A. The problem
The World Medical Association
has failed to confront adequately abuse of organ transplantation in
China. The Chinese Medical Association is a member of the World
Medical Association. Yet, Chinese doctors have been violating
the ethical standards of the Association from the moment it joined in
1997. The Association has been looking into these violations but
not doing enough about them.
Ever since China began
organ transplants, it sourced the organs from prisoners without their
consent, in violation of the most basic ethical standards. The
first prisoners who were victims of this practice were prisoners sentenced
to death. But as the demand for organs and the money to be made
from transplants increased, the supply of prisoners sentenced to death
was quickly exhausted. David Kilgour and I concluded in
a report, the first version published July 2006, the second version
published January 2007, and then a book published November 2009 all
under the title Bloody Harvest, that Communist Party/ Chinese
State moved on from prisoners sentenced to death to Falun Gong practitioners,
prisoners sentenced to nothing, combining its eagerness to profit from
transit tourism and it determination to eradicate what it saw as an
ideological competitor.
Falun Gong is a set
of exercises with a spiritual foundation, a modern update and blending
of the ancient Chinese qigong exercise and spiritual Taoist and Buddhist
traditions. The practice of Falun Gong began in 1992. It
was banned in 1999 first by the Communist Party and then by the Chinese
state after its widespread popularity led the Communist Party to fear
for its ideological supremacy.
We should not need to
convince anyone that killing innocents for their organs is a violation
of medical ethics and human rights. So is killing prisoners sentenced
to death. The Government of China denies that it is killing Falun
Gong practitioners for their organs. But it acknowledges, after years
of denial, that it was and is using the organs of prisoners, prisoners
the Government of China says have been sentenced to death and then executed.
The debate David Kilgour
and I have with the Government of China is not whether organs are coming
from prisoners. It is only a debate about what sorts of prisoners
are the sources of organs. But, for the ethical standards of the
World Medical Association, resolving that debate does not matter.
B. The history
The complicity of Chinese
doctors in organ harvesting from prisoners has been a problem for a
decade, since China joined the World Medical Association. China
first joined in 1989, but left in 1991 for failure to pay its dues.
It applied to rejoin in 1997.
The World Medical Association
realized that there was a problem in China in 1997 long before the persecution
of the Falun Gong began, in 1999. If the Association had acted
decisively then, they might not face the problem they do now. From the
very start, organ harvesting from prisoners was an issue.
The German Medical Association
moved to defer the application of China to join until it was clear whether
Chinese doctors took part in the transplantation of organs from prisoners.
The motion was overwhelmingly defeated. Dr. Anders, Chair of the World
Medical Association Council, in one of several naive statements about
China, said:
"It is important
that the Chinese Medical Association is once again a member of the World
Medical Association so that we can discuss with them the allegations
that doctors in China take part in the transplantation of organs from
executed prisoners which we deplore."
The Association announced
in April 1998 a conference to be held later in the year in China on
medical ethics and human rights spurred by reports of organs being taken
from "executed and living prisoners" in China. The conference,
as far as I can tell, never took place.
The Association and
its Chinese members issued a joint statement also in April 1998 condemning
as "illegal and completely unacceptable" the involuntary or
forced removal and sale of organs. This statement by the Chinese
became one of a long series of such statements made while the practice
flourished, without any visible impact on the practice. Dr. Anders,
in another of his naive statements, said:
"if further
allegations are made about organ trafficking we can rely on the Chinese
Medical Association to try to rectify the situation."
The World Medical Association's
Statement on Human Organ Donation and Transplantation adopted in October
2000 and revised in October 2006 declared that
"Because prisoners
and other individuals in custody are not in a position to give consent
freely and can be subject to coercion, their organs must not be used
for transplantation except for members of their immediate family."1
The Association's Statement
on Tissue for Transplantation of October 2007 had an identical provision
for tissues.2
But about China, nothing
was done. There was a revival of interest in 2006. A World
Medical Association Council meeting of May 2006 in South Africa called
on China "immediately" to cease the practice of using prisoners
as organ donors. They demanded that their Chinese members condemn
the practice and ensure that Chinese doctors are not involved in it.
The resolution reiterated the old 2000 policy.
