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GLOBAL TRAFFIC by Nancy Scheper-Hughes (University of California, Berkeley) Thank you, Madam Chair Ros-Letinen Ranking Member and Congresswoman Mc Kinney for the opportunity to speak before you and the members of the Human Rights Sub-Committee this afternoon. My name is Nancy Scheper-Hughes and I am professor of anthropology at the University of California, Berkeley where I also direct the doctoral program in medicine and society. I am the author of several books on poverty and health, including Death without Weeping: the Violence of Everyday Life in Brazil. For the last five years, however, I have been involved in active field research on the global traffic in human organs, following the movement of bodies, body parts, transplant doctors, their patients, brokers, and kidney sellers, and the practices of organs and tissues harvesting in several countries - from Brazil, Argentina, and Cuba in Latin America to Israel and Turkey in the Middle East, to India, South Africa, and the United States. I was a member of the Bellagio Task Force on the International Traffic in Organs and a co-founder, with Prof. Lawrence Cohen, of Organs Watch a small, independent, medical human rights, research and documentation center at UC Berkeley. With the assistance of a group of graduate and medical student interns from various institutions in the United States and local field assistants in several countries, we are serving as front-line workers responding to reports, complaints and allegations of irregularities in organs procurement and in the allocation and distribution of organs. Today’s hearing owes in large part to the courage of physicians like Dr. Thomas Diflo, director of the renal transplant program at the New York University Medical Center and to human rights activists, like Harry Wu, and it is an honor to be in their presence. As Director of Organs Watch, my role here is to put the specific Chinese case, as egregious as it is, into a larger global and social perspective. For the traffic in organs and tissues transcends national boundaries and involves doctors, patients, organs brokers, and impoverished organ sellers from both third world and first world contexts (see Scheper-Hughes 1998a and b; 2000). Organ Transplants in the Global Market Over the past 30 years, organ transplantation - but especially kidney transplant - has become a common procedure in hospitals and clinics throughout the world. The spread of these transplant technologies has created a global scarcity of viable organs. Despite its many obvious benefits, global capitalism has also released a voracious appetite for foreign bodies to do the shadow work of production and "fresh" bodies for medical consumption. And, we are witnessing, today, a confluence in the flows of immigrant workers and itinerant kidney sellers who fall into the hands of unscrupulous and highly sophisticated transnational organs brokers. Markets are inclined to reduce everything - including human beings, their labor and their reproductive capacity - to the status of commodities, things that can be bought, sold, traded, and stolen. And nowhere is this more dramatically illustrated than in the current markets for human organs and tissues to supply a medical business driven by "supply and demand. Bodily holism and integrity have given way to the divisible body and detachable organs as commodities, and as fetishized objects of desire and of consumption. The growth of "medical tourism" for transplant surgery and other advanced procedures has exacerbated older divisions between North and South, and between haves and have-nots. In general, the flow of organs, tissues, and body parts follows the modern routes of capital: from South to North, from third to first world, from poor to rich, from black and brown to white, and from female to male bodies. In the very worst instance, this market has resulted in theft and coercion, as in the case of China, to a self-serving belief in rights of the rich to the "spare parts" of the poor, as in the case of the many transplant junkets arranged to carry affluent patients from Saudi Arabia, Israel and North America to Turkey, India, Romania, and the Philippines where kidney sellers are recruited from prisons, unemployment offices, and urban shantytowns. Illicit and exploitative organs procurement practices are protected by the invisibility and social exclusion of the world’s population of organ suppliers and organ sellers - both living and dead - most of whom are poor and socially marginal - especially prisoners, mental patients, foreign guest workers, people in debt, soldiers, undocumented immigrants, and displaced rural workers (as in the former Soviet countries of Eastern Europe). With respect to China’s black market underground economy in organs for the lucrative business of transplant tourism, the complicity of Chinese doctors in medicalized executions in which the condemned prisoner is carefully examined, incubated, and "prepped" for organs harvesting minutes before he is executed by a bullet to his head, is reminiscent of Nazi medicine as practiced in the death camps. The feelings of revulsion expressed by some medical human rights activists are understandable. But while China provides the largest supply of organs that are available to transplant tourists today, China does not stand alone in this practice. Illicit and illegal practices of organs harvesting recognize no specific political or ideological boundaries, and can be found in both capitalist and communist countries, in secular and in religious cultures - Christian, Moslem and Jewish states alike. For example, Dr. Chun Jean Lee, chief transplant