China's organ transplant system in transition

The Lancet, Volume 377, Issue 9781, Pages 1905 - 1906, 4 June 2011

Article>doi:10.1016/S0140-6736(11)60794-0Cite or Link Using DOI

China's organ transplant system in transition

Ted Alcorn
China is attempting to move towards a more ethical, voluntary organ donation system that can service the nation's growing needs, but, as Ted Alcorn reports, that is proving easier said than done.
Dressed in striped hospital pyjamas, Wang Guoqiang stands before a poster advertising living organ donation, examining the images of families who previously underwent the procedure. He is in the urology department of Beijing's PLA Hospital 309, where he was brought from his farm in Hebei province 2 months ago with severe uraemia.
To save his life, the doctors replaced his failing kidneys with dialysis, but he needs a donor kidney to survive in the long term. And while he waits for a match, his family must pool their incomes to pay the CNY8000 (US$1200) monthly cost of his ongoing treatment, a staggering amount for a poor Chinese household. He dismisses the cost: “You know, when you are in my condition, money is no longer important. Life, we want life.” His future—along with that of more than 1 million other Chinese people who need replacement kidneys, livers, lungs, and hearts—now depends on China's organ transplantation network, a system beset by scarcity and criminality but struggling to reform.
In China, as in nearly all other countries, the number of patients in need of transplants far exceeds the number of organs available. China is unique, however, in trying to make up this imbalance by harvesting organs from the prisoners it executes, a policy fiercely criticised by foreign transplant specialists and human-rights advocates. “There is absolutely no excuse to be sourcing organs from prisoners in a system in which due legal process and the right of informed consent are by any means questionable”, says Phelim Kine, an Asia researcher with Human Rights Watch, “and in China they are highly questionable and highly unreliable”.
In recent years, Chinese officials have acknowledged that prisoners are not an appropriate source of organs, but reliance on the existing system has proven hard to break. Without first developing an alternative source of organs, rolling back this policy would be akin to a death sentence for waiting patients like Guoqiang. Michael Millis, an American transplant specialist who has worked closely with the Chinese transplant community, says this situation puts the government in a difficult position. “It's what I refer to as kind of the genie out of the bottle, in that once the genie is out of the bottle, it's impossible to get the genie back in.”
The scarcity of organs in China has also fostered a black market for illegal transplants, glimpsed by the public only through occasional reports such as the March, 2011, investigation by the Chinese newspaper Southern Weekend, which chronicled the story of a migrant worker named Hu Jie who was forced by traffickers to sell his kidney.
Even when coercion is not involved, offering organs to the highest bidder is an unethical method for distributing them, says Francis Delmonico, former head of the United Network for Organ Sharing. But he observes that, often, profits trump morals: “transplantation is a business and can be a big business”. Chinese transplant programmes routinely sold organs to both nationals and foreigners until 2007, when laws were finally passed prohibiting the practice. And transplant specialists in the USA and Europe say that they still occasionally see patients for postoperative exams who report having purchased their transplants in China.
The person tasked with rectifying all this is Vice-Minister of Health Huang Jiefu, a liver-transplant specialist who still practises medicine alongside his political work. He is unusually forthright about China's problems, and although he says that progress during his tenure has been less than he had hoped for, most observers praise him for what he has achieved.
While acknowledging that the black market still exists, he tells The Lancet that many of the grossest abuses have been curbed. “Before the year of 2007, there were over 600 medical institutions performing organ transplantations; this was a very chaotic situation because there was a lot of financially-driven malpractice and substandard transplants taking place.” By licensing transplant programmes and holding them to a set of standards, he now reports that only 163 programmes are authorised to undertake such surgeries.
But enforcing standards is more difficult than composing them. Unlike many wealthier countries, the Chinese central government provides little funding to hospitals, which restricts its ability to sanction them for infractions by withholding that money.