A year later, this call
for immediate cessation, like the calls nine years earlier, had produced
more or less nothing. The Association sent a mission to China,
led by the then head of the Council of the Association, Dr. Yoram Blachar
from Israel. The mission reported to the Association Council meeting
held in May 2007. Dr. Blachar continuing to strike the naive tone
set by his predecessor Dr. Anders and said that he was encouraged by
new legislation in China prohibiting the trade in organs.
Chinese law also prohibits
donation of organs without consent. In the case of Falun Gong
practitioners, that law is not respected. In the case of prisoners
sentenced to death, consent is not meaningful because of the coercive
prison environment. In a
ny case, consent of
these prisoners is impossible to verify.
So, trade in organs
is not the sole medical ethics problem China poses. Indeed, Chinese
prisoners do not sell their organs. They do not even know that
they are being killed for their organs. The money paid for organs
in China is paid to hospitals. The problem is not trade.
It is the lack of consent.
C. A precedent
The World Psychiatric
Association evicted the Soviet Union for abuse of psychiatry.
Psychiatrists world wide condemned the Soviet Union by resolution in
1977. The Soviets withdrew from the Association in 1983 when it
faced almost certain expulsion. The precedent is exemplary.
Why is the World Medical Association not following that precedent?
As bad as it is to put
people in psychiatric hospitals for their beliefs, killing people for
their organs is far worse. The timidity of the World Medical Association
in the face of Chinese medical practices is deeply disturbing.
Psychiatric professor
emeritus Abraham Halpern of New York Medical College wrote to the World
Medical Association in September 2006, making reference to the report
we wrote about organ harvesting. He called on the Association
to take a number of steps including the appointment of an investigative
committee to visit China and the expulsion of the Chinese Medical Association
from the World Medical Association if the Government of China did not
stop illegal organ harvesting. In that letter, he reminded the
Association of the principled action of the World Psychiatric Association
against the Soviet Union for the wrongful involuntary incarceration
of non-mentally ill dissidents in maximum security forensic psychiatric
hospitals.
He wrote a follow up
letter in April 2007 asking for an emergency meeting of the Council
of the World Medical Association on the issue. In that letter he wrote
that the action he recommended to the Medical Association is the type
of step
"that has proven
effective in the past in the Soviet Union and even in China itself in
connection with stopping the wrongful incarceration in maximum security
forensic institutions of non-mentally-ill dissidents in the Soviet Union
and Falun Gong adherents in China."
The World Psychiatric
Association eventually agreed in 1989 to readmit the Soviet Union, provided
four conditions were met. They were that the Soviet Psychiatric
Association
1) acknowledge that
systematic abuse of psychiatry for political purposes had taken place
2) promise to discontinue
the abuses,
3) rehabilitate the
victims, and
4) democratize the psychiatric
profession3.
The conditions were
conditions subsequent, not conditions precedent. The Soviet Union
was readmitted pending fulfilment of conditions with a monitoring committee
set up to monitor fulfilment of the conditions. If the conditions
were fulfilled, membership would become unconditional. If they
were not, membership would be suspended.
The Soviet Union dissolved
in December 1991. The World Congress of Psychiatry meets every
three years. Its next meeting after establishing Soviet Union
conditional membership was scheduled for 1992. Membership
of the Soviet Union in the World Psychiatric Association remained conditional
until the dissolution of the Soviet Union since the World Congress never
had a meeting to reconsider the issue of unconditional Soviet membership.
The World Psychiatric
Association provides another example about the Falun Gong. The
Chinese, like the Soviets before them, abused psychiatry to mistreat
their perceived opponents, their fantasised enemies, in the case of
China the Falun Gong. The World Psychiatric Association, after their
reaction to the Soviet abuse, could not just ignore Chinese violations.
But they succumbed to the temptation of an agreement with the Chinese.
The Association and
the Chinese agreed in May 2004 that there were
"instances
in which some Chinese psychiatrists failed to distinguish between spiritual-cultural
beliefs and delusions, as a result of which persons were misdiagnosed
and mistreated."
The parties further
agreed that these instances were attributable to a "lack of training
and professional skills of some psychiatrists rather than [to] systematic
abuse of psychiatry." The Chinese Society of Psychiatrists
agreed to take steps to "educate [its] members" about the
issues that led to misdiagnosis and mistreatment and said it welcomed
the World Psychiatric Association's "assistance in correcting this
situation" and improving psychiatric diagnosis and treatment throughout
the People's Republic of China.