surgeon at National Taiwan University Medical Center, reported to the Bellagio Task Force on organs trafficking (see Rothman et al. 1997) that until human rights organizations put pressure on his own country, transplant units in Taiwan also used executed prisoners to supply the organs they needed. China held out, Dr. Lee suggested, because of the desperate need for foreign dollars, and because there is less concern throughout Asia for issues of "informed consent." In some Asian societies the use of prisoner's organs is seen as a social good and as an opportunity to redeem the family's honor. Not only executed prisoners, but the profoundly mentally retarded are at risk of illegal organs and tissue harvesting. Following various reports appearing in respected international media (BBC; Romero 1992; Bonasso 1998) and in the British Journal of Medicine (see Chaudhary 1992) in January 2000 I visited the grounds of Colonia Montes de Oca state mental asylum, in the province of Buenos Aires, near the city of Lujan, Argentina, to verify the reports of blood, tissue, and organs harvesting from the bodies of profoundly mentally retarded, but physically healthy, inmates of the asylum, many of them abandoned and unknown ("no names"). The condition of the patients, many of them naked and severely undernourished, was already an indictment of this callous public institution, which has functioned for several years under state receivership mandated by the Argentinean courts following law suits by concerned family members and following a criminal proceeding concerning the disappearance and presumed death of a younger resident psychiatrist. At the asylum a night nurse and a ward supervisor explained the long-standing practice of blood-lettings from the living inmates and cornea and tissue removal from the deceased, without consent, which they understood as a legitimate practice justified by the cost to the state of maintaining these desperate and needy inmates. Other vulnerable populations are also at risk of illicit organs and tissues harvesting, including the poor public patients in some hospital and police mortuaries (see below) and charity patients in under-supervised ICUs in the third world. I have explored reports of illicit organs harvesting in intensive care units in Brazil, Argentina, and the Northern Province of South Africa. To give just one example, retired transplant doctors in Sao Paulo and Rio de Janeiro told me that during the military period (1964-1984) in Brazil doctors were sometimes given "quotas" of organs to be delivered to military hospitals, organs got by any means possible, including (I was told by one guilt-ridden practitioner) chemically inducing the signs of brain death in dying patients of no means and with access to minimal social support or family surveillance. Medical Tourism But by far the largest practice of illicit organs harvesting concerns the active traffic in kidneys from desperate living donors. In the Middle East residents of the Gulf States (Kuwait, Saudi Arabia, and Oman) have for many years traveled to India, the Philippines, and to Eastern Europe to purchase kidneys made scarce locally due to local fundamentalist Islamic teachings that allow organ transplantation (to save a life), but prohibit organ harvesting from brain-dead bodies. Meanwhile, hundreds of kidney patients from Israel, which has its own well -developed, but under-used transplantation centers (due to ultra- orthodox Jewish reservations about brain death) travel in " transplant tourist" junkets to Turkey, Moldova, Romania where desperate kidney sellers can be found, and to Russia where an excess of lucrative cadaveric organs are produced due to lax standards for designating brain death, and to South Africa where the amenities in transplantation clinics in private hospitals can resemble four star hotels. Dr. Zaki Shapira, head of kidney transplant services at Bellinson Medical Center, near Tel Aviv ( and, ironically, former member of the Bellagio Task Force on global transplant ethics) has been operating as a transplant outlaw since the early 1990s when he first used local Arab brokers to locate willing kidney sellers among strapped Palestinian workers in the Gaza and the West Bank. When Shapira’s hand was slapped by an ethics review board (the Cotev Commission) in the mid 1990s, Shapira simply moved his illicit practice overseas - to Turkey and to countries in Eastern Europe where the considerable economic chaos of the past decade has created parallel markets in bodies for sex and for kidneys. But affluent Palestinians from the West Bank also travel in search of transplants with purchased kidneys to Baghdad, Iraq, where several medical centers cater to transplant tourists from elsewhere in the Arab world. The kidney sellers in Iraq, I was told by one Palestinian kidney transplant patient in March 2001, are mostly young men, foreign workers from Jordan, and poor Iraqis who are housed in a special wing of each hospital in dorms that could be called "kidney motels", while they wait for the blood and cross-matching tests that will turn them into the day’s "winner" of the kidney lottery. In Iraq the transplant package, complete with pre- and post-operative care and with fully equipped modern apartments provided in the hospital complex for accompanying relatives, is only $20,000, up, we were told, from only $10,000 several years ago. In fact, it was the appearance of these successful transplanted Palestinians in the after care clinic of Hadassah hospital that prompted Jewish patients to pursue alternative transplant options for themselves. In Israel I interviewed more than 50 transplants professionals, transplant patients, and