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Irish GL, Fadhil RAS, Rondeau E, Nagral S, Ahmadipour M, Coates PT, Martin DE. International Travel for Organ Transplantation: A Survey of Professional Experiences and Attitudes Toward Data Collection and Reporting. Transplant Direct 2024; 10:e1655. [PMID: 38881742 PMCID: PMC11177827 DOI: 10.1097/txd.0000000000001655] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/21/2024] [Accepted: 03/14/2024] [Indexed: 06/18/2024] Open
Abstract
Background Lack of data regarding international travel for organ transplantation (ITOT) hampers efforts to evaluate, understand, and respond to trends in ITOT activities, such as those suggestive of organ trafficking or "transplant tourism." This study aimed to assess transplant professionals' experience of ITOT and their attitudes toward reporting ITOT data to a global registry. Methods An international cross-sectional anonymous survey of transplant professionals was conducted online (from October to December 2022). The English language questionnaire assessed professional experiences in providing care to individuals who had traveled to or from a country for living donation or transplantation, and attitudes toward reporting of ITOT data. Data were analyzed with descriptive statistics. Results Two hundred thirty-nine individuals from 68 countries completed the entire questionnaire, of whom 79% had provided care for ≥1 patient who had traveled internationally for donation or transplantation. Of these, 60.8% of individuals (n = 115) had cared for ≥1 person who engaged in ITOT between 2019 and 2022, with the most recent case experiences involving 89 countries and 157 unique routes of international travel. Predominant concerns regarding reporting of ITOT data to a global registry related to prevention of harm and protection of patient privacy; most (52.7%; n = 126) respondents expressed a preference for anonymous reporting of ITOT data. Conclusions ITOT is a global phenomenon and transplant professionals' experience with ITOT cases is more common than anticipated. Systems for the collection of ITOT activity data should be carefully designed to address potential ethical concerns of transplant professionals which may influence reporting practices.
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Affiliation(s)
- Georgina L Irish
- Transplant Epidemiology Group (TrEG), Australia and New Zealand Dialysis and Transplant (ANZDATA) Registry, South Australian Health and Medical Research Institute (SAHMRI), Adelaide, SA, Australia
- Central and Northern Adelaide Renal and Transplantation Service, Royal Adelaide Hospital, Adelaide, SA, Australia
- Department of Medicine, The University of Adelaide, Adelaide, SA, Australia
| | - Riadh A S Fadhil
- Qatar Organ Donation Center, Hamad Medical Corporation and Weill Cornell College of Medicine, Doha, Qatar
| | - Eric Rondeau
- Urgences néphrologiques et Transplantation rénale, Hôpital Tenon, Université Sorbonne, Paris, France
| | - Sanjay Nagral
- Department of Surgical Gastroenterology, Jaslok Hospital and Research Centre, Mumbai, Maharashtra, India
| | | | - P Toby Coates
- Central and Northern Adelaide Renal and Transplantation Service, Royal Adelaide Hospital, Adelaide, SA, Australia
- Department of Medicine, The University of Adelaide, Adelaide, SA, Australia
| | - Dominique E Martin
- School of Medicine, Faculty of Health, Deakin University, Geelong, VIC, Australia
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Braun HJ, Amara D, Shui AM, Stock PG, Hirose R, Delmonico FL, Ascher NL. International Travel for Liver Transplantation: A Comprehensive Assessment of the Impact on the United States Transplant System. Transplantation 2022; 106:e141-e152. [PMID: 34608102 DOI: 10.1097/tp.0000000000003970] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND International travel for transplantation remains a global issue as countries continue to struggle in establishing self-sufficiency. In the United States, the United Network for Organ Sharing (UNOS) requires citizenship classification at time of waitlisting to remain transparent and understand to whom our organs are allocated. This study provides an assessment of patients who travel internationally for liver transplantation and their outcomes using the current citizenship classification used by UNOS. METHODS Adult liver UNOS data from 2003 to 2019 were used. Patients were identified as citizens, noncitizen, nonresidents (NCNR), or noncitizen residents (NC-R) according to citizenship status. Descriptive statistics compared demographics among the waitlisted patients and demographics and donor characteristics among transplant recipients. A competing risks model was used to examine waitlist outcomes. The Kaplan-Meier method and Cox proportional hazards were used for posttransplant outcomes. RESULTS There were significant demographic differences according to citizenship group among waitlisted (n = 125 652) and transplanted (n = 71 536) patients. Compared with US citizens, NCNR was associated with a 9% increase in transplant (subdistribution hazard ratio [SHR], 1.09; 95% confidence interval [CI], 1.00-1.18; P = 0.04), and NC-R was associated with a 24% decrease in transplant (SHR, 0.76; 95% CI, 0.72-0.79; P < 0.0001) and a 23% increase in death or removal for being too sick (SHR, 1.23; 95% CI, 1.14-1.33; P < 0.0001). US citizens had significantly inferior graft and patient survival (P < 0.001). CONCLUSIONS Though the purpose of the citizenship classification system is transparency, the results of this study highlight significant disparities in the access to and outcomes following liver transplantation according to citizenship status.
