Organ Transplantation in India: NOT for the Common Good

India has demonstrated exceptional rates of growth in the number of kidney and liver transplants performed across the country (Figure 1).1 Over the 5 y from 2014 to 2019, India increased the number of transplants performed per annum, by adding approximately the total number of transplants performed in a year in France, Germany, Spain, or Turkey. This growth in capacity involved every aspect of specialized and trained surgical, medical, and nursing human resources, as well as hospital infrastructure in operating theaters and recovery wards. It is worthy of congratulations as a demonstration of the evolving power of this nation. However, with that growth has come a description of Indian organ transplant practices in the global and local media that is at once both alarming and reprehensible.2 The experience of human and organ trafficking in India today is seemingly recurrent and validated.3-5Figure 1.: Evolution of kidney (A) and liver (B) transplantation (Tx) from live organ donors (LDs) and deceased organ donors (DDs) in India. Absolute numbers and rates per million population (PMP). Adapted from: Global Observatory on Donation and Transplantation (https://www.transplant-observatory.org).The field of organ transplantation has evolved very differently across the world under the influence of different national healthcare financing systems. Healthcare is, in most countries, financed by taxation and thus through governmental budgets, in combination with private funds, mostly through contributory health insurance systems (eg, Australia, Canada, Europe, New Zealand, South America, and the United States). But across much of Asia, tertiary healthcare services, such as transplantation, are almost entirely dependent on the private finances of individuals. The impressive growth in Indian organ transplantation has been accomplished in for-profit hospitals, which have expanded Indian transplantation into 807 facilities, mostly associated with the major corporate hospital chains.6 Organ transplantation, in a part of the world where one-fifth of all people live, is thus largely not for the common good, but a treatment available for those with ample monetary resources. In India, organ transplantation has become of such a high monetary value, that a population of foreign patients also undergo transplantation in that jurisdiction, swept up in the general development of medical tourism. In 2023, the Government of India’s Ministry of Home Affairs announced the creation of the Ayush Visa category for foreign nationals, promoting travel for healthcare in India.7 Approximately 2 million patients from 78 countries go to India for all forms of medical care, generating $6 billion for the health industry of India and expected to reach $13 billion by 2026.8 Many transplant patients are thus coming to India from elsewhere in the Indian subcontinent, the Middle East, Southeast and Central Asia, and Africa with the expectation of receiving medical care. Medical tourism is a badge of excellence and national pride, but transplant tourism and commercialization have seemingly breached India’s commitments to the 63rd World Health Assembly (WHA) in 2010, driving “preferential allotment of organs to foreigners” and the repetitive media reports of trafficked poor from neighboring countries as paid living donors.2 NOT ALL TRANSPLANT PROFESSIONALS IN INDIA ARE DRIVEN BY ECONOMIC INTERESTS There is certainly a variation across the 28 states of India. There are states where all transplants are undertaken by large dedicated public hospitals and are free to the recipient. There are states where courts apparently determine whether living unrelated transplants proceed or not, and there are states where the approval process for unrelated transplants, especially from overseas donors, is seemingly waved through in the name of economic development. THE SOURCE OF THE LIVING DONORS IN INDIA. WHAT IS THEIR NATIONALITY AND RELATIONSHIP TO THE RECIPIENT? The reported number of deceased donors per million population in India was 0.67 in 2022; for every deceased organ donor in India, there were 13 living kidney or liver donors.1 The contrast to the equivalent ratios in North America or Europe could not be starker. What remains unknown is whether the organs donated by deceased Indians are preferentially allocated to foreign nationals, as proposed in media reports.2,9 Nor is it visible whether the 13 000 living donors that in 2022 provided a kidney (10 000) or a part of their liver (3000) were of Indian or foreign origin, nor is their relationship to the recipients known. The absence of transparency has enabled a repetitive experience of organ trafficking throughout the Indian Subcontinent of Asia.3-5 Alleged by media report in 2022: over the last 2 decades, for example, dozens of men from villages in Nepal were trafficked for their kidneys, with some duped with false promises of employment in Delhi. Nepal investigative officials told the “NewsHour” report that each new victim led them to the same hospital in Kolkata that has been in the headlines for illegal kidney transplants in the past, but has not been prosecuted despite the buying and selling of organs being illegal in India. NOTTO SEEKS TO FULFILL THE LAW OF INDIA AND THE RESOLUTIONS OF THE WHA It is time to support the Indian Government’s earnest intent to fulfill the ethical principles they adopted in 2010 at the WHA. A memorandum was widely distributed in Indian transplant circles recently from Dr Anil Kumar, the Director of the National Organ Transplant And Tissue Organization of the Ministry of Health of India that defines the requirement for all centers to fulfill the law of India. The memorandum requires the record and reporting of every organ transplant “whether from a living donor or deceased donor.” National Organ Transplant And Tissue Organization has emphatically expressed its concern regarding unethical practices of “commercial dealings in organs involving foreign citizens.” The transplant professionals of India must now use this opportunity to cooperate to fulfill the promise and benefit of organ transplantation for the good of the communities of India and in doing so separate the ethical majority from the unethical minority.10,11 Member States of the Assembly have now an opportunity to consider a new Resolution in the 77th WHA in Geneva in May 2024. That resolution: “Increasing Availability, Ethical Access and Oversight of Transplantation of Human Cells, Tissues and Organs” calls for transparency and oversight of practices that should identify the nationality and relationship of the living donor to the organ transplant recipient. These data should be reported annually to the regulatory agency within the jurisdiction that authorizes the center to perform organ transplants. FOR THE COMMON GOOD The Transplantation Society, founded nearly 60 y ago, selected a sculpture by Auguste Rodin entitled “the Cathedral,” to be its logo. Two right hands symbolize the right hand of an organ donor and the right hand of a recipient, with both needed to achieve a successful transplant. Two people doing extraordinary things to save lives, irrespective of ethnicity, sex, social status, or affluence. National and international professional societies of transplantation exist to advance science, provide information and education but as well illuminate policies that span all cultures in ethical propriety. The support of India for the WHA Resolution will be a testimony of many right hands for the common good.

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