organs buyers and sellers involved in commercialized transplants. Most surgeons, while worried about the risk to their patients and the potential for exploitation of both organs sellers and buyers on the part of unscrupulous doctors and their commercial brokers and intermediaries, none were willing to condemn a practice which they saw as "saving lives". The passivity of the Ministry of Health in Israel in refusing to intervene and crack down on this multi-million dollar business which is making Israel something of a pariah in the international transplant world, requires some explanation. As does the passivity of the governments of the Philippines, Iraq, Turkey, Romania, Moldava, and Georgia where specialized "kidney belts" are spring up. We in the United States cannot claim any high moral ground given the number of U.S. transplant centers, public and private, that court and cater to paying foreigners, thereby subverting the idea of donated organs as a national and community resource. Dr. Michael Friedlander, chief nephrologist at Hadassah Hospital in Jerusalem, counts among his recovering international transplant patients, several Israelis who have recently returned this year and last (2000-2001) from Europe and the United States with kidneys that were purchased from living donors. The doctors in charge of the identified kidney units where these transplants have taken place claim ignorance, on their part, saying they believed that the donors and recipients were either biologically or emotionally related. Among a great many kidney experts the understanding is that commerce in kidneys between strangers is everywhere protected by a policy of "Ask Ð but please don’t tell me anything I don’t want to hear". In March 2001 I interviewed in Israel two men, one a young student, the other a retired Israeli civil servant, who had both recently returned from transplant units in Baltimore and NYC, U.S., each with a new, purchased kidney. Itay, a graduate student in business in Jerusalem said that he preferred not to think about his living donor, and was even advised by his local transplant doctor, who accompanied him to New York, to think of his trip to the United States as an extended vacation holiday . Similarly, the older transplant patient described the fees he had paid, through a broker, to an acquaintance for her spare kidney as a "bonus" and her trip with him to the U.S. (under false pretenses, traveling as tourists) as nothing more than a paid vacation. The Fetishized Kidney What drives these new markets in living donors is the desire to control the quality of the product purchased . In Israel;, for example, there is resistance to taking the organ from a dead person when a strong, healthy, living donor can be found. A retired lawyer in Jerusalem, explained to me last March (2001) why he went through considerable expense and considerable risk to travel to Eastern Europe to purchase a kidney from a displaced rural worker, rather than wait in line for a cadaver organ in Israel: Why should I have to wait years for a kidney from someone who was in a car accident, pinned under the car for many hours, then in miserable condition in the I.C.U. [intensive care unit] for days and only then, after all that trauma, have that same organ put inside me? That organ is not going to be any good! Or, even worse, I could get the organ of an elderly person, or an alcoholic, or a person who died of a stroke. That kidney is all used up! It’s far better to get a kidney from a healthy man who can also benefit from the money I can afford to pay. Where I went the people were so poor they did not even have bread to eat. Do you have any idea of what one thousand, let alone five thousand dollars, means to a peasant? The money I paid was a gift equal to the gift that I received. Obviously, desperation on both sides and a willingness of the transplant doctors and their patients to see only one side of the transplant equation allows the commodified kidney to become an almost fetishized organ of opportunity for the buyer and an organ of last resort for the seller. Ads like the following one, which appeared in the Diario de Pernambuco, of Recife, Brazil, appear every day in newspapers around the world: I, Manuel da Silva, 38, unemployed sugar cane worker, father of three hungry children and a sick wife, announce my willingness to sell any organ of which I have two, and the immediate removal of which will not cause my immediate demise. They even come in to Organs Watch through our e-mail: Hello, I am Art, I am 22 years old and I am completely healthy, and the reason for this mail is that I am determined to donate one of my kidneys, but the thing is not simple, well, I am Mexican, however I am willing to travel. My economic situation is not the best, for which if someone is interested in obtaining the kidney and he has the economic power for make this possible, I mean, enough money for me and my family, then, we'll be speaking of a transplant immediate. Or this one from Southern California: Please, I need money to get dentures, and am a senior desperate for money. Want to sell very good kidney. Am desperate for money for teeth. Also am senior citizen in excellent medical shape, but need $40,000. For dentures. My husband and I have no dental plan. I will pay travel expenses if a donor needs my kidney. I refer to this sad state of affairs as neo - or postmodern cannibalism. Organs Watch Organs Watch developed out of the meetings in 1995-1996 of the Bellagio Task Force on Transplantation and the International Traffic in Organs (see Rothman et al 1997) of which I was a member, and in response to the urgent need to consider new ethical standards for