http://www.wsj.com/articles/SB117018697369892678

China Reconsiders Fairness Of ‘Transplant Tourism’
Foreigners Pay More For Scarce Organs; Israelis Debate Reform

By ANDREW BATSON and SHAI OSTER
Updated April 6, 2007 12:01 a.m. ET

A year ago, Avraham Abelson was No. 127 on Israel’s waiting list for a heart transplant. Doctors told the 65-year-old retired diamond dealer he’d probably die years before his number came up.

So Mr. Abelson, whose heart was damaged by a major heart attack, went to China. Today, inside his chest beats the heart of a 21-year-old Chinese man.

Mr. Abelson’s trip probably saved his life. It also thrust him into the middle of an international debate over “transplant tourism” — the lucrative business in China and elsewhere of providing organ transplants to wealthy foreigners. A Shanghai hospital charged Mr. Abelson about $150,000 to implant his new heart, and his insurance company paid up.

Rising demand for organ transplants in developed countries, coupled with the spread of transplant technology to the developing world, is fueling a global commerce in body parts between the rich and the poor. Israel is one of the only nations where insurance companies cover the cost of foreign transplants, and several companies there have built businesses around helping people like Mr. Abelson to arrange organ transplants in China. Plenty of people are willing to pay out of their own pockets, and transplant patients have also been streaming into China from the U.S., Germany, the Middle East, Japan, South Korea and Singapore. (In the U.S., insurance companies generally won’t pay for such procedures.)

In recent months, however, controversy over the ethical issues surrounding the practice has come to a head in China, Israel and elsewhere in the global medical community. China’s Ministry of Health recently instructed hospitals to stop performing transplants for foreigners, arguing that patients from wealthy foreign countries shouldn’t be getting organs when not enough are available for Chinese citizens who need them. But it’s not yet clear how rigorously the new rule will be enforced.

Doctors and human-rights groups around the world have decried China’s practice of harvesting organs from prisoners condemned to death. Concerned that lucrative foreign transplants create an incentive for China to execute more prisoners, critics in Israel are pushing for legislative restrictions. Last week, in part due to what it called the growing problem of transplant tourism, the World Health Organization proposed that countries around the world establish common practices on organ transplants.

Foreign transplant patients have become a cash cow for China’s hospitals, which are desperate for funds after a collapse of state funding for medical care. China’s medical sector is chaotic and loosely regulated, and many foreigners can pay far more than Chinese citizens can for organ transplants. The money at stake is so great that doctors and others involved in the transplant industry say transplant tourism will be hard to stamp out.

Israel has long struggled with an organ shortage because of religious objections to donations. Some rabbis oppose all organ harvesting; others want rabbis to be involved in decision-making. Israelis used to be able to get transplants in Europe. But over the past decade, one European country after another has either stopped performing transplants on foreign patients or sharply reduced the practice.

Dr. Jacob Lavee, who heads a heart-transplant unit at Sheba Medical Center near Tel Aviv, estimates that 10 of the 30 or so heart transplants performed on Israelis each year are done in China, and that 200 Israelis have received kidney transplants in China during the past five years. Dr. Lavee, who questions the ethics of harvesting organs from executed prisoners, advocates a ban in Israel on health insurers paying for transplants in China, and has debated the issue with Mr. Abelson on Israeli television.

Such ethical concerns are secondary to many patients. “If someone in your family was sick, would you ask where the organ came from?” asks Itzhak Yaron, director general of Medikt, the Tel Aviv company that helped arrange for Mr. Abelson’s heart transplant. “In life, you don’t get a second chance.”

Medikt is one of several Israeli companies that help patients locate and navigate foreign transplant hospitals. Mr. Abelson found out about Medikt, a private company, on the Internet.

China isn’t the only option for transplant patients, who also arrange for operations in Brazil, South Africa and India. When Mr. Yaron joined Medikt two years ago, the company was sending Israeli patients to Colombia and South Africa. But the longer waiting periods for organs there was discouraging. In China, the wait was a month or less, Mr. Yaron says. China does more transplants each year than any country except the U.S., in part because of the sheer size of its population.

Over the past year and a half, Medikt has sent some 150 patients to China for heart, liver and kidney transplants. Mr. Yaron, a former salesman, says Medikt accepts only transplant candidates referred by Israeli doctors. “I’m not a medical doctor,” he notes. “I’m only contacting between patients, the health insurance and the hospitals.”

Mr. Yaron says he hired someone in China to help him line up transplant hospitals to take Israelis. He vetted the hospitals, he says, to make sure they met the standards of Israeli insurers. Medikt arranges for translators to accompany patients to China, where a local Medikt representative guides them through the transplant process.

Under Israel’s medical system, health insurers must pay for operations overseas if they aren’t available domestically, although insurers have a say on the location. At first, Mr. Abelson’s insurer resisted paying for a Chinese transplant. Mr. Abelson successfully sued to force payment.

Last spring, he flew to Shanghai. An Israeli doctor who accompanied him inspected the facilities at the Zhongshan Hospital before his operation. Mr. Abelson asked his transplant doctor where his new heart had come from. The doctor responded that all he could say was that it had come from a 21-year-old man.

“The truth is, I don’t care where the heart comes from,” says Mr. Abelson. “The treatment, without exaggeration, was great.”

Officials at Zhongshan Hospital declined to comment on Mr. Abelson’s treatment. One official said that because of limited organ supplies, the hospital has stopped accepting foreign patients for now.

