Personal Opinion Paid transplants in India: the grim reality

Commercial transplants are performed in several countries, but a combination of trained transplant personnel, large impoverished population and lack of any law governing organ transplantation made India the hub of this activity in the late 1980s. Reports of large-scale transplants using kidneys bought from economically deprived living donors under questionable circumstances from different parts of the country attracted worldwide condemnation. After a lot of media criticism, the Indian Parliament passed an act in 1995 banning payment for organ donation. The practice, however, has continued, and paid transplants are still being performed in several parts of the country [1,2]. A gradual change has been observed over the last few years in the attitude of western transplant professionals towards unrelated transplants. Concerns about the continuing organ shortage have prompted calls for legalizing transplants using organs donated by strangers [2]. The excellent outcome of genetically unmatched kidney transplants from living unrelated donors done in the west [3,4] provides support to this argument. Short-term survival figures are better than cadaver transplants, and approach one-haplotype matched living transplants. The risk to donor is low [5] and advocates of such transplants are increasing in number. At first sight, this seems to be a solution to please all concerned. However, the published literature suggests that the outcome of commercial transplants performed under less than optimal conditions, and with donors of dubious backgrounds, is inferior to those that are carried out under rigorous medical scrutiny [6]. A high rate of transmission of infections including HIV, fungi and hepatitis viruses, and high short-term mortality was documented by Salahudeen et al. [7] in 1990. In a recent publication in this journal, Higgins et al. [8] report almost similar findings, suggesting little change in the situation over the last 13 years. They draw attention to the poor donor and recipient selection, and how several of the problems were related to transplantation of organs that would be rejected in standard transplant programmes. It can be argued that these reports are not representative of the outcome of all such transplants. It is telling, however, that few centres that have performed thousands of such transplants have published their results [9]. The reasons for this could be one or more of the following: (i) these transplants are performed as a commercial activity, and these hospitals are not interested in publications; (ii) the legal status of this activity has been largely dubious, and publication could draw the attention of law enforcement agencies; (iii) the majority of the recipients are ‘transplant tourists’, who travel to these cities from far off places (including foreign countries), get the organ and then go back, making follow-up impossible; and (iv) if the results are indeed as poor as the existing reports suggest, publications will be self-defeating. Any person or group who can collect outcome data on such recipients will do a great service to the transplant community, and provide a valuable database/reference point for physicians. Indeed, if the results turn out to be similar to the results of nonrelated transplants done in the west, it would strongly enhance the acceptability of this practice. The lay public, including the patients and lawmakers also need to know this data so that they can make a proper informed choice. Some transplant ethicists have strongly argued that as paid transplants benefit both the recipient and the donor, they should be permitted in a regulated manner [10–13]. It has been suggested that setting up a commission responsible for donor and recipient screening and overseeing the financial transaction will remove the unsavoury practices associated with this act. However, a major assumption behind this argument is that the western standards of justice and fair play would apply to the developing societies and that Correspondence and offprint requests to: Dr Vivekanand Jha, Associate Professor of Nephrology, Postgraduate Institute of Medical Education and Research, Chandigarh 160 012, India. Email: [email protected]