By Jelena Dragicevic

In the 2017 medical documentary The Trade Transplant, Kumar, a young, Indian father in abject poverty, decides to sell one of his kidneys to a foreign organ recipient. The foreign recipient was willing to compensate both his organ broker and Kumar a total of 40,000 rupees (~524 USD). From that, Kumar planned to spend his allotment to pay off his debt and provide for his family. But, after his procedure, Kumar found himself in greater debt than initially anticipated. Worse, after having had a rib removed during his kidney operation, Kumar started to experience intense pain in his side. Now, instead of working in a rubbish dump that often required heavy lifting, he operates an illegal, gambling operation. Kumar had hoped that selling his kidney would have provided the impetus to get his family out of debt and on track towards better financial prospects. Instead, he continues to live in poverty, worse off than before the procedure. 

Kumar is one of 2,000 people in India who annually sell their kidneys and find themselves  implicated in the broader, illicit, global organ market. Despite the Transplantation of Human Organs and Tissues Act of 1994 strictly forbidding the sale and purchase of organs in India, the problem remains rampant.

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One contributing factor to India’s illicit organ market is their lack of a national registry that extensively monitors and safely matches organ donors and recipients. Adding to the problem is India’s corruption rate, where it ranks as the 80th most corrupt country in the world. Accordingly, doctors and hospitals fail to offer adequate support to donors and recipients, and may unknowingly be involved in the illicit organ market—or may willfully participate. In Kumar’s case, it was not difficult to convince the hospital’s screening committee that his donation was legal and uncompensated. 

India ranks high on the list of organ-selling countries, alongside Bolivia, Brazil, Iraq, Israel, the Republic of Moldova, Peru, and Turkey. The leading “organ importing countries” are Australia, Canada, Israel, Japan, Oman, and Saudi Arabia, with a large number of these countries’ nationals traveling overseas to undergo a transplant operation after purchasing an organ. Driving this “transplant tourism” network is the large demand and limited supply of organs; shaping this network is a growing and sharpening divide between the developed and developing world.  

What Drives and Shapes the Transplant Tourism Network?

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Kidneys are the most commonly sold organ in the illicit organ market, accounting for nearly 75 percent of all illicit global organ sales. Currently, they are in high demand. In the United States alone, there are 121,678 people waiting for a lifesaving kidney transplant operation. Each of them can expect to wait an average of five years before receiving a match. In that time, their chances of death increase greatly. 

Desperate and having to choose between life or death, some people on transplant waiting lists purchase an organ from the illicit, global organ market. Doing so risks undergoing surgery in often unsanitary or unsafe environments. Furthermore, many doctors hesitate or refuse to offer follow-up care to patients they either suspect or know participated in transplant tourism, given that they do not know the conditions and methods by which their organ was extracted.  

Yet, for people on waiting lists on the brink of death, the gains of a new organ and another chance at life far outweigh the risks. Thus, they rely on donors who most often come from the developing world to save their life. 

Developing countries are afflicted with high rates of poverty and debt. Non-Governmental Organizations (NGOs) commonly offer microcredits to the developing world, which are collateral-free loans meant to stimulate economic activity and help reduce poverty. Increasingly, microcredits have pressured people in developing countries to sell their organs to pay off their loans and improve the financial conditions of their family. 

As Professor Monir Moniruzzaman from the Department of Anthropology at Michigan State University explained, “NGO officials pressure people to repay their loans by sitting all day long at the defaulter’s house, verbal harassment and threatening to file a police case.” In response, people commonly take out loans to pay off pre-existing loans, further entrapping themselves in a vicious cycle of debt. Thereby, indebted individuals become convinced that selling an organ will put an end to this vicious cycle and get them on a better footing to make improved financial decisions. 