Organ transplants are high-risk procedures, and ordinarily hospitals are highly selective when deciding which patients are suitable candidates. Patients given the highest chances of survival usually get priority. Some doctors, both inside and outside of China, say these criteria are often bent in China for rich patients, which leads in turn to high failure rates for the operations.

Israeli embassy officials in Beijing say they’ve had to send back the bodies of dozens of citizens who died after transplants. Dr. Lavee says that, in late January, one of his patients ignored his medical advice, went to China for a heart transplant, and died a few days later.

In China, only a few doctors have publicly criticized the practice of choosing organ recipients based on their ability to pay. That practice, they say, favors foreigners and reduces the organs available for Chinese patients.

Chen Zhonghua, a Cambridge-educated transplant surgeon who works in Wuhan in central China, has pushed for reform. “Foreigners shouldn’t be coming to China to do this,” he says. “They should do this in their home countries.” The money foreign patients are bringing into China is further complicating an already corrupt system, he says.

Even prior to the recent ban, Dr. Chen insisted that the transplant clinic where he works accept foreigners only in exceptional cases. He has tried to reduce the commercialization of organ transplants by urging patients to use living relatives as donors for organs such as kidneys.

In a recent article in an international journal, Liver Transplantation, Huang Jiefu, a vice minister of health, wrote that China does about 10,000 organ transplants a year, and that most of the organs are donated by prisoners condemned to death. Yet even with that ready supply, there is a shortage. As many as 1.5 million Chinese patients are in need of transplants, Dr. Huang wrote.

Many Chinese are uncomfortable with the notion of donating the organs of deceased family members, in part because of traditional taboos against disturbing their bodies. The government has yet to set up a national organ-donation system: There are no donor cards, registries or waiting lists. Official efforts to encourage donation have been scattershot. Critics say reliance on the prison system has stunted progress.

International medical groups have assailed the prison collection practices, arguing that because condemned prisoners are not free, they cannot make truly voluntary donations. Chinese officials have said such donations are both legal and ethical. “If some criminals become aware that they have done a disservice to society and want to atone by donating their organs after death, this is something that should be encouraged, not opposed,” Dr. Huang, the Chinese vice minister, said in November.

In Israel, press coverage of the overseas transplant business and China’s harvesting of organs from executed prisoners has stirred controversy. In November, a subcommittee of the Israeli legislature opened hearings on a proposed new transplant law. Among other things, it would forbid health insurers to fund transplants in nations where there is reason to believe that organs are collected in an unethical way.

In China, amid broad debate about the failures of the health-care system, momentum has been building to reform transplant practices. In March 2006, China’s Ministry of Health published temporary rules for organ transplants. The rules, intended to apply until China’s State Council, or cabinet, weighs in, require hospitals to set up medical and ethics committees to review each transplant candidate and each operation. The rules also create a new licensing system. The ministry has been sending inspection teams around the country to review the qualifications of the 600 or so hospitals that had been performing transplants. It intends to limit organ transplants to a smaller number of reputable hospitals that can be more easily monitored.

The health ministry convened a national conference of organ-transplant practitioners in November and set out a new code of conduct for them. The code stipulates that Chinese citizens be given priority for all organ transplants. It bans transplant tourism outright, but allows for “special circumstances,” which officials said meant that foreigners who live and work in China can apply to receive transplants.

Shortly thereafter, Mr. Yaron got word in Israel that China was changing its policy on transplants for foreigners. Nothing happened for awhile, he says. A few weeks ago, he says, he was told that the operations would have to stop. He says he hopes to find a way to resume his China business soon.

China’s health ministry is now working to line up support from other agencies for permanent rules governing organ transplants that would have the backing of the full government. On March 21, the State Council approved a draft of the proposed new rules, a signal that final regulations are on the way soon.

Deng Haihua, a spokesman for the Ministry of Health, says the rules will aim to create a “fair, open, and just” system. “It can’t just be that because I have money, I get to have an organ transplant,” he says. There are no indications that China intends to reduce its reliance on organs from executed prisoners.

China’s move to limit the number of facilities performing transplants could have the unintended effect of making it even more difficult for some Chinese citizens to get transplants. Dr. Maurice Slapak, who founded the World Transplant Games Federation to publicize the benefits of organ donation, has been lobbying China to reform. He says Chinese doctors estimate that because of the temporary rules passed last year, about 2,000 fewer transplants were performed in 2006. The Ministry of Health says it doesn’t keep statistics on transplants.

The government’s regulatory push is facing resistance from hospitals and doctors who profit from transplants. It’s not yet clear whether the changes will permanently shift China’s transplant system closer to international norms.

“The Chinese have enough regulatory power to do so,” Dr. Slapak says. “The question is: What are the next steps that they’re going to take?”

Dr. Chen, the Chinese transplant surgeon, has long pushed to gain legal and medical recognition in China for the concept of brain death. Chinese hospitals declare death only when the heart stops beating — a point at which organs quickly become useless. That’s been a barrier to getting more donations. But proposed brain-death legislation is controversial, and there has been little momentum on it in recent years.

Mr. Yaron, the Israeli middleman, says he’s not concerned by the increased scrutiny of transplant tourism or by the ethical questions about China’s harvesting practices.

“The government doesn’t take people to kill just for their organs,” he says. “They’re taken from people who were punished for a crime. If that person has agreed, why not take it?”

—Nancy Shekter-Porat contributed to this article.