Associate Professor Malpas1 rightly draws our attention to the historical evidence for, and possible continued practice of, commerce in deceased donor organs for transplantation in China. The moral repugnance that she expresses is not solely directed at the black market in organs but the known use of executed prisoners as an organ source and the associated targeting of prisoners of conscience, especially the Falun Gong. After describing the egregious behaviour within China’s borders, we are asked what the moral imperatives might be here in New Zealand. Indeed, Associate-Professor Malpas argues that we have done little to dissuade New Zealand patients from travelling to transplant centres within China, we continue to provide medical care for such patients on their return home, and we train Chinese surgeons in the craft of transplantation, thereby indirectly aiding and abetting in a horrific abuse of our fellow human beings.
Not quite. While the arguments made about the moral implications for New Zealand clinicians might have weight, the lack of accurate data about current practices within China means that there is uncertainty about the most appropriate response and, indeed, the proportionality of that response if patient care and training of medical practitioners is to be impacted.
The Transplantation Society of Australia and New Zealand has agreed to, and affirmed, the Declaration of Istanbul (2008), a statement decrying the consequences of organ trafficking, transplant tourism and commercialism. It is unsurprising then that most transplant physicians in New Zealand try to persuade their patients that travelling to any overseas country with a view to purchasing an organ transplant is a bad idea. This is based on both ethical and medical considerations, there being clear evidence that such black market organs do not perform as well in transplant recipients. But actually banning such patients from overseas travel would be well beyond the purview of transplant physicians, would require inter-sector concurrence, and may well run afoul of the New Zealand Human Rights Commission.
Training of transplant surgeons via accredited programmes overseen by the Royal Australian College of Surgeons only occurs in one centre in New Zealand, namely Auckland, which has active liver, kidney, pancreas, heart and lung transplant programmes. There have been no surgeons from mainland China training in liver, kidney or pancreas transplantation in the last 20 years in Auckland. In terms of cardiothoracic transplantation, there has only been one locum mainland Chinese cardiothoracic surgeon employed briefly in Auckland over the same time interval—this would hardly qualify as training given that the individual was already fully certified.
Denial of medical care to patients transplanted elsewhere; be that in Australia, the UK, US or China, is not really an option for publicly funded healthcare providers in New Zealand if such patients are eligible under the current statutory requirements. While individual clinicians may object to providing ongoing medical care for those that have opted out of orthodox processes, a duty of care remains to sustain health and prevent the inevitable deterioration that would occur without transplant clinician oversight. As in poker, there are only so many times the buck may be passed before it stops on a designated dealer. Some New Zealand transplant clinician within the public health system would eventually have to provide such care. In reality, few have qualms about this—the transplant is done and it seems foolish to sacrifice a patient’s welfare because of the impropriety of a preceding, extra-mural event.
Another means of helping with what may well be an ongoing abuse of human rights in China, is to do our best to subdue the demand. To this end, New Zealand society in general and its organ donation professionals, along with its transplant physicians and surgeons in particular, is trying its best to improve access to both living and deceased donor organs. This has had a modicum of success. Organ donor rates are up, there are reimbursement provisions in law for living donors that are the best in the world, and there have been recent Ministerial reviews of both organ donation and transplantation. In crude terms, there has been, over the past three years, a 50% increase in the volume of kidney, liver and lung transplants performed in New Zealand. This does not completely remove the temptation of transplant tourism but it does help. Obviously, the more we do in this regard, the better.
Almost certainly the ethical and practical responses we have made in New Zealand to the abuses of human rights in China for transplant expediencies have been imperfect—weaker, perhaps, than what Associate-Professor Malpas would wish to see—but they are not absent.