Except, as we observed in Kumar’s case, that is often not the result. People sell their organs under false pretenses, promised greater compensation and overly idealistic results than can rarely be guaranteed. In Bangladesh, Mohammad Mehedi Hasan was offered 700,000 taka (9,690 USD) for part of his liver. After his procedure, he only received 150,000 taka (2,046 USD). Even in instances where individuals receive full compensation, like Kumar they often return to similar levels of poverty with new, worrying health conditions hardly ever addressed in follow-up care. 

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Thus, donors involved in the illicit, global organ market are objectified and coerced into negligent care and harassment by brokers and buyers. Such behavior on part of brokers and buyers stands in direct violation of basic tenets within the United Nation’s Universal Declaration of Human Rights (UDHR): everyone has a right to “life, liberty, and personal security; freedom from torture and degrading treatment; and recognition before the law.” 

Nevertheless, the buyers’ rights are also at stake, as their life-threatening conditions worsen on unreasonably long waiting lists. Participating in the illicit organ market further jeopardizes these basic tenets within the UDHR. 

As transplant surgeon Dr. Kesava Reddy said in the 2017 Real Stories documentary The Trade Transplant, “Neither [of the] people involved in the transaction is a criminal. One is a victim of disease, the other likely of poverty. How can you possibly say the system isn’t moral? Is it unethical to want to live?”

Taking these different perspectives into consideration, one is left wondering what solutions exist to optimize the organ supply, without severely transgressing human rights violations of either the donor or buyer. 

Ending the Illicit, Global Organ Market: Reactive and Preventative Measures: Interviews with Dr. Julio Elias and Alex McDonald

Dr. Julio Elias, an economist at the Universidad del CEMA, believes the answer to ending the illicit, global organ market is rooted in legalizing the compensation of organ donors. His curriculum vitae lists an impressive number of renowned research papers that thoroughly assess this pressing topic. Among this extensive research is his 2007 paper co-written with economist Dr. Gary S. Becker: “Introducing Incentives in the Market for Live and Cadaveric Organ Donations.”  

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During my interview with Dr. Elias, he summarized the results from his and Becker’s paper. As Dr. Elias explained, “When Becker and I decided to write the paper, we asked ourselves, ‘What is the ideal price to give to the donor, in this case someone particularly donating their kidney?’” We thought, “If the compensation is too high, there will likely be an increase in the supply of organs because there is a monetary incentive, but then we risk the demand for organs going down because transplantation then becomes too costly.” 

Using economic and statistical models and calculations, Dr. Elias and Dr. Becker equalized this difference to produce the ideal price for compensating a kidney donor. “We determined that the price of compensation needed to account for 1) the risk of dying in surgery, also called the ‘statistical life’; 2) risk of reduced quality of life as a result of undergoing the operation; 3) cost of time that it takes to recover, including time off from work (2-4 weeks).” 

“We discovered that live kidney donors should be compensated 15,000 (USD). At the time of our research, the typical cost for kidney transplant surgery was 160,000 (USD). The marginal increase adding in donor compensation would be less than 10%, coming to be 175,000 USD.” The result? Eliminated wait time and suffering for sick patients waiting for a kidney. Dr. Elias continues: “The current kidney transplant system that exists is heavily reliant on deceased (cadaveric) donors, but this is not enough. But, when you allow the price mechanism to work, you eliminate the shortage of kidneys by providing an incentive for the quantity supply to increase.” 

When asked whether the black market could survive such measures, offering donors higher compensations than the price mechanism, Dr. Elias believed that it was unlikely. “If our estimates are right, the legal market should be able to attract people at the 15,000 USD mark.”

Dr. Elias elaborated on this point. “What is the alternative to, for example, a person in India? Sell in a safer environment and be compensated more. When better alternatives appear, which based on our research occur at the 15,000 USD mark, the black market will no longer exist. The focus is not a prohibition to the black market but providing a better alternative to the people involved in it.” 

Adding credence to Dr. Elias’ statement, organ donors (including kidney donors) typically earn 3,000-15,000 USD on the black market. Even though an actual kidney can be retailed for upwards of 262,000 USD to buyers, brokers typically keep a majority of the profit. By legally compensating donors more than what they would receive on the black market, there would no longer be any incentive for people to continue supplying the black market. With that, the demand would also shift towards a legal, safer network. 

