times? An allegation has been made that in China the bodies of
healthy living people have been systematically eviscerated and their organs
taken for transplantation.
It is now accepted as
fact that the organs of executed criminals in China are used for transplantation. It is
claimed that they consent, but can this be freely given? That apart, an
argument of the
greater good and lesser evil can be invoked: if an individual has lost the right
to life under judicial process, perhaps he has also lost the right to have his
kidneys buried with him. Why should they be wasted when two innocent victims of
renal failure could have an improved and extended life? But there is a still
greater concern. As part of an expansion in religious activity into the
ideological vacuum left by the collapse of communism, a spiritual movement
called the Falun Gong has grown. Practitioners meet to perform their exercises
and to meditate. They are pacifist by inclination and seek to meld modern
science with Chinese traditions. It is hard to determine why they have attracted
such disfavour but they are cast as seditious and undesirable.4 It seems that
they are incarcerated in their tens of thousands in order to correct their way
of thinking. Apparently when arrested, they are routinely blood tested. There is
no reason to believe that it is for the benefit of the Falun Gong but blood
group matching is critical to organ donation. The suspicion that Falun Gong
practitioners are a source of organs is central to the investigative work of
David Matas and David Kilgour who have formulated the allegation. The recipients are
predominantly those travelling internationally for health care; if Matas and
Kilgour are correct the organs come from incarcerated members of an innocent
sect; and the perpetrators are of necessity medical practitioners. As the
allegation unfolds, the story seems horrific to the point of being beyond
belief. So alarmed was I on learning of this allegation that I struggled to make
sense of it. The element of the story that horrifies me most, if it is true, is
that it is my medical colleagues, the doctors, who perpetrate these acts. This
is the only element that I have the capacity to address. While I cannot get more
evidence than has already been offered3 I can at least test this allegation for
credibility.
Transplantation of
kidney, liver, cornea, heart and lung offer benefit in survival and/or life
quality for the recipients, in an approximate descending order of QUALYs gained.
The sum total of quality adjusted life years donated by the dead person to
others is considerable, and very great indeed if multiple organs are donated and
successfully transplanted into several individuals. To achieve that goal the
operation on the donor and the allocation of organs must be expertly
coordinated. I have been party to both removing and transplanting various
organs. My personal involvement peaked in the weekend when I successfully
transplanted hearts into three patients within 72 hours. A necessary preliminary
was the process of removing those organs and it is incompatible with organ
removal after execution. What happens is that an anaesthetic team continues to
monitor and carefully adjust the vital physiology of the person declared brain
dead, solely in order to maintain viable organs for transplantation. The heart
and lungs are kept functioning while meticulous dissection and mobilisation of
the liver is completed. Then, in a rapid sequence, the organs – heart, lungs,
liver, kidneys and then corneas - are removed, preserved and taken away. These
are the necessary practicalities of the donor’s operation, and it should be
noted that it is not compatible with retrieving organs after any process of
judicial execution. The unprepared normal person might well find this both
macabre and repulsive but transplant teams have to necessarily immure themselves
from these emotional and visceral responses. How have we arrived at
this point? Medical ethics are neither absolute nor static. In the West we have
repeatedly challenged prior beliefs and stretched the norms of behaviour in the
last fewdecades. For example, termination of pregnancy and manipulation of
fertility (in both directions) have attracted extensive negotiation and there is
still no unanimity on many points. The distinction between life and death has
been redefined, specifically for the benefit of transplantation. A kidney from a
cadaver can recover while the recipient is supported on dialysis but once the
myocardium necroses, the heart is irretrievable dead. It was the absence of a
heartbeat that defined death until the advent of heart transplantation very
publicly forced the issues in the late 1960s. Once the process of dying is
completed to the point that the heart stops or fibrillates, it is likely to be
of damaged beyond recovery. For heart transplantation to succeed, death had to
be redefined as brain death. Transplantation unquestionably pushed the
boundaries of what doctors would and would not do and in turn society accepted
new definitions. For multiple organ donation to be achieved something that would
have been horrific in another time became not only tolerable but laudable under
the new rules. The blunting of our visceral responses and the redefining of
ethical boundaries are steps that could lead us, if we are not careful, to the
ethicists’ slippery slope and must be recognised as such. But can there be any
possible precedent which would make even remotely credible the allegation that
doctors engage in the systematic harvesting of organs from unconsenting healthy
victims? In the 1930s the first
steps on the road to the holocaust were taken - and they were taken with the
complicity of doctors.5 How this came about merits attention; if we do not
recognise the facts and understand how it happened, how can we guard against it
happening again? In Germany, as everywhere, there were people in long term
institutional care. Such patients vary in their capacity for interaction with
their carers; at one end of the spectrum there is no evidence of awareness or
any capacity for sensate being. The view arose, as it inevitably does, that if
