Ethical Perspectives on Organ Transplantation

in China

Abstract
Background and Objective China has been criticized long time for its unethical use of
deceased organs from executed prisoners as well as lacking of regulating transplant
trafficking. This article is aimed to present the whole picture of organ transplantation in
China regarding ethical dilemmas. Furthermore, it also explores what is behind those
ethical perspectives. Methods Literature and articles on PubMed, Wan Fang (online
Chinese Periodicals Database), WHO, as well as Chinese news portals were retrieved
respectively while government official sites of China MOH, Hong Kong and Taiwan were
searched too in terms of official documents. Articles and regulations involving organ
transplantation were identified. Results Presently, China including Hong Kong, and Tai
Wan has not yet formulated any law on organ transplantation. And at least three major
ethical challenges about organ transplantation in China are identified: ① definition of
death; ②donation of organs; ③allocation of organ resource. Meanwhile, comparing with
regulations of organ transplantation in Hong Kong and Taiwan, there still be lots of
experience for us to draw lessons on.
Key words China; Organ transplantation; Ethics; Legislation
1. Introduction

The use of transplantation as treatment for patients with terminal organ failure has
become a more and more irreplaceable regimen as to save lives and improve recipients’
quality of life. At the global level, estimates for kidney, liver and heart transplantations
were 66,000, 21,000 and 6,000, respectively. In kidney transplantation, the ratio of
donations from deceased donors (DD) to donations from living donors (LD) varied across
the WHO regions (from 4.55 in EURO to 0.05 in EMRO). 1

Because of high incidence of HBV which

naturally trends to develop to hepatocirrhosis or
even worse disease as hepatic cancer ， the
demand for liver transplantation has been rising
dramatically during the last three decades in
China. According to a report released by China
Ministry of Health (MOH) on August 2007, by
that time, total number of patients who
underwent liver transplantation was 14,613
while the annual number reached 3,000～3,500
as well.2

Apart from liver transplantation, kidney

transplantation is another blooming
transplantation application in China. Over 7000
kidney transplants in 2005 and totally 86,800
kidney transplantation have been performed
until 2008.
Fig1. Timeline of transplants in China
Therefore, In terms of the above two organ transplantation, China has already become the
2nd largest country in the globe.

However, problems have also been identified in the course of such rapid development.
Among all those concerns, the one that has been criticized most intensely is the usage of
deceased organs from executed prisoners. Some other criticism include transplantation
tourism, organ trafficking, lacking of regulation, etc.

In response to international pressure and increasing internal transplant practice, the

Regulation on Human Organ Transplantation was enacted in China in 2007 and 164
medical institutions have been legitimately licensed for organ transplantation since then.
2. Current Status and Major Ethical Challenges

During the past three years, China has taken concrete steps to formulate policies in
regulating organ transplantation and protecting both donors’ and recipients’ rights. Some
efforts that have been committed to this area include strictly surveilling transplant tourism
and initiating a pilot organ donation system in 10 provinces/cities as to speed up organ
transplants.

However, current regulation in China is literally not enough to ensure quality, safety and
efficacy in managing organ transplants. Comparing with developed countries, China still
has a lot to improve regarding the following major ethical challenges.

a) Definition of Death

Although brain death is widely accepted by healthcare practioners, most Chinese people
only acknowledge the absence of respiration and heartbeat as the official definition of
death. Such a view has hampered the introduction of legislation on brain death. Because
15 minutes after the cessation of the heartbeat and breathing, the current legal definition
of death, organs are irreparably damaged and can no longer be used for transplants, the
shortage of organ in China is much more prominent than any other countries.

More important than legislation is to raise public awareness of brain death. Both
government and public media should facilitate every kind of opportunity to spread public
education.

Hopefully, the authorities in China is said to gear up to introduce a nationwide definition of

brain death to facilitate human organ transplants.

