Dilemma over Live-Donor Transplantation: Organ Transplants Save Thousands of Lives Each Year, but Put Many Live Donors at Risk Due to an Unregulated Organ Trade That Exploits the Vulnerable in Developing Countries and Complicates Legitimate Organ Donation Efforts. Countries Face a Dilemma: How They Can Increase the Supply of Organs in a Manner That Is Ethical and Humane

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In rural Pakistan, Haleem Bibi had no choice but to support her family after her husband's hand was severed in a work accident. To make ends meet in February last year, the mother of seven sold one of her kidneys for about US$ 1500 to a clinic serving overseas clients, who pay up to US$ 40 000 for an organ transplant.

Months later, Bibi's family, who live in Jandala village in eastern Pakistan, remained mired in debt and her health worsened after receiving no post-operative care, a common feature of commercial organ harvesting. "The money has all been spent and now I have to work all day, which is very tiring," Bibi told the Bulletin in a recent interview.

Bibi's story is echoed by thousands more in Pakistan and other countries, where the neediest are often exploited by a thriving market for organs.

About 10% of the 63 000 kidney transplantations carried out annually worldwide involve payment of non-related donors of different nationalities, according to the World Health Organization (WHO). Globally, at least 200 000 people are on waiting lists for kidneys, and many more have no access to transplantation or dialysis services.

In industrialized and developing countries, kidney transplantation wherever possible is preferable to dialysis, which is physically taxing on patients and more costly than transplants. Every year, a million people develop end-stage renal disease, said Dr Luc Noel, coordinator of WHO's clinical procedures team, but only a fraction of those receive any kind of renal replacement therapy, and even fewer receive kidney transplants.

Different approaches are being taken to meet the demand for organs and halt transplant tourism, which is growing due to an increase in kidney disease and renal failure.

"There are two prevailing concepts of transplantation. One relies on money and leads to increased inequality, besides putting a price on the integrity of the body and human dignity. The second is based on solidarity and the donor's sole motivation to save a life," Noel said. "We should seek a common global approach to donation and transplantation characterized by respect for the donors, so that they are proud of what they have done."

Donating a kidney holds some risks for the living donor, even though kidney donation is a widely recognized procedure. Careful selection of donors is vital to avoid renal failure later in life. The nephrectomy--removal of a kidney--procedure has risks, such as haemorrhage, as well as delayed and chronic recurring pain. The risk that the donor could die due to surgery has been put at one in 3000.

Scientists are investigating alternatives to human-to-human transplantation, such as human cell and tissue engineering and the use of animal organs. Pre-clinical studies in which pig hearts and kidneys were transplanted into baboons show promise.

At the same time, more preventive medical care is needed to stop people from developing conditions, such as renal failure, that make them seek new organs in the first place. But none of these approaches is expected to satisfy the need for human organs for transplantation in the next five years.

In 1991, the World Health Assembly endorsed the WHO Guiding Principles forbidding organ sales, which state: "The human body and its parts cannot be the subject of commercial transactions. Accordingly, giving or receiving payment (including any other compensation or reward) for organs should be prohibited." The assembly, in 2004, further resolved to make countries accountable for transplant activities by calling on member states to protect the most vulnerable from transplant tourism and the sale of tissues and organs.

WHO advocates increasing the supply of kidneys from deceased patients, followed by those from living related donors in national, noncommercial and ethical programmes governed by legal frameworks.

Noel praised models such as Spain's national programme, which maximizes donations from deceased individuals by using professionals to identify potential donors in hospitals and discuss the concept with their relatives. …


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