Interviewed by: Ashlyn Chou
Dr. Frederike Ambagtsheer is an Assistant Professor at the Erasmus Medical Center (Erasmus MC) Transplant Institute in Rotterdam, Netherlands. From 2012 to 2016, Ambagtsheer coordinated the HOTT project, an international research initiative on human trafficking for the purpose of organ removal. This was an EU-funded collaboration between several European research institutions, including the Lund University in Sweden, the Bulgarian Center for Bioethics, and the Academic Society for the Research of Religions (SACRI) in Romania.
During the interview, Dr. Ambagtsheer shared her experiences and major findings during the HOTT project, as well as her views on legalizing the organ trade to address the worldwide organ donor shortage crisis.
What was your inspiration for initiating the HOTT project?
Dr. Ambagtsheer: I think it was back in 2010 when I was invited to attend a meeting at the United Nations in Austria. In Austria, they have the headquarters of the [United Nations Office on Drugs and Crime], which is the department that focuses on organized crime. There was a meeting specifically devoted to organ trafficking, where we discussed a need to have more knowledge to collect more empirical data; to use that data, then, to improve awareness across a range of stakeholders, and in particular, the need to improve enforcement of cases. So, to help guide police and prosecutors in identifying criminal activities, how to investigate it, and ultimately prosecute those who facilitate illegal organ transplantations. Looking back, this meeting was an important source of information for me to write an application for the HOTT project, which was then submitted to the European Commission.
What is transplant tourism and how does it relate to organ trafficking?
Dr. Ambagtsheer: Transplant tourism is a very loaded concept and there is confusion about its definition. It’s derived from the term “medical tourism,” which isn’t, per se… something problematic, immoral, or even illegal. Medical tourism is a global phenomenon that exists because we live in a globalized world. And then transplant tourism, essentially, involves patients travelling to other countries to undergo transplantation. However, travel for transplantation is considered “transplant tourism” when there is some kind of immorality or illegality involved. That can be different for each country depending on what the law defines as being illegal [or even] what is perceived as culturally immoral.
…To answer your question, according to the Declaration of Istanbul, travel for transplantation is legitimate [and the] travel of patients [is accepted]. However, it becomes transplant tourism when there are illegal payments being made – for instance, to a donor, a broker, or even an individual doctor. There is a link to organ trafficking when there are payments made by patients to individuals that are not meant to be paid.
Researchers for the HOTT project collaborated with law enforcement in South Africa, the United States of America, and Kosovo, as well as the Hebrew University of Jerusalem in Israel, to study several large-scale organ trafficking cases from each of these countries1. Dr. Ambagtsheer elaborated on two cases in particular: the Netcare case in South Africa and the Medicus case in Kosovo.
What were the similarities and differences between the Netcare and Medicus cases, and why was only the Medicus case prosecuted as a human trafficking case?
Dr. Ambagtsheer: [In both cases] there were transplant professionals wittingly involved and facilitating these illegal organ transplantations. Both of the cases had a huge international dimension, so there were many different countries involved. Patients and donors were recruited from different countries and then transported to a third country where the transplant operations
took place. Obviously, what they had in common was the huge financial profits that were made. Patients were paying amounts up to $120,000 USD for a transplantation.
There were also important differences. The Medicus case took place at a clinic that wasn’t licensed to conduct transplant operations in the first place. This clinic, just by performing these transplantations, was doing something illegal because in Kosovo, where the Medicus case was based, you’re not allowed to perform any kind of organ transplantation; it’s prohibited by law.
The Netcare case was very different in that sense. Their illegal transplantations took place in hospitals that have been, and still are, performing transplants for many years. They were mandated to perform the transplantations, so there was a very strong embeddedness of this criminal network within the legal transplant industry in South Africa. Also, if you look at the variety of transplant professionals [who] were involved in South Africa – transplant coordinators, blood bank employees – it was more complex in the sense that there was a large variety of legal actors, as we say in criminology, that were involved.
The reason why the Netcare case in South Africa wasn’t prosecuted as a human trafficking case was because, at that time (two decades ago), there was no law in South Africa that prohibited human trafficking for the purpose of organ removal. In Kosovo, on the other hand, there was adequate, good legislation – prosecutors who had very good knowledge of human trafficking, who had experience prosecuting human trafficking cases. [Therefore], it was a bit easier for them to recognize the Medicus case as a case constituting human trafficking for the purpose of organ removal.
In Canada2 and the USA3, organ and tissue donors receive no monetary compensation from their respective governments. In fact, in these countries, the sale and purchase of organs is prohibited by law. During the second part of our interview, Dr. Ambagtsheer shared her opinions regarding the prohibition of the organ trade and the potential benefits of its legalization.
How has organ prohibition contributed to the illegal organ trade?
Dr. Ambagtsheer: What we know based on anecdotal empirical research is that prohibition has led to more violent means of recruitment. There was a study in Egypt by Dr. Seán Columb who found this recently, and it’s been described in detail in his book that came out last year (Trading Life- Organ Trafficking, Illicit Networks, and Exploitation). Obviously, you can imagine that if
you prohibit organ sales and purchases, this drives up the price because there’s still a huge demand… Organs have increased in value, which means there’s more at stake for many of the intermediaries – brokers, recruiters, and so forth. They have more to lose, so in that way, you could say it’s become more lucrative.