It is also unlikely that a black market could resurge as a result of brokers readjusting compensation deals, once a legal system is put in place. If this were to occur, the price of illicit organ transplantation would increase as well, reducing the incentive for buyers to participate in the black market, especially when they could receive a transplant operation in a legal and safer setting for less money. 

Nevertheless, there are critics who vehemently disagree with Dr. Elias’ position, instead positing that legalizing a market for organs would exploit the poor. The belief is that if a monetary incentive exists, the market will predominantly attract low-income donors. As philosopher Samuel Kerstein explained, “To have value as a person is to have incomparable worth...so a market for organs that treats the poor as ‘tools available for the right price’ is wrong.” 

Dr. Elias refutes this argument. “Of course, there should be some regulation to help ensure the protection of donors. The key author of the market-based system of organ compensation is the doctor, who would be in charge of reviewing registered donors. They would make sure the donor is healthy and compatible, as well as review how many times the donor has potentially donated before. However, checks on the doctors and review board would exist, too. The check is competition because it will limit abuse and force doctors to behave well, otherwise they risk donors and buyers dropping out of a transplant deal.”

Despite supporting some regulation on a legalized market-based system of organ transplantation, Dr. Elias does not believe there should be a minimum income requirement for donors. Doing so would risk a resurging black market, as potential donors who do not meet the threshold would be enticed to utilize a black market for any monetary compensation. 

With this mix of regulations, there would naturally be a cap on who can donate their organs; but, the black market would still be unlikely to resurge as a result of unqualified donors because the legal, safer market alternative could create a large enough supply to attract buyers away from a black market. 

Implementing all of these checks and balances would still leave poor people more likely to donate their organs. As Dr. Elias put it, “One of the problems that arise in any market is that not everyone has the same income.” However, Dr. Elias is convinced that his method provides a safer environment for donors’ and buyers’ operations to take place. The alternative to a compensatory organ system is the black market, which is riddled with far greater human rights violations. Essentially, a market-based compensatory system would be working to minimize, not continue or expand, human rights violations on poorer populations. 

Finally, another key component to Dr. Elias’ argument is that under his model, poor people would be just as able to donate and receive an organ. Under Dr. Elias and Dr. Becker’s model, dialysis dependency would drop, as the supply of organs would grow. Currently, dialysis costs 87,000 USD per patient, per year, which, in the US, is about seven percent of Medicare's budget. As dialysis use drops, the budget could be reallocated to cover transplantation operations for the poor who desperately need an organ.

Dr. Elias’ research provides a long-term solution to the gross human rights violations taking place under the current illicit, global organ market. His methods could take years of reform to implement and would still require political approval to legalize. 

On the other hand, there are measures people and organizations can start implementing now to help decrease organ demand and reduce the incentive to participate in the black market. During an interview with Alex McDonald, a director at Donor Connect, an organization that manages the Yes Utah and Yes Idaho donor registries, he emphasized the importance of education and prevention. 

“Be more proactive instead of reactive. It is important to educate people on the importance of lifestyle so that they don’t get sick. This would be an example of preventative measures meant to help reduce the likelihood of organ failure.”

Going Forward

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The power in learning about the illicit, global organ market is that it illuminates underlying and concurrent human rights violations that demand global attention and collective action. Inefficient healthcare systems, abject poverty, and rising inequality are all examples of underlying human rights abuses lending to continued human rights violations through a black market. 

The  illicit, global organ market functions because it takes advantage of people who are in the most vulnerable of conditions; however, also needing heightened scrutiny are the circumstances that cause people to become so vulnerable. Together, such analysis highlights the urgency by which forces around the world need to couple preventative and reactive measures, including lifestyle and compensatory interventions, to ensure the protection of “life, liberty, and personal security; freedom from torture and degrading treatment; and recognition before the law” for donors and recipients alike.

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