However, unless this comes true, the shortage of organs will not be changed or even
worsen in the future.

b) Donation of Organs

A growing organ shortage is one of the main challenges all over the world. In 2002 over
6,000 Americans died while waiting for organs, according to UNOS data. And in China,
this situation is no different either. About 1.5 million Chinese patients need transplants
every year but only 1 percent undergo the surgery. That means four in five will die in
waiting for a suitable match3. With the waiting list approaching higher and higher, more
and more attention has been attracted to promoting organ donation.
 i. Deceased Organ Donation

In China, it has historically been difficult to obtain cadaver organs for transplantation
primarily because of socio-cultural beliefs and customs, particularly the tradition of not
parting with their organs after death. Therefore, just as Huang Jie-fu, an official
representative in China MOH acknowledged recently, two-thirds of organ donors in China
are executed prisoners, which is criticized intensely by international society as
profit-driven and unethical.

Autonomy and justice, as two fundamental principles of healthcare ethics, should be

applied to everyone no matter he or she is a criminal or not. Hence executed prisoners are
definitely not a proper source for organ donation because of potential external pressure
and coercion.

In a solid effort to reduce its dependence on deceased organs from executed prisoners,
China has launched a national donation system since August 26, 2009, which consists of
a registry system for donors and a distribution system for recipients and is maintained by
the Red Cross Society of China and the China MOH (Ministry of Health). The pilot regions
are the cities of Tianjin, Shanghai, Xiamen, Nanjing and Wuhan and the provinces of
Liaoning, Zhejiang, Shandong, Guangdong and Jiangxi.

Even in the long run, the new donor system could not solve all problems caused by organ
shortage. As the latest move in China to better regulate organ transplants, it will definitely
help China fighting with thriving black market in body parts and encouraging voluntary
donation.

ii. Living Organ Donation

Because of organ shortage and improvement of medical practice, the use of living donor
organs has increased gradually across the world. Similar scenario happens in China.
According to Chen zhong-hua, Professor of the Institute of Organ Transplantation of
Tongji Hospital, the percentage of transplants from living donors has risen from 15% in
2006 to 40%.4

Although the regulation of organ transplantation in China requires living organ donation
must happen between relatives or spouses and such donation behavior always gets huge
moral praise from Chinese society, donors do have medical and financial risks.
Considering beneficence as one fundamental principles of healthcare ethics, is it ethical to
subject a healthy individual to give up his or her own beneficence just for the sake of
others’ beneficence? Furthermore, do they fell compelled to do so because of family or
social pressure? After they come back to their previous lives, is there any procedure to
ensure their safety and quality of life? Unfortunately, there is no risk assessment and
insurance for living donors in China at the moment yet. All these confusions at least cloud
the nobility of living organ donation.5,6
 c) Allocation of Organ Resource

Equitable, justice and public allocation of scarce organ resource is an essential rule in
organ distribution. Yet the nation's first transplant regulation, which banned illegal trade,
was fail to cover the allocation of organs, especially fail to define who has the right to
choose about potential organ donation for an individual.

Currently, the decision-making for organ allocation is mainly at the hospital level. It’s the
hospitals decide where the organs go. This situation has lead to several ethical issues,
especially since hospitals mainly depend on themselves while the government does not
provide enough involvement. So, it is not surprising that they take economics as the only
criteria of organ allocation.7

In 2005, Fu Biao, a famous Chinese actor who had advanced hepatic cancer received two
liver transplants within several months and died at last, which raised great ethical concern
about the fairness of organ allocation. Considering the waiting time for the general public
can be years, let alone he had a second surgery.8, 9

So here comes another criticism that organ resource is wasted on unsuitable recipients
just because of their wealth or privilege.10

Transplant tourism, a purely profit-driven practice is another notorious example of unfair

allocation of organ resource, which has been officially banned by China since 2007. Ever
since then, Chinese citizens will receive priority, and foreigners will only be treated under
special circumstances.

