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Saudi Journal of Kidney Diseases and Transplantation
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SPECIAL ARTICLE Table of Contents   
Year : 2010  |  Volume : 21  |  Issue : 1  |  Page : 138-147
The declaration of Istanbul on organ trafficking and transplant tourism

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Date of Web Publication8-Jan-2010

How to cite this article:
. The declaration of Istanbul on organ trafficking and transplant tourism. Saudi J Kidney Dis Transpl 2010;21:138-47

How to cite this URL:
. The declaration of Istanbul on organ trafficking and transplant tourism. Saudi J Kidney Dis Transpl [serial online] 2010 [cited 2022 Dec 2];21:138-47. Available from: https://www.sjkdt.org/text.asp?2010/21/1/138/58790
Participants in the International Summit on Transplant Tourism and Organ Trafficking convened by The Transplantation Society and International Society of Nephrology in Istanbul, Turkey, April 30-May 2, 2008*

   Preamble Top

Organ transplantation, one of the medical mi­racles of the twentieth century, has prolonged and improved the lives of hundreds of thou­sands of patients worldwide. The many great scientific and clinical advances of dedicated health professionals, as well as countless acts of generosity by organ donors and their families, have made transplantation not only a life-saving therapy but a shining symbol of human solida­rity. Yet these accomplishments have been tar­nished by numerous reports of trafficking in human beings who are used as sources of organs and of patient-tourists from rich coun­tries who travel abroad to purchase organs from poor people. In 2004, the World Health Organization, called on member states "to take measures to protect the poorest and vulnerable groups from transplant tourism and the sale of tissues and organs, including attention to the wider problem of international trafficking in human tissues and organs". [1]

To address the urgent and growing problems of organ sales, transplant tourism and trafficking in organ donors in the context of the global shortage of organs, a Summit Meeting of more than 150 representatives of scientific and me­dical bodies from around the world, govern­ment officials, social scientists, and ethicists, was held in Istanbul from April 30 to May 2, 2008. Preparatory work for the meeting was undertaken by a Steering Committee convened by The Transplantation Society (TTS) and the International Society of Nephrology (ISN) in Dubai in December 2007. That committee's draft declaration was widely circulated and then revised in light of the comments received. At the Summit, the revised draft was reviewed by working groups and finalized in plenary deliberations.

This Declaration represents the consensus of the Summit participants. All countries need a legal and professional framework to govern organ donation and transplantation activities, as well as a transparent regulatory oversight system that ensures donor and recipient safety and the enforce-ment of standards and prohi­bitions on unethical practices.

Unethical practices are, in part, an undesi­rable consequence of the global shortage of organs for transplantation. Thus, each country should strive both to ensure that programs to prevent organ failure are implemented and to provide organs to meet the transplant needs of its residents from donors within its own popu­lation or through regional cooperation. The the­rapeutic potential of deceased organ donation should be maximized not only for kidneys but also for other organs, appropriate to the transplantation needs of each country. Efforts to initiate or enhance deceased donor transplan­tation are essential to minimize the burden on living donors. Educational programs are useful in addressing the barriers, misconceptions and mistrust that currently impede the development of sufficient deceased donor transplantation; successful transplant programs also depend on the existence of the relevant health system infrastructure.

Access to healthcare is a human right but often not a reality. The provision of care for living donors before, during and after surgery- as described in the reports of the international forums organized by TTS in Amsterdam and Vancouver [2],[3],[4] -is no less essential than taking care of the transplant recipient. A positive out­come for a recipient can never justify harm to a live donor; on the contrary, for a transplant with a live donor to be regarded as a success means that both the recipient and the donor have done well.

This Declaration builds on the principles of the Universal Declaration of Human Rights. [5] The broad representation at the Istanbul Summit reflects the importance of international colla­boration and global consensus to improve do­nation and transplantation practices. The Decla­ration will be submitted to relevant professio­nal organizations and to the health authorities of all countries for consideration. The legacy of transplantation must not be the impoverished victims of organ trafficking and transplant tou­rism but rather a celebration of the gift of health by one individual to another.

   Definitions Top

Organ trafficking is the recruitment, trans­port, transfer, harboring or receipt of living or deceased persons or their organs by means of the threat or use of force or other forms of co­ercion, of abduction, of fraud, of deception, of the abuse of power or of a position of vulnera­bility, or of the giving to, or the receiving by, a third party of payments or benefits to achieve the transfer of control over the potential donor, for the purpose of exploitation by the removal of organs for transplantation. [6]

Transplant commercialism is a policy or practice in which an organ is treated as a commodity, including by being bought or sold or used for material gain.