Abraham Halpern, the
voice of reason in all this, reacted this way:
"The allegations
of psychiatric abuse in China involve mistreatment, torture, and fraudulent
diagnoses in the case of large numbers of political dissidents and Falun
Gong practitioners and should not be dismissed as mere `failures in
accurate diagnosis.'"
The organ harvesting
of Falun Gong practitioners is systematic and not just the failure,
in a few instances, to follow appropriate transplant procedures.
The numbers of organs harvested from Falun Gong practitioners, David
Kilgour and I estimate in the tens of thousands, allow for no other
description.
D. The agreement
In a news release dated
5 October 2007 the World Medical Association announced at the annual
General Assembly in Copenhagen an agreement with the Chinese Medical
Association. The Chinese Medical Association agreed that organs of prisoners
and other individuals in custody must not be used for transplantation,
except for members of their immediate family4.
In a letter to the World
Medical Association, the Vice President and Secretary General of the
Chinese Medical Association, Dr Wu Mingjiang, said:
"We would like
to inform you that after discussions in the Chinese Medical Association,
a consensus has been reached, that is, the Chinese Medical Association
agrees to the World Medical Association Statement on Human Organ Donation
and Transplantation, in which it states that organs of prisoners and
other individuals in custody must not be used for transplantation, except
for members of their immediate family.
The Chinese Medical
Association will, through its influence, further promote the strengthening
of management of human organ transplantation and prevent possible violations
of the regulations made by the Chinese Government. We also hope
to work more closely with the WMA and exchange information and views
on the management of human organ transplantation."
Dr Edward Hill, chair
of the World Medical Association, said the announcement by the Chinese
Medical Association was a very positive step forward and added:
"We shall now
continue our dialogue with the Chinese Medical Association and include
other national medical associations in a project to find best practice
models for ethically acceptable organ procurement programmes.
This would help not only China and its high demand for organs, but also
other regions in the world that have the same problems of coping with
a severe shortage of organs."
The agreement between
the World Medical Association and the Chinese Medical Association to
end organ sourcing from prisoners in China except for prisoners donating
organs to their immediate family members covered all prisoners
and not just prisoners sentenced to death. This broader terminology
means that, in principle, the agreement encompasses also Falun Gong
practitioners who are held in detention but sentenced to nothing.
The former chair of
the World Medical Association, Dr Yoram Blachar, who led the World Medical
Association delegation to China, stated that differences between the
two sides remained. The World Medical Association needs to continue
to press the Chinese Medical Association on this issue until the practice
in China of killing prisoners for their organs ends entirely.
Over four years later,
prisoners remain the chief source of organs in China. Transplant
professionals have neither enforced nor followed the stated policy of
the Chinese Medical Association; they have not refused to conduct
transplants of organs they must know are sourced from prisoners.
Nor has the Chinese Medical Association taken any steps to discipline
members who are involved in these transplants or the preliminary prison
medical examinations garnering blood and tissue type information and
assessing organ health.
E. Next steps
The World Medical Association
is holding its next General Assembly in Montevideo, Uruguay October
12 to 15th 2011. The Assembly needs to deal with this issue.
With the 2007 agreement,
a number of concerns remain.
1 The Chinese Medical
Association is not a governmental entity. Its promise to avoid to avoid
organ sourcing from prisoners indicates the good will of some Chinese
medical doctors. However, it is not binding on the government,
and is not binding on doctors in China who are not members of the Chinese
Medical Association. The Chinese Medical Association cannot make decisions
for the government. The Government sets the rules for associations and
not vice versa. The practice of sourcing organs from prisoners, whether
prisoners sentenced to death or Falun Gong practitioners, was and is
tolerated by the Chinese government. Only the Chinese government
can stop this practice.
2 Even if it had been
the Government of China which had entered into the agreement instead
of the Chinese Medical Association, it is questionable whether the agreement
would be effective. The Chinese government has issued over time
issued several laws and regulations prohibiting the selling of organs
without the consent of the source. The very repetition of such laws
is evidence that these laws are not effective.