organs harvesting and transplant surgery in light of many well -documented abuses world-wide in procuring and allocating organs and tissues for transplant. The Task Force, consisting of a dozen international transplant professionals, human rights experts, and medical social scientists, concentrated its efforts on exploring allegations of organs and tissue theft; the extent of the global traffic in kidneys purchased from living "donors"; and the use of executed prisoners in Asia as convenient sources of organs for transplant and of foreign capital. At its final meeting in Bellagio, Italy in September 1996 the Task Force concluded that organ sales were prevalent and could be found in affluent as well as in poor nations. The Task Force called for basic research and documentation on the traffic in organs recommended the creation of an international "clearinghouse" to explore allegations of ethical and human rights violations in organs procurement and transplant surgery and to make recommendations to the appropriate medical bodies, such as the World Medical association, of strategies that might be used to enforce existing, but ineffectual, international regulations and standards on organs procurement and transplant. Organs Watch was founded, therefore, as an interim and stop gap measure in the absence of any other organization of its kind. At present, Organs Watch is mapping the routes by which organs, doctors, patients, brokers, capital, and organ sellers circulate, and our findings to date ( see Cohen 1999; Scheper-Hughes 1998a,b, 2000, 2001) indicate several pressing issues that need to be addressed, among these: The collapse of cultural and religious sanctions about body dismemberment in the face of tremendous market pressures to sell an organ. My associate, Lawrence Cohen, who has worked in small town in the south and western regions of India reports that in a very brief period the idea of trading " "a kidney for a dowry" has caught on and become a fairly common strategy for poor parents to arrange a comfortable marriage for an otherwise economically disadvantaged or "extra" daughter. In other words, a spare kidney for a spare daughter. Cohen notes that ten years ago when villagers and townspeople first heard through newspaper reports of kidney sales occurring in the big cities of Bombay and Madras they responded with predictable alarm and revulsion. Today, some of these same villagers now speak matter-of-factly about when in the course of a family cycle it might be necessary to sell a "spare" organ. Some village parents say they can no longer complain about the fate of a dowry-less daughter. "Haven't you got a spare kidney?", one or another unsympathetic neighbor is likely to respond. Similarly, in rural Brazil I encountered kidney sellers who insisted that they had donated altruistically, and "from the heart" even if they did receive as compensation a small cash payment, a used car, or help in locating a house or a new job. "Wouldn’t you feel obligated [I was asked] to give something of which you had two to a person who had none at all?" Race, Class and Gender Inequalities We found in many countries - from Brazil and Argentina to India, Russia, Romania, Turkey to South Africa and parts of the United States - a kind of "apartheid medicine" that divides the world into two distinctly different populations of "organs supplies" and "organs receivers" . In South Africa, under apartheid, is was customary to take organs from Black and mixed race patients in segregated ICUs and to transplant them into the bodies of mostly white males. But even today the new state has abandoned support for most dialysis and transplant patients so that these medical procedures are reserved for those who can afford care in private hospitals where white, affluent Black, and foreign patients predominate (see Scheper-Hughes 1998). In the U.S. there are marked social class inequities in the allocation of organs by region and by racial group. Medical exclusions based on poor tissue matches, previous medical and reproductive histories, exposure to infectious disease, disqualify a great many African-American candidates for transplant surgery. One has to be relatively "healthy," affluent, and (one could add) preferably white in the U.S. to be a candidate for a cadaveric organ. Under these exclusionary conditions, resistance to organ donation is predictable. African-Americans are counseled by their doctors to pursue live (kidney) donation, more frequently than white Americans are. Meanwhile, African-Americans express greater resistance (than Euro-Americans) to making such demands on their loved ones. Tissue Banks - an unregulated, international, multi-million dollar business in body parts. Contemporary mortuary practices and tissues harvesting in many parts of the world, including the United States, resemble a kind of human strip farming. Heart valves, pituitary glands, cornea, skin grafts, bone, and other body parts removed are used for research, teaching, product testing, and for sale to biotech companies. There now exists an unregulated, international, multi-million dollar business in tissues and body parts, obtained from naive donors who believe their gifts are being used in heroic rescues to save lives and comfort burn victims. Instead, as in many parts of the U.S., donated bone and skin are sold and processed (sometimes abroad) by private bio-tech firms into expensive products for dentistry and plastic surgery. Dermalogenª, a product made of processed human skin, a skin-based gel, is sold to plastic surgeons for use in operations to enlarge the lips and smooth wrinkles. Sometimes donation is a coerced or manipulated gift, one grounded in