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Affiliation(s)
- Hillary J Braun
- Division of Transplant Surgery, Department of Surgery, University of California, San Francisco, San Francisco, CA
| | - Dominic Amara
- School of Medicine, University of California, San Francisco, San Francisco, CA
| | - Amy M Shui
- Division of Transplant Surgery, Department of Surgery, University of California, San Francisco, San Francisco, CA
- Department of Epidemiology and Biostatistics, University of California, San Francisco, San Francisco, CA
| | - Peter G Stock
- Division of Transplant Surgery, Department of Surgery, University of California, San Francisco, San Francisco, CA
| | - Ryutaro Hirose
- Division of Transplant Surgery, Department of Surgery, University of California, San Francisco, San Francisco, CA
| | | | - Nancy L Ascher
- Division of Transplant Surgery, Department of Surgery, University of California, San Francisco, San Francisco, CA
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Horák F, Lacko D, Klocek A. Legal Consciousness: A Systematic Review of its Conceptualization and Measurement Methods1. ANUARIO DE PSICOLOGÍA JURÍDICA 2021. [DOI: 10.5093/apj2021a2] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
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Martin DE, Harris DCH, Jha V, Segantini L, Demme RA, Le TH, McCann L, Sands JM, Vong G, Wolpe PR, Fontana M, London GM, Vanderhaegen B, Vanholder R. Ethical challenges in nephrology: a call for action. Nat Rev Nephrol 2020; 16:603-613. [PMID: 32587403 DOI: 10.1038/s41581-020-0295-4] [Citation(s) in RCA: 18] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/17/2020] [Indexed: 12/14/2022]
Abstract
The American Society of Nephrology, the European Renal Association-European Dialysis and Transplant Association and the International Society of Nephrology Joint Working Group on Ethical Issues in Nephrology have identified ten broad areas of ethical concern as priority challenges that require collaborative action. Here, we describe these challenges - equity in access to kidney failure care, avoiding futile dialysis, reducing dialysis costs, shared decision-making in kidney failure care, living donor risk evaluation and decision-making, priority setting in kidney disease prevention and care, the ethical implications of genetic kidney diseases, responsible advocacy for kidney health and management of conflicts of interest - with the aim of highlighting the need for ethical analysis of specific issues, as well as for the development of tools and training to support clinicians who treat patients with kidney disease in practising ethically and contributing to ethical policy-making.
