LETTER TO THE EDITOR
Year : 2010 | Volume
: 21 | Issue : 2 | Page : 345--347
Seeking consent in the country of origin for transplantation from a brain-dead refugee in the host country
Katayoun Najafizadeh1, Fariba Ghorbani1, Ameneh Rostami1, Omid Ghobadi1, Esmail Barbati1, Shahram Salehi Rad2, Shervin Assari2,
1 Lung transplantation Research Center, National Research Institute of TB and Lung Disease, Shaheed Beheshti Medical University, Iran
2 Medicine and Health Promotion Institute, Tehran, Iran
Lung transplantation Research Center, National Research Institute of TB and Lung Disease, Shaheed Beheshti Medical University
|How to cite this article:|
Najafizadeh K, Ghorbani F, Rostami A, Ghobadi O, Barbati E, Rad SS, Assari S. Seeking consent in the country of origin for transplantation from a brain-dead refugee in the host country.Saudi J Kidney Dis Transpl 2010;21:345-347
|How to cite this URL:|
Najafizadeh K, Ghorbani F, Rostami A, Ghobadi O, Barbati E, Rad SS, Assari S. Seeking consent in the country of origin for transplantation from a brain-dead refugee in the host country. Saudi J Kidney Dis Transpl [serial online] 2010 [cited 2020 Dec 2 ];21:345-347
Available from: https://www.sjkdt.org/text.asp?2010/21/2/345/60209
To the Editor,
As defined by the United Nations High Commissioner for Refugees (UNHCR), "The one who is outside his/her country and cannot return owing to a well-founded fear of persecution because of race, religion, nationality, political opinion, or membership of a particular social group" is considered a "refugee".  According to UNHCR, an estimated 8 million persons across the world meet these criteria for a refugee status; and Asia hosts more than half of this population, with the majority of the refugees having Middle Eastern origins. 
Afghanis account for the world's largest group of refugees; Afghanistan's two neighboring countries of Iran and Pakistan, therefore, bear the brunt of this large-scale movement of people. In fact, about 1 of 5 refugees in the world is currently officially known to be sheltered in Iran and Pakistan, although the figures in reality transcend this statistic since a large proportion of refugees reside along border areas and are virtually impossible to be included in official statistics.  Unfortunately, this latter group of refugees cannot be registered officially and are, as a result, ineligible to receive many types of aid.
The problem is compounded by the fact that most refugees have a low socio-economic status and are faced with many hurdles when seeking health care services. With respect to organ transplantation, one of the most complicated and costly medical services, many refugees who are deprived of such basic facilities as drinking water cannot conceivably be given a realistic chance.  It may come as no surprise that refugees are an ideal target for organ trafficking in the world.  To preclude organ trafficking, the Islamic Republic of Iran has introduced legislation that not only bans the transplantation of a foreigner's organ to an Iranian citizen but also prohibits the donation of an organ from an Iranian citizen to a transplantation candidate from another nationality. , It is deserving of note that the current law only applies to living donors, but the Iranian Ministry of Health and Medical Education imposes this regulation on cadaveric organs as well while awaiting pertinent legislation from the parliament.
We herein report the case of a brain-dead Afghan refugee whose kidneys were transplanted to two of his compatriots in Iran after consent had been obtained from next of kin in Afghanistan thanks to the resolve of an Iranian organ procurement unit and the assistance of the Iranian Embassy in Kabul in exploring the necessary diplomatic avenues.
The Story of Organ Transplantation from a Brain-dead Refugee to Two other Refugees in the Host Country
To the best of our knowledge, the case we present here is unique. In the year 2007, an Afghan refugee suffered brain death in Iran. The deceased refugee's organs were suitable for harvesting; however, the fact that there was no access to next of kin in Iran for obtaining the mandatory consent rendered the practice impossible.
In the Iranian Transplantation System, whereas there is no waiting list for Iranian citizens to receive renal transplantation, foreigners are registered on a waiting list until organs have been procured from foreign donors. The list showed that there were two Afghan refugees with end-stage renal disease waiting for years. The coordinator of the organ procurement unit of Masih Daneshvari Hospital in the Iranian capital, Tehran, set out with the intention of seeking the brain-dead refugee's immediate family in Afghanistan through establishing contact with UNHCR and the Iranian Ministry of Foreign Affairs. Sparing no efforts and exhausting all possible channels, the Iranian Embassy in Kabul succeeded in tracking down the family in a small village. The family members were fully informed about brain death and were asked to grant written consent to the donation of the kidneys to the two Afghan candidates. The story had a happy ending in that the two Afghan refugees underwent successful renal transplantation in Iran.
