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BMJ. 2007 November 10; 335(7627): 961.
PMCID: PMC2072033

A matter of life or death: China moves towards changing its transplantation practices

China is changing—and changing fast. And, partly to gain acceptance on the global health stage, it has begun to tackle one of its more controversial healthcare practices: using organs harvested from executed prisoners for transplantation.

For Zhonghua Klaus Chen, vice chairman of the Chinese Organ Transplantation Society, a recent statement by the Chinese Medical Association against the use of executed prisoners' organs is a welcome boost to efforts to bring Chinese transplantation practices into line with international standards.

Having trained in Germany and the United Kingdom, including a stint with Cambridge University under the transplantation surgeon Roy Calne, Professor Chen became convinced that prisoners were not in a position to give free consent for organ donation after their deaths.

“As part of the organ procurement team in Cambridge I was very proud of what I was doing,” he said, “yet, in China, surgeons using prisoners' organs can't discuss their work with international colleagues. Execution is the dark side of human nature, and transplantation is the glorious side of health care. They can't be easily bundled together, and that should be stopped.”

He was delighted when the practice was deemed unacceptable by the Chinese Medical Association in October, during the World Medical Association's annual general assembly in Copenhagen. The Chinese association came out against the use of organs harvested from executed prisoners for transplantation, stating that the organs should be used only for immediate family members. The Chinese association's chair and one vice chair are appointed by the Ministry of Health; thus the statement signals a tacit recognition by the Chinese government that what has been common practice in China is not acceptable to the worldwide medical community.

The statement's strong wording surprised even those in China's transplantation surgery profession. The statement said, “The Chinese Medical Association will, through its influence, further promote the strengthening of management of human organ transplantation and prevent possible violations of the regulations made by the Chinese government.”

Although it is a big step in the right direction, Professor Chen believes that clearly defined rules are also needed to encourage organ donation from living relatives and harvesting of organs from patients who are brain stem dead.

China has already announced a series of new regulations to tighten control over transplantation—but it also needs to balance this by increasing organ donation from more acceptable sources.

In early 2006 new qualification criteria for transplantation centres reduced the number of qualifying hospitals by three quarters, to 164. In July 2007 new regulations came into force, banning organ trafficking and “transplant tourism.” These regulations reiterated the requirement for consent for donation, promoted the equitable distribution of organs, and limited the scope of donation from living donors to close relatives.

“This really was a great step forward,” said Professor Chen. “The Ministry of Health invited a lot of specialists in ethics, law, general medicine, and transplantation within China, and the regulations included all international standards except one: the criterion for death. They needed a document first to control the turmoil in transplant surgery but left defining standards for brain death to a later time. The only specification was that death has to be pronounced by a doctor not involved in the transplantation team.”

In a bid to clamp down on the lucrative business of transplant tourism, the government subsequently announced restrictions on non-Chinese people receiving transplants. Foreigners can receive transplants in China only with the Ministry of Health's permission, ensuring that priority is given to Chinese nationals and permanent residents of Hong Kong, Macau, and Taiwan, while leaving the door ajar for important foreign patients.

Meanwhile, the effort to build up an ethical supply of organs falls to a handful of doctors like Professor Chen, who are working to promote donation from living relatives and from brain stem dead donors.

Since he returned to China in 2000 Professor Chen has not carried out any transplantations using organs from executed prisoners, concentrating instead on living donors. “This year we are expecting around 2000 living related organ transplantations in China, a dramatic increase over previous years,” he said. The next step was to encourage the adoption of international practices by harvesting organs from donors who are brain stem dead, but in doing so he and his colleagues step into what is currently a legal vacuum.

“There is no legally accepted definition of brain death in China,” Professor Chen explained. Chinese medical textbooks define death as when the heart and lungs stop functioning. His efforts to promote the internationally recognised definition of brain stem death earned him intense criticism from lawyers and the domestic media, who accused him of promoting the concept of brain stem death for his own interests.

To resolve the conflict of interest, he resigned from his post as director of the Institute of Organ Transplantation of Tongji University, Wuhan, in August 2006 and set up the Chinese Organ Procurement Organisation soon after, the only project of its kind in China.

Since then Professor Chen and his team of five colleagues have created a network of 40 hospitals that take part in an organ sharing project. To date they have harvested organs from 63 donors who were certified brain stem dead according to internationally accepted standards, yielding 282 organs for 270 recipients.

The costs of organ harvesting are borne by the beneficiary's hospital, with financial transactions managed by a third party, the Shenzhen Red Cross. Professor Chen does not receive a salary from the organisation, and his colleagues are paid in an overtime arrangement with their full time employers. The small number of participating hospitals means that developing equal sharing, graded according to each patient's need, is an ongoing process of work towards international standards.

“In January we held the first Chinese Organ Procurement Organisation [and] Chinese United Network for Organ Sharing workshop in Guangzhou with 200 participants,” said Professor Chen.

“What we are doing is a tangible way to promote ethical organ harvesting to colleagues and make it more formally recognised step by step. Sooner or later prisoners' organs will be gone, and for the continuation of transplantation surgeons' careers they will have to find a better source.”

Transplantation in China: some statistics

The Chinese Organ Transplantation Society says that more than 9500 transplantations took place in China in 2006, but few used organs from living relatives or brain stem dead donors.

Of the 6600 kidney transplantations nationwide, 850 used organs from living relatives and 20 from non-related donors. There is no public information on the source of the other 5730 organs. Although it is likely that most came from prisoners, these figures cannot be confirmed, mainly because the government does not publish information on how many prisoners are executed each year. International rights groups say that between 5000 and 12 000 prisoners are executed each year.

In 2006 there were 2750 liver transplantations, of which only 80 involved a donation from a living relative.


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