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Affiliation(s)
- Dominique E Martin
- School of Medicine, Deakin University, Geelong Waurn Ponds Campus, Geelong, VIC, Australia.
| | - David C H Harris
- University of Sydney at Westmead Hospital, Westmead, NSW, Australia
| | - Vivekanand Jha
- George Institute for Global Health, UNSW, New Delhi, India
- University of Oxford, Oxford, UK
- Manipal Academy of Higher Education, Manipal, India
| | - Luca Segantini
- International Society of Nephrology, Brussels, Belgium
- European Society for Organ Transplantation - ESOT c/o ESOT, Padova, Italy
| | - Richard A Demme
- Renal Division and Department of Medical Humanities and Bioethics, University of Rochester School of Medicine, Rochester, NY, USA
| | - Thu H Le
- Nephrology Division, Department of Medicine, University of Rochester School of Medicine, Rochester, NY, USA
| | - Laura McCann
- American Society of Nephrology, Washington, DC, USA
| | - Jeff M Sands
- Renal Division, Emory University School of Medicine, Atlanta, GA, USA
| | - Gerard Vong
- Center for Ethics, Emory University, Atlanta, GA, USA
| | | | - Monica Fontana
- European Renal Association - European Dialysis and Transplant Association, Parma, Italy
| | - Gerard M London
- Manhes Hospital, Nephrology Department GEPIR, Fleury-Mérogis, France
| | | | - Raymond Vanholder
- Nephrology Section, Department of Internal Medicine and Pediatrics, University Hospital, Corneel Heymanslaan 10, B9000, Gent, Belgium
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Management of Patients Who Receive an Organ Transplant Abroad and Return Home for Follow-up Care: Recommendations From the Declaration of Istanbul Custodian Group. Transplantation 2018; 102:e2-e9. [PMID: 29019810 DOI: 10.1097/tp.0000000000001963] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
Eradicating transplant tourism depends on complex solutions that include efforts to progress towards self-sufficiency in transplantation. Meanwhile, professionals and authorities are faced with medical, legal, and ethical problems raised by patients who return home after receiving an organ transplant abroad, particularly when the organ has been obtained through illegitimate means. In 2016, the Declaration of Istanbul Custodian Group convened an international, multidisciplinary workshop in Madrid, Spain, to address these challenges and provide recommendations for the management of these patients, which are presented in this paper. The core recommendations are grounded in the belief that principles of transparency, traceability, and continuity of care applied to patients who receive an organ domestically should also apply to patients who receive an organ abroad. Governments and professionals are urged to ensure that, upon return, patients are promptly referred to a transplant center for evaluation and care, not cover the costs of transplants resulting from organ or human trafficking, register standardized information at official registries on patients who travel for transplantation, promote international exchange of data for traceability, and develop a framework for the notification of identified or suspected cases of transnational transplant-related crimes by health professionals to law enforcement agencies.
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Ambagtsheer F, de Jong J, Bramer WM, Weimar W. On Patients Who Purchase Organ Transplants Abroad. Am J Transplant 2016; 16:2800-2815. [PMID: 26932422 DOI: 10.1111/ajt.13766] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/12/2015] [Revised: 02/22/2016] [Accepted: 02/24/2016] [Indexed: 01/25/2023]
Abstract
The international transplant community portrays organ trade as a growing and serious crime involving large numbers of traveling patients who purchase organs. We present a systematic review about the published number of patients who purchased organs. With this information, we discuss whether the scientific literature reflects a substantial practice of organ purchase. Between 2000 and 2015, 86 studies were published. Seventy-six of these presented patients who traveled and 42 stated that the transplants were commercial. Only 11 studies reported that patients paid, and eight described to what or whom patients paid. In total, during a period of 42 years, 6002 patients have been reported to travel for transplantation. Of these, only 1238 were reported to have paid for their transplants. An additional unknown number of patients paid for their transplants in their native countries. We conclude that the scientific literature does not reflect a large number of patients buying organs. Organ purchases were more often assumed than determined. A reporting code for transplant professionals to report organ trafficking networks is a potential strategy to collect and quantify cases.