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China has introduced licensing and sets of standards for its transplant programmes

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China's Vice-Minister of Health, Huang Jiefu, is reforming the transplant system
Shi Bingyi, a transplant surgeon and vice-chair of the China Medical Organ Transplant Association, points out that the returns for doing unauthorised transplants are still enormous compared with the risk of punishment. “It is just like driving without a licence: it's banned in all countries since day one but people keep violating it. Why? Because when they hit the road without the licence, they…do what they want. Some doctors may argue that they do this [unauthorised transplants]out of humanitarian concern for the patient who urgently needs a new kidney; others may do it purely for financial gain; still others for prestige. But whatever the cause is, it's wrong.” Huang agrees that strengthening enforcement is crucial, but he refers to a handful of hospitals that were recently stripped of their licences as evidence that oversight is increasing.
Underlying all these problems is the insufficient quantity of donated organs, so Huang says his top priority is to develop a voluntary organ donation system that draws from the general population. In March, 2010, the Ministry of Health partnered with the Red Cross Society of China to initiate pilot programmes in 11 provinces and municipalities, with the objectives of encouraging posthumous donation and of establishing a registry of donors and a waiting list of those in need.
Progress has been gradual. More than a year underway, the programmes have facilitated fewer than 60 transplants, a minuscule portion of the 8000 done in the country in 2010. But Millis, who helped design the programmes, says that the transition demands substantial, if intangible, changes in the behaviour of individual physicians as they gradually become familiar with the criteria and procedures for non-heart-beating donation. “Even down to the micro-level, huge changes in the culture of the hospitals have to take place.”
After the pilots facilitate their 100th transplant, which Huang estimates will occur in autumn, 2011, the programme will be implemented nationally. But many outstanding issues must still be clarified before a national policy can be articulated. Delmonico expresses concern over the lack of clear standards emerging from the pilots: “What is the consent process for donation and the selection criteria pertaining to the wait-list? Who's making the recovery of the organs and who's determining death?” These and other protocols, he asserts, must be clarified before a national policy can be articulated.
Once a national programme is initiated, Huang hopes to use this growing source of organs as a carrot to wean transplant programmes from their dependence on executed prisoners. Hospitals that demonstrate they can recruit non-heart-beating donors will earn authorisation to do transplants, and, those that do not, will lose their qualifications. Provincial hospitals that recruit more than ten non-heart-beating donors in a year will be rewarded by elevation to the national level. Huang says, “I wish that, at the end of the next 5 years, our country will have eliminated the practice of using executed prisoners as a source of organs”.
One crucial uncertainty remaining is how the public will respond. By many accounts, Chinese citizens are reticent to part with their organs after death, and the opacity of the current allocation system and widespread doubts about its fairness have also undermined participation. “There has to be a general sense of trust in the system, and the way it operates right now, there is none”, says Kine. “There's a huge gap in terms of government rhetoric on issues of public health and safety generally, and the credibility of that rhetoric among Chinese people.”
But the current system is truly unsustainable. More than 500 000 Chinese people are estimated to be on dialysis and the number is climbing, as economic development shifts their society towards a higher proportion of non-communicable disease and brings more citizens into the formal health-care system. If China follows the trajectory taken by Japan, South Korea, and Taiwan as they grew wealthier, the number of Chinese people waiting for kidney transplants could double in the next 15 years.
At the same time, China's Government claims to be reducing the number of people it executes—although the precise figure, thought to be in the thousands, has never been revealed. In any case, this source is vastly insufficient to provide transplants for the population as a whole. “The demand is huge in China and we have to develop a system that can more adequately meet it, and the prisoner system is not ever going to do that”, says Millis. Only a voluntary organ transplant system drawing from the general population can be proportional to the country's needs.
If implemented successfully, the development of such a system could have broader implications for the society as a whole, as Chinese citizens come to a new understanding of the social contract binding them together. But until the government and health system prove that they can operate a transparent, equitable organ donor system, they will hinder rather than advance its development. “Progress in organ transplantation practice indicates the direction in which Chinese society is moving”, says Huang. “So it's a very important, very crucial task for us.”

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