Organ transplantation has existed in the Western world for more than five decades now, and over that time, a lot of kinks had to be worked out. Medical questions about how best to perform such procedures and protect the health of the recipient and donor were paramount, and the technique of organ transplant has advanced in leaps and bounds. But there were also logistical and ethical challenges surrounding transplants that the medical world needed to resolve: Where should the organs come from? Who gets them first? How can the best interests of the donor be protected? Should people be allowed to travel to foreign countries to receive transplants?
The United States and Europe have had 56 years to formulate clear policies to answer such questions. For example, in the U.S., transplant centers are allowed to perform no more than 5 percent of organ transplants on foreign nationals, to discourage “transplant tourism.” But in China, the history of organ transplantation is much shorter, and the availability of transplants has far outpaced consideration of the ethical issues surrounding the procedure. That created an almost law-less transplant environment in China in the 2000’s, with 600 different centers offering organ transplants under minimal oversight by the country’s Ministry of Health. Inevitably, that regulatory void produced practices frowned upon by Western countries, with much of the organ supply coming from executed prisoners, rampant medical tourism, and a thriving black market for living donors.
But China’s health care leaders have set out to reform the country’s transplant practices. For good reason too; with more than 100 million people carrying the hepatitis B virus (one-third of the world’s prevalence), liver transplants will be a critical piece of the country’s health care arsenal. So China has turned to international transplant experts to help them clean up and legitimize the field.
Michael Millis, professor of surgery and medical director of transplantation services at the University of Chicago Medical Center, is one of those experts. Wednesday, he spoke at the MacLean Center for Clinical Medical Ethics weekly seminar about his advisory role in China, working with the Ministry of Health and the Peking Union Medical College – a hospital in Beijing founded, like the University of Chicago, by John D. Rockefeller. Millis said his role in advising China’s transplant community was not to scold them for practices considered unethical in our country, but to help move them away from such practices by improving and modernizing the donation process.
“All current donors are shot in the head,” Millis said. “My goal has been to develop a different system so that that system [of prisoner organ donation] goes away…but we also recognize that for a number of reasons, we need to find a different source of organs to allow that to occur, in reality.”
After international scrutiny focused on a rapid increase in transplants of prisoner organs in the mid-2000’s, China’s Ministry of Health took greater control of the country’s transplant centers. Tighter regulations dropped the number of those centers from 600 to 160, discouraged transplant tourism that had drawn transplant recipients from around the world looking for cheap organs, and tried to shift the organ supply away from prisoner executions.
The problem is that, at the moment, there are presently very few alternatives for organ supply in China, Millis said. Living-donor transplants, not officially sanctioned or banned by the government, face cultural resistance and are susceptible to organ-trafficking schemes and black markets. Cadaverous donation, which provides the bulk of organ donation in the United States and Europe, was almost non-existent when Millis arrived, due to different perspectives on “brain death” in China.
“Brain death is one of the criteria we utilize in order to get donors in the United States, and there’s been some effort for that in China,” Millis said. “They recognize that brain death is going to be necessary to ultimately fulfill their demand, but right now there’s still no brain death law.”
The lack of a legal definition of brain death has health care ramifications beyond organ transplant – Millis said that roughly 20 percent of ICU beds in China are occupied by brain-dead patients with no hope of recovery. Due to a high rate of motor vehicle accident fatalities in China (more than 350,000 a year), a lot of potential organ donations are lost without a clear brain-death/organ donation policy. Millis estimated that an effective deceased donor organ procurement system could increase the number of liver transplants each year to 35,000 in 20 years – 10 times the amount possible from prisoner donations.
With an estimated 1.5 million Chinese in need of a liver transplant, that’s a drop in the bucket, but a much bigger drop than is currently available. Creating that transplant infrastructure won’t be easy – the current brain death law is in political limbo, Millis said – but there are signs of hope, with a few transplant centers now performing occasional cadaverous donations and public awareness efforts promoting donation in the media. Small steps that could generate crucial momentum for a country that, thanks to its enormous size, will soon be a hotbed of organ transplants one way or the other.
“China has really led the whole Asian region in recognizing that transplant tourism is not something that should be encouraged,” Millis said. “China is on a course that will make it the most active transplant country in the world, probably in a relatively short period of time, but the important aspect from our point of view is that it is pushing forward in a way that is consistent with international standards and a respect for the donor and recipient.”