3 The Chinese government
has had a history of duplicity in this field. An example is the
case of Dr. Wang Guoqi. On June 27, 2001, Dr. Wang Guoqi testified before
the Subcommittee on International Operations and Human Rights of the
US Congress, that organs for transplants are sourced from prisoners5.
The Chinese government called him a liar. This position was held until
2005, when for the first time Chinese officials admitted publicly that
they indeed harvested organs from prisoners.
4 Liu Zhi, of the Chinese
Medical Association's international department, said that the agreement
with the World Medical Association has no legal effect. He expressed
the hope that the agreement would influence Chinese 500,000 doctors
and government decisions. This statement minimizes the effect
the agreement might have. At the very least, the Chinese Medical
Association can insist that its own members comply with the terms of
the agreement as a precondition for continued membership in their association.
The fact that the Chinese Medical Association has not done this indicates
a less than wholehearted support for the agreement.
5 The agreement does
not address the issues of onus and standard of proof. In many
cases in China, doctors are supplied an organ and told a source, but
make no independent determination whether what they are told about the
source is accurate or not.
The agreement with the
Chinese Medical Association does not mean very much if Chinese Medical
Association doctors could claim respect for the agreement simply by
turning a blind eye to practices around them. The agreement does
not ensure that Chinese transplant professionals are respecting the
substance of the agreement as well as its form.
6 There is no verification
system in place to determine whether or not the agreement with the Chinese
Medical Association is being kept. Such a verification system needs
to be independent from the Government of China and the Chinese Medical
Association itself.
7 There is no documentation
available of the sources of organs used by Chinese Medical Association
doctors in transplant operations. This is true on both an individual
and aggregate basis. On an individual basis, there is an absence
of traceability. The World Health Organization Guiding Principles
on Human Cell, Tissue and Organ Transplantation set out traceability
as a requirement in Guiding Principle 10.
8 On an aggregate basis
the sources of Chinese organs are not transparent. The World Health
Organization Guiding Principles 11 requires transparency of sources,
open to scrutiny, while ensuring that personal anonymity of donors and
recipients are protected.
The absence of transparency
presents a double problem. One is the closed nature of the transplant
registries. Indeed, since the 2007 World Medical Association agreement
with the Chinese Medical Association, the problem has gotten worse.
There are in China four
separate registries compiling statistics, one each for liver, kidney,
heart and lung. The Liver Transplant Registry6 is located
at Queen Mary Hospital, The University of Hong Kong, Hong Kong.
The Kidney Transplant Registry7 is located PLA (People's
Liberation Army) No. 309 Hospital, Beijing. The Heart Transplant
Registry8 is located at Fuwai Cardiovascular Hospital, Chinese
Academy of Medical Sciences, Beijing. The Lung Transplant Registry9
is located at Wuxi People's Hospital, Wuxi. The Liver Transplant
Registry has been in existence since 200510.
The China Liver Transplant
Registry used to be publicly accessible, but is no longer. It
has now shut down public access to statistical aggregate data on its
site. Access is available only to those who have a Registry issued
login name and password. The data on the other three sites
is and always was accessible only to those who have registry issued
login names and passwords.
At The Transplantation
Society Congress in Vancouver in 2010, Haibo Wang, assistant director
of the China Liver Transplant Registry, presented at the same session
I did. I asked him why public access to the data on the Registry
website was shut down and if it could be restored. His answer
was that public access was shut down because people were misinterpreting
the data. If anyone is to get access now, the Registry has to
know first the purpose for which the data is being used and has to have
some confidence that the data will not be misinterpreted.
When China took over
Hong Kong from Britain, the unification was based on the principle of
one country, two systems. However, when it comes to public access
to aggregate statistical transplant data, there is now one country with
one system.
9 The second transparency
problem has to do with death penalty statistics. The claim of
the Government of China is that the source of organs for transplants
is in substance prisoners sentenced to death and then executed.
According to Deputy Health Minister Huang Jiefu, 95% of all organs for
transplants come from prisoners. Yet, the Government of
China does not publish official death penalty statistics.
At the United Nations
Human Rights Council Universal Periodic Review for China in February
2009, six different countries - Canada, Switzerland, United Kingdom,
France, Austria, Italy - recommended that China publish these statistics.