A major difference between the United States and China is the management of recipients
on waiting lists. In China, the situation today is similar to that in the United States in the
early 1960s. Most medical institution in China maintains its own list and procures its own
donor organs for transplantation. Thus, there is no opportunity for sharing organs among
transplantation institutions in China. Thus China should use UNOS as a good model for
further improvement in regarding organ allocation.

3. Further improvement on Organ Transplantation

Comparing with the regulation of organ transplantation in Hong Kong and Taiwan, there
still be lots of experience for China to draw lessons on.

a) Legislation Requirement

Again, brain death should be added into current legislation in order to solve the desperate
shortage of organs.
Moreover, current regulation of organ transplantation in China does not provide coverage
for cornea and bone marrow transplantation. Yet both of them contribute a lot to the
number of annual transplant surgery. Although there are China Eye Bank (CEB)and
Chinese Marrow Donor Program (CMDP) in China for patients to look for matched donor.
Without legislation, it shall be very difficult for China to regulate clinical performance and
prevent organ trafficking in the reality.

b) Ensure Donor Welfare

Donation for life saving is only one side of a coin while the other side is to protect donor’s
welfare. In terms of protecting donors’ beneficence, the first important step is to fully
inform donors about medical risks caused by living organ donation. The consent must be
voluntary and without external moral coercion which might be common in Chinese culture.

Some other solid actions should be taken into account in the near future include providing
financial support, both pre- and post-surgery, routine medical test after the surgery, etc.
Such support could definitely improve the donors’ qualify of life and be of great help for
them to come back to the society.

Presently, only Taiwan provide limited commercial compensation to the relatives of

deceased donors as part of raising public recognition and awareness.12 But as far as living
organ donation concerned, there is not easy to draw a clear line between financial support
and commercial compensation. Especially the later might encourage illegal organ trade
and trafficking.

How could we provide fairness to donors who do suffer financial consequences as a result
of their altruistic acts while at the same time, such benevolence might open a black door
for abuse? This ethical dilemma has not been well answered yet.

c) Distribute Organ Fairly and Efficiently

With respect to current inequality and inefficient ways in organ allocation, there should be
a more well functioned donation system in China as to prioritize all recipients’ request on a
country level rather than only considering their economic status.

Furthermore, strictly controlling suitable indications for organ transplants may also avoid
waste of organ resources to some extent which requires more education on the doctor
side.

d) Provide Psychosocial Support

When it comes to life saving, we easily tend to look at medical intervention as a mere
solution for organ recipients. However, psychosocial support plays at least similar vital
role in improving recipient’s quality of life.

Recent findings indicate that psychiatric difficulties which include depression, anxiety, and
adjustment disorders are found common in liver transplantation candidates. While
neurological and neuropsychological changes has well been documented as associating
with hepatic encephalopathy and cirrhosis, liver transplantation might improve patients'
quality of life, but their psychological level does not necessarily return to normal. Both
psychiatric and neuropsychologic difficulties may make it more difficult for patients to
comply with medical recommendations as we all know compliance improves survival and
recipient’s quality of life. Therefore, detection of and early intervention of psychological
symptoms may assist liver transplant survivors in their return to everyday life.11 And some
other studies demonstrate similar psychological findings among kidney, heart transplant
recipients.13,14,15

Consequently, a bit more invest on psychosocial support to recipients may produce much
more return in terms of QOL improvement and lengthening qualified life span.

4. Conclusion

Presently due to not yet formulating official law of brain death and still strongly depending
on deceased organs from executed prisoners, China is facing at least three major ethical
challenges about organ transplantation: ① definition of death; ②donation of organs; ③
allocation of organ resource.

Through concrete efforts in initiating a new legal framework as well as piloting a new
organ donation system for national oversight, Chins has consistently improved its
commitment to protect patient rights and save their lives. Meanwhile, a lot of experience
could also be drawn on from other regions such as Hong Kong and Taiwan.
Reference
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