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Affiliation(s)
- F Ambagtsheer
- Department of Internal Medicine, Transplantation and Nephrology, Erasmus MC, University Medical Center Rotterdam, Rotterdam, the Netherlands
| | - J de Jong
- Analysis and Research Department, Central Division of the National Police, Driebergen, the Netherlands.,Willem Pompe Institute for Criminal Law and Criminology, Utrecht University, Utrecht, the Netherlands
| | - W M Bramer
- Medical Library, Erasmus MC, University Medical Center Rotterdam, Rotterdam, the Netherlands
| | - W Weimar
- Department of Internal Medicine, Transplantation and Nephrology, Erasmus MC, University Medical Center Rotterdam, Rotterdam, the Netherlands
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Caulfield T, Zarzeczny A. Curbing transplant tourism: Canadian physicians and the law. CMAJ 2016; 188:935-936. [PMID: 27270121 DOI: 10.1503/cmaj.160497] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/01/2022] Open
Affiliation(s)
- Timothy Caulfield
- Health Law Institute, Faculty of Law (Caulfield), University of Alberta, Edmonton, Alta.; Johnson Shoyama Graduate School of Public Policy (Zarzeczny), University of Regina, Regina, Sask.
| | - Amy Zarzeczny
- Health Law Institute, Faculty of Law (Caulfield), University of Alberta, Edmonton, Alta.; Johnson Shoyama Graduate School of Public Policy (Zarzeczny), University of Regina, Regina, Sask
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van Balen LJ, Ambagtsheer F, Ivanovski N, Weimar W. Interviews With Patients Who Traveled From Macedonia/Kosovo, The Netherlands, and Sweden for Paid Kidney Transplantations. Prog Transplant 2016; 26:328-334. [DOI: 10.1177/1526924816667951] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Background: Patients travel worldwide for paid kidney transplants. Although transplantations abroad are not always illegal, they are commonly perceived to be illegal and unethical involving risks. Aim: We aimed to describe the motivations and experiences of patients who traveled abroad for paid kidney transplantations and to examine how these transplantations were facilitated. Methods: We interviewed 22 patients who traveled from Macedonia/Kosovo, the Netherlands, and Sweden for paid kidney transplantations between years 2000 and 2009. Results: Patients traveled because of inadequate transplant activity in their domestic countries and dialysis-related complaints. However, 6 patients underwent preemptive transplantations. Cultural factors such as patients’ affinity with destination countries, feelings of being discriminated against by the health-care system, and family ties also help explain why patients travel abroad. Seven of the 22 patients went to their country of origin. They were able to organize their transplantations by arranging help from family and friends abroad who provided contacts of caregivers there and who helped cover the costs of their transplants. The costs varied from €5000 to €45 000 (US$6800-US$61 200). Seven patients paid the hospital, 5 paid their doctor, 4 paid a broker, and 6 paid their donors. Conclusion: Research should include interviews with brokers, transplant professionals, and other facilitators to achieve a full picture of illegally performed transplantations.
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Affiliation(s)
- L. J. van Balen
- Department of Internal Medicine, Section of Nephrology and Transplantation, Erasmus MC University Hospital Rotterdam, Rotterdam, the Netherlands
| | - Frederike Ambagtsheer
- Department of Internal Medicine, Section of Nephrology and Transplantation, Erasmus MC University Hospital Rotterdam, Rotterdam, the Netherlands
| | - N. Ivanovski
- University of St Cyril and Methodius, Medical Faculty Skopje, Republic of Macedonia
| | - W. Weimar
- Department of Internal Medicine, Section of Nephrology and Transplantation, Erasmus MC University Hospital Rotterdam, Rotterdam, the Netherlands
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Caulfield T, Duijst W, Bos M, Chassis I, Codreanu I, Danovitch G, Gill J, Ivanovski N, Shin M. Trafficking in Human Beings for the Purpose of Organ Removal and the Ethical and Legal Obligations of Healthcare Providers. Transplant Direct 2016; 2:e60. [PMID: 27500253 PMCID: PMC4946496 DOI: 10.1097/txd.0000000000000566] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/13/2015] [Accepted: 11/18/2015] [Indexed: 11/25/2022] Open
Abstract
Physicians and other health care professionals seem well placed to play a role in the monitoring and, perhaps, in the curtailment of the trafficking in human beings for the purpose of organ removal. They serve as important sources of information for patients and may have access to information that can be used to gain a greater understanding of organ trafficking networks. However, well-established legal and ethical obligations owed to their patients can create challenging policy tensions that can make it difficult to implement policy action at the level of the physician/patient. In this article, we explore the role-and legal and ethical obligations-of physicians at 3 key stages of patient interaction: the information phase, the pretransplant phase, and the posttransplant phase. Although policy challenges remain, physicians can still play a vital role by, for example, providing patients with a frank disclosure of the relevant risks and harms associated with the illegal organ trade and an honest account of the physician's own moral objections. They can also report colleagues involved in the illegal trade to an appropriate regulatory authority. Existing legal and ethical obligations likely prohibit physicians from reporting patients who have received an illegal organ. However, given the potential benefits that may accrue from the collection of more information about the illegal transactions, this is an area where legal reform should be considered.