The Government of China publicly and explicitly rejected this recommendation.
Why is the Government
of China refusing to disclose both death penalty and transplant statistics?
One answer is that, if these statistics became publicly accessible,
the discrepancy between the number of transplants and the number of
prisoners sentenced to death and executed would then become screamingly
obvious. The Government of China would be hard pressed not
to account for the discrepancy once it has itself disclosed it.
10 In China, transplant
surgery has become essential for financing the medical profession and
hospitals. A dramatic decrease of transplant surgeries would impose
financial burden on the health care system. Without an increase
in the Government funds to the health care system, it is unlikely that
hospitals will cease relying on transplantation for money. While
sourcing of organs and payment for organs are conceptually distinct,
they are linked in fact. The need for funds pushes doctors and
hospitals to increasing transplant numbers and using historically available
sources, prisoners.
11 The Chinese Medical
Association agreement does not bind military doctors who are not members
of the Chinese Medical Association nor military hospitals. Yet,
organ recipients recount that military doctors and hospitals are heavily
involved in organ transplant surgery.
12 The agreement with
the Chinese Medical Association does not change the Chinese infrastructure
for organ transplants. There is no effective donation system.
China began a donation system as a pilot project in eleven cities in
March 2010. After one year, the system produced only 37 donations11.
There is no law allowing for organ sourcing from the brain dead but
cardiac alive. The implementation of the agreement with the Chinese
Medical Association, in the absence of an effective donation system
and a brain dead law, would mean that the organs transplantation in
China would be almost non-existent, an unlikely result.
13 The mere fact that
the recipient is an immediate family member of the prisoner does not
automatically mean that the prisoner has freely consented to the donation.
This exception is found in the World Medical Association's Policy on
Human Organ Donation and Transplantation. However, it is not to
be found in the ethical principles of the Transplantation Society.
The prohibition without exception which the Transplantation Society
has adopted is preferable to the prohibition with the immediate family
member exception which the World Medical Association has adopted.
Simply getting the Chinese
Medical Association to promise is not enough. The 2007 agreement
has not worked. The changes in China in transplants are more cosmetic
than real.
There are two possibilities,
two paths taken by the World Psychiatric Association to follow.
One is simply evicting the Chinese Medical Association from the World
Medical Association.
No precedent is exact.
The abuse in the Soviet Union with which the World Psychiatric Association
was concerned was not centred in a small subspecialty of Soviet psychiatry,
but rather in Soviet psychiatry as a whole.
The Chinese Medical
Association has about 500,000 members from about two millions doctors
and assistant doctors in China12. Transplantology is
one of eighty four specialties under its umbrella. Transplant
professionals are a small percentage of the membership of the Chinese
Medical Association. Evicting the Chinese Medical Association
from the World Medical Association would mean cutting off links between
the World Medical Association and all Chinese doctors, most of whom
have nothing to do with organ transplant abuse. Such a step may
be warranted if it can be established that Chinese non-transplantologists,
through inaction, are complicit in organ transplant abuse; but other
steps have to be tried first.
The second alternative,
following a second example of the World Psychiatric Association, is
to change Chinese membership from unconditional to conditional. The
Chinese Medical Association needs to be confronted with its own commitment
to uphold medical ethics. A committee would be set up to monitor compliance
with the conditions. Those conditions would include:
a) support for publication
of death penalty statistics;
b) public access to
the four transplant registries;
c) expulsion from the
Chinese Medical Association of transplant professionals who can not
establish beyond a reasonable doubt that their sourcing of organs is
proper;
d) establishing traceability
of sources for transplants in which its members participate;
e) promotion of the
Chinese donation system;
f) support for a law
allowing the sourcing of organs from the brain dead cardiac alive; and
g) establishment of
an outside, independent verification system for compliance with the
2007 agreement.
F. The Letter
Dr. Torsten Trey, the
Chief Executive Director of Doctors Against Forced Organ Harvesting,
wrote to the World Medical Association on May 31, 2011 expressing many
of the concerns set out in this talk. Dr. Wonchat Subhachaturas,
President of the World Medical Association, in a letter dated July 18th,
2011, replied:
Yet, the Association
could appoint a committee which is suited to engage in such an investigation.