the bad faith of medical institutions and tissue banks. Advantage is taken of exemplary people who are asked to perform acts of mercy and altruism at a time of profound grief, like Linda Johnson-Schuringa, from Orange, California who put her late husband's body into the care of the Orange County Eye and Tissue Bank, believing that his tissues and bone would alleviate the suffering of another person, only to discover later that the gift of her husband's bones had been shipped to Germany and "processed" into a dental product and sold internationally. In many third-world countries human tissue is exchanged with first-world countries for medical technology or expertise. In South Africa the director of an experimental research science unit of a large public medical school showed me official documents approving the transfer of hundreds of human heart valves taken (without consent) primarily from the bodies of poor Black males in the police mortuary and shipped for "handling costs" to medical centers in Germany and Austria. These fees, which were intentionally inflated to the maximum, helped support the unit's research program in the face of austerities and the downsizing of advanced medical research facilities in the new South Africa. In South Africa when a super-abundance of Black bodies struggle piled up in police mortuaries, the result of the anti-apartheid struggle, organs and tissues were taken without consent for transplant and other advanced medical procedures. In Gugaletu township I interviewed Mrs. Thandiwe-Sitsheshe Mfundese who took her complaint- the desecration of her son Andrew's body at the Salt River Mortuary in Cape Town, after he was killed in township violence in 1992-to the highest arbiter of human suffering in South Africa today, the Truth and Reconciliation Commission. Ms. Sitshetshe sees organs and tissue harvesting without consent as a continuing residue of the practice of an apartheid medicine in which black bodies were and continue to be disrespected in preference for servicing the needs of mostly white and affluent transplant patients in South Africa. Debt Peonage Organs Watch has followed the emergence of new forms of "debt peonage" stimulated by the global economy in which the "commodified kidney" occupies a critical role as collateral. Here the work of my colleague Lawrence Cohen on the emergence of "kidney belts" in southern India is pivotal. Cohen interviewed half a dozen women in a municipal housing-project in a Chennai (Madras) slum in South India, each of whom had sold a kidney for about $1,000 and undergone her "operation" at the clinic of Dr. K. C. Reddy, India's most outspoken advocate of the individual's "right to sell" a kidney. The women Cohen interviewed were primarily low-paid domestic workers with husbands in trouble or in debt. Most said that the kidney sale was preceded by a financial crisis - the family had run out of credit and the money lenders were knocking at the door. Friends had passed on the word that there was quick money to be had by selling a kidney. Cohen asked whether the sale made a difference in their lives, and he was told that it did for a time, but the money was soon swallowed by the interest charged by the money lenders, and the families were in debt once again. Would they do it again? He asked. Yes, the women answered. What other choice did they have with their debts piling up and the children needing food and school supplies? If only there were three kidneys, with two to spare, then things might be better for them. When townspeople had first heard through newspaper reports of kidney sales occurring in the cities of Bombay and Madras, they responded with alarm. But now, Cohen says, some of these same people speak matter of factly about when it may be necessary to sell a "spare" organ. And today the "spare" kidney represents every poor person’s last resort and his or her ultimate collateral. Entrapment to Donate or Sell an Organ Organs Watch researchers have identified patterns of "compensated and coerced gifting between employers and employees, neighbors, and distant kin in which body parts are exchanged for emotional and/or material support, including secure work and other benefits, or where prisoners offer kidneys in exchange for reduced sentences or to alleviate their disgraced social condition. In March 20001 I spent the day with Abraham Sibony, a recent immigrant to Israel from Morocco, who had embarked on a career as a petty thief. Sibony was in and out of jail for several years when he was contacted in a prison workshop by a warden attached to a local organs broker. ÔDo you want to find a quick way out of your troubles, Sibony was asked. Surprised to learn that he could make $30,000 by selling one of his kidneys, and even more surprised to be told by an outlaw transplant doctor that "people were healthier and lived longer with only one kidney", Sibony was in and out of surgery in a few days during a brief furlough from prison. Though Sibony has not, unlike many other unlucky kidney sellers, suffered from any significant medical complications, he was ill-prepared for a long period of recovery in prison, and angry that he was paid only $6,000 and had no legal recourse against the lawyer-transplant recipient and his broker who had deceived him, a story that is very common among the world’s kidney sellers. Meanwhile, many kidney patients who have been eliminated from organs waiting lists for reasons of age, frailty, or complicated medical conditions are preyed on by brokers and corrupt transplant surgeons who disregard the normal medical criteria for transplant. For example, Mr. Tati, a municipal public health food inspector from Jerusalem, went