The prohibition of organ sales is also a huge impediment to the investigation of criminal cases. If, as a prosecutor, you’re looking for a victim but they are reluctant to report the abuse because they are scared of being prosecuted for selling their kidney, that’s going to hamper your case. I know based on conversations I’ve had with prosecutors that it’s very difficult for them to find the victims; they tend to be invisible, they tend to disappear because they’ve been threatened not to speak about their kidney sale. Brokers know this and use this to threaten them, to keep them silent. This obviously is something that I have been advocating for, to at least consider decriminalizing organ sales because of the negative impact this has on the position of organ sellers. They are already vulnerable, and by criminalizing what they do, you don’t protect them.
What are the pros and cons of legalizing organ sales? Do the benefits outweigh the costs?
Dr. Ambagtsheer: To be very honest, we don’t know what the effect would be if you allowed payments because there’s never been a trial. There’s never been an actual pilot or experiment where a government sets a fixed fee that’s then given to living kidney donors within a centralized, monopsonistic system that also doesn’t allow donors and patients to meet… This is the kind of recommendation that many scholars have been giving over the last few years; to run a trial, just to see… whether that would be more ethical than a prohibitionist system… [The current system] not only leads to black market usage of donors, but also huge mortality rates of patients on the waitlist all across the world.
Has the organ trade been legalized in any countries? If so, what has the experience been like for them?
Dr. Ambagtsheer: Iran is the only country that currently allows payments to living kidney donors… The government of Iran has this set fee that it gives to individual donors… In addition, [Iran] does allow donors and recipients to meet and negotiate payments… This is a transaction that is unregulated, that is tolerated, but not necessarily, in my view, moral. I don’t think that is something that we should want – a world where we allow donors and patients to negotiate payments, because of all the inequality issues that can arise from that. But I think the time has been right for this for a long time [and] that it would be beneficial to at least run a trial, an experiment, and get data based on that.
There [was] an excellent survey [conducted] in the US two years ago…by [Mario Macis, Nicola Lacetera, and Julio Elias]… where US citizens were asked about these questions. I think about 70% [of participants responded positively] towards the idea of rewarding living kidney donors, as long as patients don’t have to pay and if that reward eliminates kidney transplant waitlists… These are two important conditions that the US public themselves gave… I think [it] is fascinating to see that there’s probably more consensus or more acceptance across the general public [for the legalization of organ sales and purchases]… So there is evidence that there is support, but it’s the willingness of governments. I believe that is the problem.
What can we do to dispel the stigma around legalizing the organ trade?
Dr. Ambagtsheer: Sharing pros and cons – encouraging people to really think through some things. For example, the idea of having an altruism-based organ donation system. What is altruism? Does it actually exist? If someone sells [their] organs to feed their family, is that not altruistic? And who are we to claim that people who are poor cannot make decisions for themselves? Is there maybe some paternalism or ethnocentrism hidden within these prohibitionist stances that we witness nowadays, especially from Western countries?
In many countries, it is considered unethical not to reward donors because they save patients’ lives. Economists have calculated that one living kidney donation makes a financial contribution to society which is the equivalent of roughly €80,000, which would probably be $90,000 USD, per year – because you save a patient’s life and you save dialysis costs. And everybody benefits from that transplant, right? Not just the patient, also the hospital, the surgeons… the health insurance companies are very happy with this donation because they don’t have to cover dialysis costs of the patient, even taxpayers… Then why not let donors also share a little bit of that money that they save society? And these are questions that I think a lot of people don’t ask themselves or arguments that are not really considered because there is often a lot of emotion involved when it comes to this topic.
In summary, it was a privilege to speak with Dr. Ambagtsheer about the HOTT project and her opinions on organ prohibition. As a global leader in organ trafficking research, her experience collaborating with fellow researchers, prosecutors, and other diverse international voices has allowed her to develop a holistic and pragmatic perspective on the organ trade. Certainly, the concept of a legalized organ trade remains a highly nuanced subject that many still consider taboo. However, as organ shortages continue to claim hundreds of thousands of lives annually, it becomes increasingly important to set our personal prejudices aside, consider all possible solutions through an objective lens, and encourage those around us to do the same.
1. Ambagtsheer, F., Pascalev, A., de Jong, J., Lundin, S., Ivanovski, N., Codreanu, N., Gunnarson, M., Jankov, J., Frunza, M., Byström, I., Bos, M., & Weimar, W. (2014). Trafficking in human beings for the purpose of organ removal: A comprehensive literature review. Transplant Immunology, 31(4), 254-254. https://doi.org/10.1016/j.trim.2014.11.201
2. Kidney Foundation. (2022). Frequently Asked Questions (FAQ).
https://kidney.ca/Get-Involved/Be-an-Organ-Donor/Additional-FAQs 3. Donor Alliance. (2021, May 21). Can you sell organs in the United States?. https://www.donoralliance.org/newsroom/donation-essentials/can-you-sell-organs/