Three years ago, in New York, one of Dr. Thomas Diflo's patients on a long waiting list for a kidney transplant showed up with a new problem: She no longer needed a kidney, but suddenly needed after-transplant care.
"She had just returned from a trip to China and, to my surprise, had undergone a transplant while she was there," said Diflo, of New York University Medical Center, where he is director of kidney transplants.
The woman, a Chinese-American, was vague about where the kidney had come from, but others who have come to Diflo for treatment have been more forthcoming, confiding that they got the organs from executed Chinese prisoners.
Kidneys, livers, corneas and other body parts from these prisoners are being transplanted into US citizens or permanent residents who otherwise would have to wait years for organs. Many of the patients come back to the US for follow-up care, which Medicaid or other government programs pay for.
The transplants in China, which doctors in both countries say are increasing, has presented the US medical establishment with an ethical quandary: Should US doctors treat patients who have received organs from executed prisoners and, if so, would they be tacitly condoning the practice and encouraging more such transplants.
Or should they rebuke patients who, in desperation, participate in a process that mainstream transplant advocates condemn as morally wrong?
"That's a decision that has to be made by each individual physician," said Dr. Thomas McCune, a transplant physician in Norfolk, Virginia, and chairman of the patient care and education committee of the American Society of Transplantation.
Executed prisoners are China's primary source of transplantable organs, though few of the condemned, if any, consent to having their organs removed, people involved with the process say. Some of the unwitting donors may even be innocent, having been executed as part of a surge of executions propelled by accelerated trials and confessions that sometimes were extracted through torture.
The American transplantation society says that decisions to donate organs must be made freely and without coercion or exploitation of any sort. It opposes any organ donations by prisoners, even to their relatives, because the circumstances of incarceration make it impossible to ensure that the decision is not colored by secondary benefits, like an improved diet, that a prisoner may stand to gain. Donations from death row inmates are even more suspect.
Various initiatives are under way to protest the harvesting of organs from China's prisoners. One bill would bar entry to the US of any doctors from China who want transplant training. Chinese transplant specialists now travel freely to the US to take part in seminars and other activities that help hone their skills.
But US doctors say there is little they can do to stop the flow of prisoner organs to the US because the Chinese supply is growing just like the American demand.
More transplantable organs are available in China because more people are being executed. This year, 5,000 prisoners or more are likely to be put to death during a nationwide anti-crime drive. Many of them will be stripped of their vital organs, though there is no available data to say how many. Government policy allows the harvesting if the prisoner or the prisoner's family has given written consent, or if the body is not claimed after execution. In practice, though, the rules are often ignored and illegal harvesting tolerated.
Meanwhile, China has made great strides in transplant techniques, having performed 35,000 kidney transplants since its first successful one in 1961. As a result, transplant centers have opened around the country, some with special wards catering to high-paying foreign patients.
Most of the organs are transplanted into Chinese citizens, but a growing number are going into foreigners, particularly Southeast Asians, Japanese and Americans, who would otherwise face years of illness or the risk of death if they were to wait for transplants in their home countries.
Hospitals welcome foreign patients because they pay as much as 10 times the price local patients pay for the same operation. For an American patient, the Chinese charges are somewhat below the comparative cost in the US.
It is hard to say how many Americans are receiving such organs each year. Anecdotal evidence in both countries suggests the number is small but growing and cuts across various regions.
"I think this is pretty widespread," said Dr. Diflo. "You'll see it anywhere you have an Asian community."
All five hospitals that do kidney transplants in Shanghai say they treat foreign patients.
"There was one from America in July or August," a nurse in the urology department at Changhai Hospital, affiliated with the Shanghai Second Military Medical University, recalled last week. The doctor who performed the transplant said the patient, a woman, recently returned home to California.
More than 78,350 Americans are awaiting organ transplants, according to the United Network for Organ Sharing, a nonprofit group that matches donors to transplant patients in the US.
With the wait for a kidney transplant stretching to six years or more in parts of the US, it is little wonder that patients with the necessary money and contacts opt for an ethically questionable transplant.
China is not alone in using prisoner organs to meet the demand for transplants. Taiwan also harvests organs from executed prisoners, albeit with strict consent requirements, as do some South American countries. The idea has even gained currency with some people in the US. Last year, a state lawmaker in Florida introduced a bill that would facilitate the transplant of organs from death row inmates after execution.
Transplant organizations in the US unanimously condemn such proposals, and the Florida bill, which did spark some debate, is unlikely ever to become law.
"Obviously a person condemned to death cannot consider organ or bone marrow donation as a coercion-free option," reads a statement by the ethics committee of the United Network for Organ Sharing.
Doctors are divided about whether to treat patients with transplanted organs from executed prisoners
Dr. Stephen Tomlanovich, a kidney transplant specialist at the University of California, San Francisco, has several patients who traveled to China to receive kidneys that he suspects came from executed prisoners. The patients involved told him that they were not certain of their organs' origins and Tomlanovich accepted that.
But if presented with a clear case in which an organ came from an executed prisoner, he says he would probably decline to treat the patient.
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