to Turkey for an illegal transplant of a kidney purchased from an Iraqi soldier and returned home close to death and very poor indeed. To begin with, Mr. Tati was a very poor candidate for a transplant. He had suffered a coronary event in his early 40s and he was removed from the official kidney transplant waiting list by his doctors at Hadassah Hospital and was told that dialysis was his best solution. Approached by brokers, Mr. Tati took his medical records to another, competing hospital in Tel Aviv where Dr. Zaki Shapira, a renowned medical outlaw, agreed to include him on his list of transplant tourists. Immediately following his risky transplant, and while he was still in the recovery room, Mr. Tati suffered a second and this time, massive heart attack. This was followed by a crisis of kidney rejection. The outlaw surgeons packed the frail man back into the private jet with an RX to his regular doctors at Hadassah Hospital to treat the medical mess they had created. The doctors at Hadassah were furious, but treated Mr. Tati at the government's expense. Seven months later, when I first interviewed him, Mr. Tati was still a hospital patient. "He is a real basket case," his attending physician told me ruefully, "but he did manage to survive the ordeal." The next time I visited Mr. Tati, in March 2001, he was living at home in a modest working class housing project, but he was unemployed and disabled. But even worse, he said, was the huge debt he had accumulated. In getting together the $145,000 in cash ("green," i.e., American dollars) to pay for his transnational transplant, Mr. Tati had borrowed from banks and from family, friends and co-workers. His Israeli medical insurance plan paid $80,000 for the transplant procedure. But he still owed the rest. Desperate transplant patients are prey to active brokers and scam artists in the organs black market. In Israel, a Bulgarian guest worker, Pettia, offered her kidney several times over to desperate transplant candidates in Jerusalem, soliciting from each several hundred dollars for pre-tests and cross-matches that always proved disappointing. Meanwhile, Pettia kept the money and her kidney. Similarly, in the U.S. the FBI have investigated Jim Cohan, an indefatigable broker from West Hollywood, Los Angeles, a man who widely advertises the ability to broker organs without any real ability or commitment to do so. In fact, there is no evidence that Cohan has ever arranged a transplant. But he has collected substantial "deposits" up to $10,000 from the sick and desperate people he has solicited over the years with his "Dear Prospective Organs Recipient" letter in which he claims to have arranged hundreds of transplants in the Philippines, Africa and Europe for up to $225,000 for a heart, lung or liver and $125,000 for a kidney. Cohan’s letter boasts the promise of a quality product. He writes : "While organs are procured in the United States from "older, sick or diseased people," he has access to organs from "young, healthy people," including "vegetarians, people who exercise and hard-working individuals." The desperately sick are easy prey to kidney scams like these. Kidney Theft Black markets lead, ultimately, to criminal behavior. Organs Watch has examined allegations of documentation of kidney theft from poor and otherwise socially marginal hospital patients, (especially women and foreign workers) during routine and minor surgeries for other medical problems. Several cases are mired today in complicated legal proceedings in India Brazil and Argentina. The following brief summary selected from several similar cases that I have cases explored on site and in great detail in Brazil and Argentina will illustrate this hard to believe phenomenon: During the summer of 1998, I was sitting at a sidewalk cafe in downtown Sao Paulo with Laudiceia Cristina da Silva, a young mother and office receptionist who had just legally requested an investigation of the large public hospital where in June 1997 during a routine operation to remove an ovarian cyst she had "lost" a kidney. That she was missing a kidney was discovered soon after the operation by the young woman's family doctor during a routine follow-up examination. When confronted with the information, the hospital representative told a highly improbable story - that her missing kidney was embedded within her ovarian cyst. But the hospital refused to produce the medical records or any evidence to support their story. The regional Medical Ethics Board refused to review the case. Laudiceia believes that her valuable kidney was taken to serve the needs of another, wealthier, patient in the same hospital. To make matters worse, Laudiceia's brother had been killed in a random act of urban violence several weeks earlier, and the family arrived at the hospital too late to stop organ retrieval. Brazil's new "presumed consent" law allows organs harvesting without prior consent by the individual or by his family members. "Poor people like ourselves are losing our organs to the state, one by one," Laudicea said angrily. The Discourse on Scarcity The "demand" for human organs, tissues, and body parts - and the search for wealthy transplant patients to purchase them - is driven by the medical discourse on scarcity. The specter of long transplant "waiting lists" - often we have found only virtual lists with little material basis in reality-has motivated and driven questionable practices of organ harvesting with blatant sales alongside "compensated gifting"; doctors acting as brokers; and fierce competition between public and private hospitals for patients of means. At its worst the scramble for organs and tissues has lead to human