their lives were to slip quietly away it would be no loss. Perhaps it would be a
blessing. It must surely be a relief for their families. And then there were the
saved resources of time, money and love and devotion from parents and nurses
that could be released to a better purpose. Their state was captured in the
German phrase lebensunwertes Leben meaning “life unworthy of life”.5 The
ethical question was whether it was permissible to take any active steps to
bring about their end; in parallel the medical question that arose was how it
might be done. How it might be done is in itself important because if the stark
truth of what we are doing can be masked by the argument of secondary intent, it
may be found permissible to bring about the end of life. Various methods were
considered. Putting in place a policy of increasing sedation to reduce any the
possible distress was one. Another was starvation by systematic underfeeding or
a feeding a diet designed to be deficient in some essential component. But how
to implement the policy? A
team of doctors was asked to devise a questionnaire, a form, on which could be
collected information about the individual’s functional level. The job was done
and criteria were established. These
questionnaires were completed on all potential lebensunwertes Leben
patients by another set of doctors. It seems likely that the carers who
completed these forms were inclined to overstate the degree of disability,
evidently in the belief that this would bring more care to their charges rather
than less. The forms then went to three independent assessors who in turn were
asked to take a view, against proffered criteria, as to whether this was a life
not worth living. The second and third assessor could see the previous opinions
on the form, which had the effect of encouraging unanimity. The forms were
returned to a bureau and medical transport teams were dispatched to bring those
individuals identified as lebensunwertes Leben to another facility where
the treatment was administered. Finally, a doctor would phrase a plausible death
certificate. And so it was done. The cogs turned but none knew the purpose of
the whole machine. There was a paper trail which is why we can be sure that what
I have written happened.5 There were let outs for those who got an inkling of
what was going on and demonstrated themselves to be “not up to the task”. They
could be relieved of these duties and transferred to other work. With the onset
of war incomprehensible horror ensued but it was the policies and methods
developed for the lebensunwertes Leben which provided a blue print for
what followed, and doctors were implicated throughout.
So how does this
relate to transplantation? Of its nature there are cogs turning to drive this
machine also. The
carers of the potential donor see no future for their ventilator dependent
charges. They inform
transplant co-ordinators who have a laudable mission to maximise the
opportunities for the many potential recipients and work towards obtaining
consent from the families. An international network, established on the basis of
fairness, is informed of the availability of donor organs. The designated
retrieval team, usually trainee surgeons or so called “research” or transplant
fellows, go where they are sent for they have a job to do. It is nearly always
at dead of night, when the operating theatres are free and road and air routes
are clear, and it is always under extreme time pressure to maximise the quality
of the organs. Meanwhile the transplant teams call recipients off waiting lists
and set up urgent transplant operations, in several different hospitals, all
against the clock. The time pressure, the geographical dispersion, the
complexity of the matching of multiple organs, the need to respect
confidentiality and the anonymity of donor and recipient, and the sheer
logistics of it all means that no member of the medical staff has an overview of
the whole process. Nor would they expect to in China. This is what makes it
plausible that it could happen and that doctors themselves could do it, largely
unaware, or at least sufficiently distant to turn a blind eye and a deaf
ear. Revealing the exact
source of all donor organs, with a complete and transparent paper trail would be
sufficient to refute the allegations but interestingly it may well be difficult
to do even in countries more open than China is at present. In the circumstances
in which I was involved, there was an explicit understanding that the process
only starts when it is what the donor would have wished but the fact is that I
was never been in a position to inspected the documentation of the consent
process. The hearts arrived in our operating room without a name attached and by
then the recipient was anaesthetised and we were well on the way to removing the
sick heart. Factors that make the allegations plausible are the partitioning of
the logistic elements and technical steps just as described for transplantation
anywhere, and the necessity forhaste. What makes it credible are the numerical
gap between the reported number of transplants compared with what is possible in
other countries, the short waiting times and the confidence with which
operations are offered in the global health market1 and the routine blood
testing of the Falun Gong. References 1. China International
Transplantation Network Assistance Center. The cost of the transplantation. http://archive.edoors.com/render.php?uri=http%3A%2F%2Fen.zoukiishoku.com%2Flist%2. 2006. Ref Type: Electronic
Citation Last accessed 9th October
2006 2. Zhang Feng. New
rule to regulate organ transplants. http://www.chinadaily.com.cn/china/2006-05/05/content_582847.htm. 2006.
23-9-2006. Ref Type: Electronic
Citation Last accessed 9th October
2006 3. Matas D, Kilgour D.
Report into allegations of organ harvesting of Falun Gong practitioners.
http://www.davidkilgour.ca/. 2006.
23-9-2006. Ref Type: Electronic
Citation Last accessed 9th October
2006 4. Chinese Embassy.
http://www.chinaembassycanada.org/eng/xwdt/t261810.htm. 2006.
23-9-2006. Ref Type: Electronic
Citation Last accessed 9th October
2006 5. Lifton RJ. The Nazi
Doctors. Basic Books USA; 2000.