It could as well seek permission. Moreover, the help of the Chinese
Medical Association could be enlisted in getting that permission. While
such permission may be denied, it is unduly pessimistic to assume, without
asking, that it would be denied.
The letter goes on to
state:
"We do not
take defamatory approaches; rather we offer our help to improve the
ethical methods of organ procurement and to fight the causes for the
high organ demand."
The letter does not
state what the author considers to be a defamatory approach. Dr.
Trey had stated in his original letter that practitioners of Falun Gong
are being killed for their organs. The implication is that this
statement is defamatory. Yet, for defamation to exist, the statement
has to be false. This oblique dismissal of a conclusion behind
which a wealth of overwhelming uncontradicted evidence stands is unworthy
of the World Medical Association.
The letter sets out:
"Prof. Huang
... said that he would not get the necessary political support to change
the practice of harvesting organs from executed prisoners immediately."
What has political support
got to do with compliance with medical ethics? Organ transplants are
done by medical practitioners, not politicians. An absence of political
support is not a justification for violating medical ethics. Doctors
are not excused from violating medical ethics simply because politicians
would prefer that they do so.
The letter goes on to
state:
"We have seen
considerable progress since then. Websites offering organs from executed
prisoners for sale have vanished."
Yet, websites offering
organs for sale at no time in China ever indicated that the sourcing
was executed prisoners. Websites offering organs for in China
have diminished, it is true, but they have not vanished. For instance,
the website of the Omar Health Care Service states:
"We, Omar Healthcare
Service (OHS), are here to assist the overseas patients who intend to
be treated in China by those world-famous specialists, or who are seeking
a help of getting a kidney, liver or heart transplant in China. Please
browse through our website to find out more information about the service
we provide and contact us for more customized items. We are cooperating
directly, as a service provider, with the most qualified two hospitals
concerning transplantation in China:
Tianjin First Central Hospital
International Cardiovascular Hospital
Those above-mentioned
hospitals of which the First Central is famous for liver & kidney
treatment/transplant while the International Cardiovascular for heart,
with the license issued by the Ministry of National Health of the People's
Republic of China, are surely where the dying-patients reborn."13
After clicking on "Organ
transplant in China", you see this:
"As a sector
of modern medical system, Chinese doctors and scientists in line with
organ transplantation have been winning satisfactory achievements worldwide
recognized. More and more dying patients from all directions of the
world are coming to China to seek for rebirth, of which most are survived
successfully. It is true that the source of organ supply are fairly
abundant in China compared with that in western countries (italics
added), but the excellent skill in performing such demanding operations
is no doubt an important factor for them to make decisions before leaving
home for China."14
The website languages
are English and Arabic.
The World Medical Association
letter further states:
"In your letter
you mention pharmaceutical companies doing anti-rejection trials without
verifying the source of the organs. We assume that you mean, organs
used in those studies are from executed prisoners. We would appreciate
to get the names of those companies, so that we would have a chance
to ask them for a statement."
In a talk I gave at
the parallel session to the American Transplant Congress, Philadelphia,
April 30, 2011 hosted by Doctors Against Forced Organ Harvesting and
at a poster presentation at the Congress, I provided the names of those
companies and more detail about their practices than I suspect the World
Medical Association could possibly want. The text of the talk
can be found at the website of Doctors Against Forced Organ Harvesting15.
The World Medical Association indicates that they will ask the companies
involved for a statement. Let's see if they do.
The letter, as part
of its demonstration of "considerable progress" states,
"The Chinese
Medical Association accepted our policy in total and, most importantly
of all, we can discuss the issue."
The World Medical Association
should not grasp at straws. There may be a temptation, to avoid
a confrontation, to accept changes in China as movement in the right
direction and leave it at that. It would be a mistake to succumb
to that temptation.
The Chinese party-state
has lied so often before, the abuse of transplant surgery has gone on
now for so long, that Chinese Medical Association is no longer entitled
to the benefit of the doubt. Only when the World Medical Association
can be certain that the abuse has stopped beyond any reasonable doubt
should China be allowed continued unconditional membership in the Association.
....................................................................................................................................
David Matas is an international
human rights lawyer based in Winnipeg, Manitoba, Canada.