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Affiliation(s)
- Timothy Caulfield
- Health Law Institute, University of Alberta, University of Alberta, Edmonton, Canada
| | - Wilma Duijst
- Radboud University Medical Centre, Nijmegen, The Netherlands
| | - Mike Bos
- Eurotransplant International Foundation, Leiden, The Netherlands
| | | | | | | | - John Gill
- University of British Columbia, Vancouver, BC, Canada
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Indicators to Identify Trafficking in Human Beings for the Purpose of Organ Removal. Transplant Direct 2016; 2:e56. [PMID: 27500249 PMCID: PMC4946497 DOI: 10.1097/txd.0000000000000568] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/20/2015] [Accepted: 11/08/2015] [Indexed: 11/26/2022] Open
Abstract
This article presents indicators to support transplant professionals, judicial and law enforcement authorities and victim support workers with the identification of trafficking in persons for the purpose of organ removal. It outlines the legal and illegal service providers that facilitate trafficking in human beings for the purpose of organ removal and guides the reader through the following criminal process: recruitment, transport, entrance, documents, housing, transplant, aftercare, and finance. Identification of illegal transplant activities by transplant professionals can support police and judiciary with the investigation, disruption, and prosecuting of trafficking networks.
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Stimulating and Enhancing Partnerships Between Transplant Professionals and Law Enforcement: Recommendations. Transplant Direct 2016; 2:e57. [PMID: 27500250 PMCID: PMC4946488 DOI: 10.1097/txd.0000000000000567] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/13/2015] [Accepted: 10/22/2015] [Indexed: 12/25/2022] Open
Abstract
To help combat trafficking in human beings for organ removal (THBOR), transplant professionals need to do more than carry out careful, multidisciplinary screening of potential living donors; they also need to communicate and collaborate with law enforcement professionals. This will involve transplant professionals educating investigators and prosecutors about transplant practices and in turn learning about THBOR and how it is prosecuted. Cases of illegal organ transplantation need to be detected at different levels. First, the victims of the crime itself need to be identified, especially when they present themselves for screening. Physicians have a collective responsibility to prevent exploitation of people, including THBOR victims. The second level involves the more difficult matter of making reports that involve transplant tourists who have returned home after receipt of an organ and need follow-up care. Besides counseling patients prospectively about the legal as well as medical risks in receiving a vended organ in a foreign transplant center, physicians treating such patients could have an obligation to report what has happened, if the government has established a mechanism that either allows reporting THBOR that does not include the identity of the patient or that treats patients as victims provided they cooperate in investigation and prosecution of the persons responsible for obtaining or implanting the organs. The third level of cooperation involves transplant professionals who participate in THBOR. Professional societies need to undertake programs to make physicians and nurses aware that their responsibility to protect their professions' reputation includes identifying members of their professions who depart from professional ethics. Doing so allows the local professional societies and state boards to discipline such violators. All 3 of these functions would be facilitated by the creation by an international body such as World Health Organization of a registry of patients who travel internationally to receive a legitimate organ transplant.
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