rights abuses and violations in intensive care units and in public morgues. But the very idea of organ "scarcity" is what Ivan Illich would call an artificially created need, invented by transplant technicians and dangled before the eyes of an ever-expanding sick, aging, and dying population. Bio-ethics creates the semblance of ethical choice (e.g., the right to buy a kidney based on a principle of individual autonomy) in an intrinsically unethical context. Unfortunately, there is no lack of desperate people willing to sell a kidney for a pittance, as little as $1,000. Many wait outside transplant units or in special waiting rooms and wards of surgical units reserved for them, in India, Iraq, and Turkey, begging to be considered and hoping for a good match with a prospective buyer. The sale of human organs and tissues requires that certain disadvantaged individuals, populations, and even nations have been reduced to the role of "suppliers." It is a scenario in which only certain bodies are broken, dismembered, fragmented, transported, processed, and sold in the interests of a more socially advantaged population of organs and tissues receivers. I use the word "fetish" advisedly to conjure up the displaced magical energy that is invested in the purchased living, and thereby strangely animate, kidney. The magical transformation of a person into a "life" that must be prolonged, saved, at any cost, has made life into the ultimate fetish as recognized many years ago by Ivan Illich. The idea of "life" itself as an object of manipulation, a relatively new idea in the history of modernity. The fetishization of life - a life preserved, prolonged, enhanced at almost any cost-erases any possibility of a social ethic. What’s Wrong With Buying or Selling a Kidney? If a living donor can do without an organ, why shouldn't the donor profit and medical science benefit? In the third world, poor people cannot really "do without" their "extra" organs. Transplant surgeons have disseminated an untested hypothesis of "risk-free" live donation in the absence of any published, longitudinal studies of the effects of nephrectomy (kidney removal) among the urban poor living anywhere in the world. Living donors from shantytowns, inner cities, or prisons face extraordinary threats to their health and personal security through violence, injury, accidents, and infectious disease that can all too readily compromise the kidney of last resort. As the use of live kidney donors has moved from the industrialized West, where it takes place among kin and under highly privileged circumstances, to areas of high risk in the third world, transplant surgeons are complicit in the needless suffering of a hidden population. During a field trip to Brazil in 1998, I encountered in Salvador, Bahia, a "worst-case scenario," showing just how badly a live kidney donation could turn in a third-world context. "Josefa," the only girl among eight siblings from a poor, rural family in the interior of the state, developed end-stage kidney disease in her twenties. With the help of people from her local Catholic church, Josefa moved to Salvador for dialysis treatments, but there her condition continued to deteriorate. Her only solution, she was told, would be a transplant, but as a "public" patient her chances of getting to the top of local "waiting lists" was next to nil. At her doctor's suggestion, Josefa sought a kidney donor among her siblings. An older brother, "Tomas," the father of three young children, readily offered to help his "baby" sister. But what first seemed like a miraculous transfer of life, rather quickly turned problematic. Soon after the "successful" transplant, Josefa suffered a crisis of rejection and lost her new kidney. Meanwhile, Tomas himself fell ill and was himself diagnosed with kidney disease resulting from a poorly treated childhood infection. What the doctors referred to as a "freak accident" and a stroke of "bad luck" struck Josefa (and her brother) as evidence of a larger social disease: "We were poor and ignorant; the doctors didn't really care whether we were properly matched or whether I could afford the drugs I needed to stay alive after the transplant." Josefa's enormous guilt toward her dying brother brought tears to her eyes throughout our interviews. She was committed to doing everything possible to help out his family to which she felt so miserably indebted. Tomas, a slender, nervous man, looking far older than his years, said ruefully during a separate interview: "I love my sister, and I don't hold her responsible for what has happened. The doctors never asked about my own medical history before the operation. And afterwards it was too late." Whose Values are These? Bio-ethical arguments about the right to sell are based on Euro-American notions of contract and individual "choice." But the social and economic contexts that make the "choice" to sell a kidney in an urban slum of Calcutta or in a Brazilian favela anything but a "free" and "autonomous" one. Consent is problematic with "the executioner"-whether on death row or at the door of the slum resident-looking over one's shoulder. A market price on body parts-even a fair one-exploits the desperation of the poor, turning their suffering into an opportunity. For many bio-ethicists the "slippery slope" in transplant medicine begins with the emergence of a black market in organs and tissue sales; for the medical anthropologist the slippery slope begins the first time one ailing human looked at another living human and realized that inside that other body was something that could prolong his or her life. Are regulated sales the way to go? Asking the law to negotiate a fair price for