In this report we touched upon the role of international collaboration in organ transplantation. Our experience was that of a new form of international cooperation in overcoming transplantation barriers, and we hope that it contributes, however little, to the available literature on organ exchange between countries. 
One of the salient points in our report, which is a factor that can loom large in the field of organ transplantation, is the ethical and legal issue of obtaining "proper consent" from next of kin. ,, Families have the right to decline organ donation, even if the donor-eligible deceased would have sanctioned the practice.  Indeed, the major factor limiting the number of organ donors is the low percentage of families willing to consent to donation.  A 1995 study of families of donor-eligible patients found that only 47.3% of the 86.5% who had been asked to donate gave their consent;  this relatively scant percentage is borne out by some other similar studies. ,
The Islamic Republic of Iran's generous contributions to refugees as regards organ transplantation have been universally acknowledged. A report on organ transplantation for refugees in Iran pointed to a rising trend in transplantation from Afghan to Afghan between 2001 and 2004.  As stated by the authors of the said report, from a total of 241 refugees with endstage renal disease in the first half of the year 2004, 62 (age range: 15 to 79 years old) had undergone renal transplantation. Living unrelated donors accounted for 81% and living related donors 16% of the kidneys donated.  It has also been reported that Afghan refugees who have received organs in Iran enjoy comparable survival rates with their Iranian counterparts: graft and patient survival rates for one, three, and five years of 97 and 98, 86 and 95, and 73 and 95 percent, respectively. 
We herein sought to underline the significance of the involvement of a country at a ministerial level in coordinating organ transplantation with another country, which would have become fruitless had it not been for the timely decision and perseverance of an organ procurement unit.
|1||UNHCR: Trends in Refugees Status Determi-nation 1 January - - 30 June 2006. Available from http://www.unhcr.org.uk . Accessed March 3,2007.|
|2||UNHCR: Refugees by number 2003. Available from http://www.unhcr.org.uk. Accessed March 3, 2007.|
|3||UNHCR: 2005 Global Refugees Trends. Avai-lable from http://www.unhcr.org.uk. Accessed March 3, 2007.|
|4||Cass A, Devitt J, Preece C, et al. Barriers to access by indigenous Australians to kidney transplantation: the IMPAKT study. Nephrology (Carlton) 2004;9(suppl 4):S144.|
|5||McClellan WM, Flanders WD. Risk factors for progressive chronic kidney disease. J Am Soc Nephrol 2003;14:S65.|
|6||Ghods AJ, Nasrollahzadeh D, Kazemeini M. Afghan refugees in Iran model renal trans-plantation program: Ethical considerations. Transplant Proc 2005;37:565.|
|7||Ghods AJ, Nasrollahzadeh D. Transplant tou-rism and the Iranian model of renal trans-plantation program: Ethical considerations. Exp Clin Transplant 2005;3:351.|
|8||Parturkar D. Legal and ethical issues in human organ transplantation. Med Law 2006;25(2): 389-98.|
|9||Einollahi B, Nourbala MH, Bahaeloo-Horeh S, Assari S, Lessan-Pezeshki M, Simforoosh N. Deceased-donor kidney transplantation in Iran: trends, barriers and opportunities. Indian J Med Ethics 2007;4(2):70-2.|
|10||Einollahi B. Iranian experience with the non-related renal transplantation. Saudi J Kidney Dis Transpl 2004;15(4):421-8.|
|11||Individual and family consent to organ and ti-ssue donation: Is the current position coherent?|
|12||Factors Influencing Families′ Consent for Donation of Solid Organs for Transplantation|
|13||Siminoff LA, Arnold RM, Caplan AL, Virnig BA, Seltzer DL. Public policy governing organ and tissue procurement in the United States. Ann Intern Med 1995;123:10-7.|
|14||Gortmaker SL, Beasley CL, Sheehy E, et al. Improving the request process to increase family consent for organ donation. J Transpl Coord 1998;8:210-7.|
|15||Beasley CL, Capossela CL, Brigham LE, Gun-derson S, Weber P, Gortmaker SL. The impact of a comprehensive, hospital-focused inter-vention to increase organ donation. J Transpl Coord 1997;7:6-13.|
|16||Einollahi B, Kidney Transplantation in Afghan Refugees Residing in Iran: The First Report of Survival Analysis. Minority and Health 2008. accepted for publication.|