Every now and then the trade in human organs makes national, even international, news.
In March 2023, a Nigerian politician, his wife and a medical middleman were found guilty of an organ-trafficking plot after they brought a man to the UK from Lagos to sell his kidney. Several months later in Kenya, following the arrest of a televangelist on charges of a mass killing of his followers, autopsies on the corpses revealed missing organs, raising suspicions of forced organ harvesting. And, in 2020, researcher Sean Columb exposed how numerous African migrants sold their kidneys in Cairo, Egypt, in hopes of using the earnings to pay smugglers to take them across the Mediterranean into Europe.
These reports and cases are part of a global proliferation of the organ trade that started in the late 1980s. It coincided with advancements in transplantation. Until the 1980s, transplantation was regarded as a risky and experimental procedure. Since the introduction of immunosuppressive drugs in the 1980s (which help to prevent the body from rejecting organs), it has become standardised practice. Organ transplants are now conducted in hospitals in more than 90 countries.
Transplantation has however become a victim of its own success, with demand for organs far outpacing supply. Despite strategies to enlarge the donor organ pool, the worldwide organ shortage grows every year.
I am an organ trade and trafficking researcher . I've investigated many aspects of the activity including transplant tourism, the buying of organs, experiences of transplant professionals and police and prosecutors working on criminal cases and how trafficking networks operate.
I've found that claims are made about the organ trade in the absence of factual data. These have strengthened popular notions of the issue as an underground crime, organised by mafia-like criminals and "rogue" doctors who perform transplants clandestinely.
The reality is starkly different. The nature of the organ trade is far removed from these mythical depictions. In all criminal cases reported to date, illegal transplants took place in medical hospitals and clinics with the involvement of medical staff. Organ trafficking networks are highly organised with close collaborations between the legal "upperworld" (medical doctors, notaries, lawyers) and the criminal "underworld" (recruiters, brokers).
While it's likely that there are also unreported, hidden cases that do not take place inside medical institutions, the available knowledge indicates that the medical sector is helping to organise and facilitate the trade in human organs.
The organ trade is a complex crime and is fuelled by the high demand for organ transplants and rising global inequalities. The root causes of the trade need to be addressed, and stronger responses (not necessarily laws) are needed to tackle the more organised and exploitative forms of the trade.
What is the trade in human organs?
Organ trade constitutes the sale and purchase of organs for financial or material gain. The World Health Organization (WHO) first prohibited payments for organs in 1987. Many countries subsequently codified the prohibition into their national laws.
Although reliable figures are lacking, the WHO estimated in 2008 that 5% of all transplants performed worldwide were illegal. Living donor kidneys is the most commonly reported form of organ trade.
The WHO has further estimated that the total number of transplants performed worldwide is less than 10% of the global need. Of all organs, kidneys are highest in demand. About 10% of the world's population suffers from chronic kidney disease. Between two and seven million of these patients are estimated to die every year because they lack access to proper treatment.
Under these circumstances, desperate patients seek illegal ways to obtain organs outside their home countries. The increased value of organs makes them more profitable. This fuels the desire of some people to trade and sell.
Global developments and catastrophes such as the widening gap between the rich and poor, conflicts, famine, climate change and forced migration further increase the risk of organ sale and exploitation among the world's vulnerable populations.
Addressing a complex crime
How then can responses to the organ trade be improved? A first step would be to reach agreement on what types of organ trade we find condemnable. This requires an understanding of the trade's complexity.
Some studies demonstrate that the organ trade can constitute serious organised crime. It can involve physical force, even torture, and the execution of prisoners. But these reports don't describe the organ trade as a whole.
The organ trade involves a variety of practices which range from excessive exploitation (trafficking) to voluntary, mutually agreed benefits (trade).
These varieties warrant different, data-driven responses.
For example, organ sellers are reluctant to report abuses because organ sales are criminalised and sellers will be held liable. Although many can be considered human trafficking victims and be offered protection, this rarely occurs. Law- and policymakers should therefore consider decriminalising organ sales (removing penalties in the law) and offer organ sellers protection, regardless of whether they agree to provide evidence that helps to dismantle criminal networks.
Countries should also allow medical professionals to safely and anonymously report dubious transplant activity. This information can support the police and judiciary to investigate, disrupt and prosecute those who facilitate illegal organ transplants. Portugal and the UK already have successful organ trafficking reporting mechanisms in place.
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Finally, a contested example of a possible solution to reduce organ scarcity and avoid black market abuses is to allow payments or other types of rewards for deceased and living organ donation to increase organ donation rates. To test the efficacy and morality of these schemes, strictly controlled experiments would be needed.
Trials on incentivised organ donation schemes have been proposed since the 1990s by transplant professionals, economists, lawyers, ethicists and philosophers who point out that there may be good reasons to allow payments under controlled circumstances.
While such experiments are currently forbidden by law, national surveys have found various degrees of public support for different types of incentives. In the US, for example, a recent study found that 18% of respondents would switch to favouring payments for sufficiently large increases in transplants, provided that recipients didn't have to pay out of pocket and that allocation of organs would occur based on objective medical criteria. In short, rather than exclusively focusing on stricter laws, a broader range of responses is needed that both address the root causes of the problem and that help to disrupt organ trading networks.
Frederike Ambagtsheer, Assistant Professor (Internal Medicine, Kidney Transplantation & Nephrology), Erasmus University Medical Center