a live human kidney goes against everything that contract theory stands for. When concepts like individual agency and autonomy are invoked in defending the "right" to sell an organ, the long established belief that "living" things are not alienable or proper candidates for commodification? And the removal of a non-renewable organs is an act in which medical practitioners, given their ethical commitment to beneficence and non-malfeasance, should not be asked to participate. Finally, the argument for "regulation" of kidney sales is out of touch with the social and medical realities operating in many parts of the world but especially in second and third world nations. The medical institutions created to "monitor" organs harvesting and distribution are often dysfunctional, corrupt, or compromised by the power of organs markets and the impunity of the organs brokers and of outlaw surgeons willing to violate the first premise of classical medical bio-ethics: above all, do no harm. Organs Watch asks that organs harvesting practices respect the bodies of donors, living and dead. Transplant surgeons need to pay attention to where organs come from and the manner in which they are harvested so that the "gift of life" never deteriorates into a "theft of life." Organ donation should be voluntary and free of coercion, whether psychological or economic. The bodies of organ donors - living and dead - need to be protected, not exploited, by those doctors charged with their care. Transplant tourism, and with it, a culture of self-defined transplant outlaws - doctors, patients, brokers, and kidney sellers - short-circuit national waiting lists and make a mockery of professional codes of ethics and international regulations and national laws prohibiting the sale of organs from living or dead donors. The key actors in this global scenario are a new class of entrepreneurial organs brokers, who prey on medically incited organs scarcity panics and on the desperation of both the kidney buyers and the organs sellers. Since every international medical body of medical ethics has condemned the buying and selling of organs, those doctors who are involved in arranging or facilitating transplants with paid donors should face professional sanctions. Doctors posing as ordinary tourists who travel to foreign countries accompanying their patients for commercialized transplants arranged by local or international organs brokers should be prosecuted for visa fraud. Alternatives to the increasing slide toward related and unrelated living kidney (and liver) donation should be pursued, including the possibility of presumed consent laws or some forms of real or symbolic compensation and special recognition to families who agree to donate. (We have seen that that contributions by the municipal government toward the funeral expenses of public organ donors in Sao Paulo, Brazil, has served to recognize the compassionate and socially conscientious act.) Finally, the "risks" and "benefits" of organ transplant surgery need to be more equally distributed among and within nations, and among ethnic groups, the sexes, and social classes. While to transplant surgeons an organ is just an object, a heart is just a pump, and a kidney is just a filter, a commodity better used than wasted, to a great many ordinary people around the world an organ is something else - it remains a lively, animate, spiritualized part of the self and more than a spare part to be sold or bartered on the open market to the highest bidder.
References Cited and Additional Suggested Readings Berliner, Giovanni and Volnei Garrafa. 1996 La merce finale; saggio sulla compravendita di parte del corpo umanao. Milano: Baldini and Castoldi. Cohen, Lawrence. 1999 Where it Hurts: Indian Material for an ethics of organ transplantation. Daedalus 128(4): 135-166. Richards, Janet Radcliffe., et al. 1998 The Case for Allowing Kidney Sales. The Lancet 351: 1950-52. Rothman, David, et al. 1997 The Bellagio Task Force Report on Transplantation, Bodily Integrity, and the International Traffic in Organs". Transplantation Proceedings 29: 2739-2745. Rothman, David. 1998 The International Organ Traffic. The New York Review of Books. March 26, pp. 14- 17. Saalahudeen, A. K., et al. 1990 High Mortality among Recipients of Bought Living- Unrelated Kidneys. The Lancet, 336(8717): 725- 728. Scheper-Hughes, Nancy. 1996 Theft of Life: Globalization of Organ Stealing Rumors. Anthropology Today 12(3): 3-11. Scheper-Hughes, Nancy 1998a Organ Trade: The New Cannibalism. The New Internationalist April : 14-17. Scheper-Hughes, Nancy. 1998b Truth and Rumor on the Organ Trail. Natural History Magazine. October: 48-57. Scheper-Hughes, Nancy. 1998c Bodies of Apartheid: Witchcraft, Rumor and Racism Confound South Africa’s Organ Transplant Program. WorldView 11(4): 47-53. Scheper-Hughes, Nancy. 2000 The Global Traffic in Human Organs. Current Anthropology 41(2): 1-22. April. Sharp, Lesley A. 2000 The Commodification of the Body and its Parts. Annual Reviews of Anthropology 29: 287-328. Soros, George. 1998 The Crisis of Global Capitalism. New York: Public Affairs. World Medical Association. 1985. Statement on Live Organ Trade, Brussels, Belgium, October. Newspaper Articles Barra, Erik and Rebecca Cooney. China’s Kidney Transplant Trade. The Village Voice, May 8, 2001. Finkler, Michael. This Little Kidney Goes to Market. The New York Times Magazine, Sunday, May 27, 2001. Max, Arthur. 1995 Stolen Kidneys Supplying India's Transplant Industry. San Francisco Chronicle, April 6. The New York Times. 1999 Researchers to Monitor Trade in Human Organs. New York Times, Nov.5, 1999, A-23. |
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