Travel for transplantation is the movement of organs, donors, recipients or transplant pro­fessionals across jurisdictional borders for trans­plantation purposes. Travel for transplantation becomes transplant tourism if it involves or­gan trafficking and/or transplant commercia­lism or if the resources (organs, professionals and transplant centers) devoted to providing transplants to patients from outside a country undermine the country's ability to provide trans­plant services for its own population.

   Principles Top

1. National governments, working in collabo­ration with international and non-govern­mental organizations, should develop and implement comprehensive programs for the screening, prevention and treatment of organ failure, which include:

  1. The advancement of clinical and basic science research;
  2. Effective programs, based on interna­tional guidelines, to treat and maintain patients with end-stage diseases, such as dialysis programs for renal patients, to minimize morbidity and mortality, alongside transplant programs for such diseases;
  3. Organ transplantation as the preferred treatment for organ failure for medically suitable recipients.
2. Legislation should be developed and im­plemented by each country or jurisdiction to govern the recovery of organs from de­ceased and living donors and the practice of transplantation, consistent with interna­tional standards.

  1. Policies and procedures should be de­veloped and implemented to maximize the number of organs available for trans­plantation, consistent with these prin­ciples;
  2. The practice of donation and transplan­tation requires oversight and accountability by health authorities in each country to ensure transparency and safety;
  3. Oversight requires a national or re­gional registry to record deceased and living donor transplants;
  4. Key components of effective programs include public education and awareness, health professional education and trai­ning, and defined responsibilities and accountabilities for all stakeholders in the national organ donation and trans­plant system.
3. Organs for transplantation should be equi­tably allocated within countries or jurisdic­tions to suitable recipients without regard to gender, ethnicity, religion, or social or financial status.

  1. Financial considerations or material gain of any party must not influence the application of relevant allocation rules.
4.The primary objective of transplant poli­cies and programs should be optimal short­and long-term medical care to promote the health of both donors and recipients.

  1. Financial considerations or material gain of any party must not override primary consideration for the health and well-being of donors and recipients.
5. Jurisdictions, countries and regions should strive to achieve self-sufficiency in organ donation by providing a sufficient number of organs for residents in need from within the country or through regional cooperation.

  1. Collaboration between countries is not inconsistent with national self- suffi­ciency as long as the collaboration pro­tects the vulnerable, promotes equality between donor and recipient popula­tions, and does not violate these prin­ciples;
  2. Treatment of patients from outside the country or jurisdiction is only accepta­ble if it does not undermine a country's ability to provide transplant services for its own population.
6. Organ trafficking and transplant tourism violate the principles of equity, justice and respect for human dignity and should be prohibited. Because transplant comercia­lism targets impoverished and otherwise vulnerable donors, it leads inexorably to inequity and injustice and should be prohi­bited. In Resolution 44.25, the World Health Assembly called on countries to prevent the purchase and sale of human organs for transplantation.

  1. Prohibitions on these practices should include a ban on all types of adver­tising (including electronic and print media), soliciting, or brokering for the purpose of transplant commercialism, organ trafficking, or transplant tourism.
  2. Such prohibitions should also include penalties for acts-such as medically screening donors or organs, or trans­planting organs-that aid, encourage, or use the products of, organ trafficking or transplant tourism.
  3. Practices that induce vulnerable indi­viduals or groups (such as illiterate and impoverished persons, undocumented immigrants, prisoners, and political or economic refugees) to become living donors are incompatible with the aim of combating organ trafficking, trans­plant tourism and transplant comer­cialism.

   Proposals Top

Consistent with these principles, participants in the Istanbul Summit suggest the following strategies to increase the donor pool and to prevent organ trafficking, transplant comercia­lism and transplant tourism and to encourage legitimate, life-saving transplantation programs:

To respond to the need to increase deceased donation

  1. Governments, in collaboration with health care institutions, professionals, and non­governmental organizations should take appropriate actions to increase deceased organ donation. Measures should be taken to remove obstacles and disincentives to deceased organ donation.
  2. In countries without established deceased organ donation or transplantation, national legislation should be enacted that would initiate deceased organ donation and create transplantation infrastructure, so as to ful­fill each country's deceased donor poten­tial.
  3. In all countries in which deceased organ donation has been initiated, the therapeutic potential of deceased organ donation and transplantation should be maximized.
  4. Countries with well established deceased donor transplant programs are encouraged to share information, expertise and tech­nology with countries seeking to improve their organ donation efforts.
To ensure the protection and safety of living donors and appropriate recognition for their heroic act while combating transplant tourism, organ trafficking and transplant commercialism

1.The act of donation should be regarded as heroic and honored as such by represen­tatives of the government and civil society organizations.

2. The determination of the medical and psy­chosocial suitability of the living donor should be guided by the recommendations of the Amsterdam and Vancouver Forums. [2],[3],[4]

  1. Mechanisms for informed consent should incorporate provisions for eva­luating the donor's understanding, in­cluding assessment of the psycholo­gical impact of the process;
  2. All donors should undergo psychoso­cial evaluation by mental health pro­fessionals during screening.
3. The care of organ donors, including those who have been victims of organ traffi­cking, transplant commercialism, and trans­plant tourism, is a critical responsibility of all jurisdictions that sanctioned organ trans­plants utilizing such practices.

4. Systems and structures should ensure stan­dardization, transparency and accountabi­lity of support for donation.

  1. Mechanisms for transparency of process and follow-up should be established;
  2. Informed consent should be obtained both for donation and for follow-up pro­cesses.
5. Provision of care includes medical and psychosocial care at the time of donation and for any short- and long-term conse­quences related to organ donation.

  1. In jurisdictions and countries that lack universal health insurance, the provi­sion of disability, life, and health insu­rance related to the donation event is a necessary requirement in providing care for the donor;
  2. In those jurisdictions that have univer­sal health insurance, governmental ser­vices should ensure donors have access to appropriate medical care related to the donation event;
  3. Health and/or life insurance coverage and employment opportunities of per­sons who donate organs should not be compromised;
  4. All donors should be offered psycho­social services as a standard compo­nent of follow-up;
  5. In the event of organ failure in the do­nor, the donor should receive:

  1. Supportive medical care, including dialysis for those with renal failure, and
  2. Priority for access to transplan­tation, integrated into existing allo­cation rules as they apply to either living or deceased organ transplan­tation.
6. Comprehensive reimbursement of the actual, documented costs of donating an organ does not constitute a payment for an or­gan, but is rather part of the legitimate costs of treating the recipient.

  1. Such cost-reimbursement would usually be made by the party responsible for the costs of treating the transplant re­cipient (such as a government health department or a health insurer);
  2. Relevant costs and expenses should be calculated and administered using trans­parent methodology, consistent with national norms;
  3. Reimbursement of approved costs should be made directly to the party supplying the service (such as to the hospital that provided the donor's medical care);
  4. Reimbursement of the donor's lost income and out-of-pockets expenses should be administered by the agency handling the transplant rather than paid directly from the recipient to the donor.
7. Legitimate expenses that may be reim­bursed when documented include:

  1. the cost of any medical and psycho­logical evaluations of potential living donors who are excluded from dona­tion (e.g., because of medical or im­munologic issues discovered during the evaluation process);
  2. costs incurred in arranging and effec­ting the pre-, peri- and post-operative phases of the donation process (e.g., long-distance telephone calls, travel, accommodation and subsistence ex­penses);
  3. medical expenses incurred for post­ discharge care of the donor;
  4. lost income in relation to donation (consistent with national norms).

   References Top

1.World Health Assembly Resolution 57.18, Human organ and tissue transplantation, 22 May 2004, http://www.who.int/gb/ebwha/pdf_files/ WHA57/A57_R18-en.pdf.  Back to cited text no. 1      
2.The Ethics Committee of the Transplantation Society (2004). The Consensus Statement of the Amsterdam Forum on the Care of the Live Kidney Donor. Transplantation 78(4):491-92.  Back to cited text no. 2      
3.Barr ML, Belghiti J, Villamil FG, Pomfret EA, Sutherland DS, Gruessner RW, Langnas AN& Delmonico FL (2006). A Report of the Vancouver Forum on the Care of the Life Organ Donor: Lung, Liver, Pancreas, and Intenstine Data and Medical Guidelines. Transplantation 81(10):1373-85.  Back to cited text no. 3      
4.Pruett TL, Tibell A, Alabdulkareem A, Bhandari M, Cronon DC, Dew MA, Dib-Kuri A, Gutmann T, Matas A, McMurdo L, Rahmel A, Rizvi SAH, Wright L& Delmonico FL (2006). The Ethics Statement of the Vancouver Forum on the Live Lung, Liver, Pancreas, and Intestine Donor. Transplantation 81(10):1386-87.  Back to cited text no. 4      
5.Universal Declaration of Human Rights, adopted by the UN General Assembly on December 10, 1948, http://www.un.org/Overview/rights.html .  Back to cited text no. 5      
6.Based on Article 3a of the Protocol to Prevent, Suppress and Punish Trafficking in Persons, Especially Women and Children, Supplemen-ting the United Nations Convention Against Transnational Organized Crime, http://www.uncjin.org/Documents/Conventions/dcatoc/final_documents_2/convention_%20tr aff_eng.pdf.  Back to cited text no. 6      

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