As Wales becomes the latest country to make organ donation opt-out, the illegal organ trade continues around the world.
It is a tragically narrow bottleneck of modern medicine: hundreds of thousands of people stuck on transplant lists for lifesaving organs, waiting for someone who's a viable match to die.
In the UK, there are some 7,000 people on the list—and many more who might benefit from a transplant, but for various mitigating reasons don't make the cut. In the US, the number awaiting transplant is around 120,000, with 20 dying each day for want of an organ. It's a grimly capricious, seemingly archaic system on which to stake your life. UC Berkeley Anthropology Professor Nancy Scheper-Hughes tells me over Skype that transplant surgeons 200 years from now will "look back and say we were savages. We were cannibals. We were like those 17th Century doctors that were pulling bodies out of the ground to do their anatomical training."
There's no consensus on how to approach the dearth of organs. On December 1, the Welsh government will introduce an opt-out system (whereby everyone is assumed to be OK with donating their organs after death unless they officially register otherwise), citing the 36 people who died in 2012/2103 while waiting in vain for a transplant. This follows a similar approach in Spain, which has the highest number of organ donors per head of population in Europe. It tackled its shortage with a two-pronged approach: make organ donation opt-out, and put a transplant coordinator in every hospital to appeal to grieving families.
There are two incentives for all countries to step up the availability of organs. The first is obvious. People who don't die waiting for a kidney transplant, for instance, must usually subsist on dialysis until a matching organ "becomes available" (read: a friend or family member donates one, or a stranger dies). But the second imperative to expand the donor pool is darker and just as pressing: the multimillion dollar global trade in black market organs, fuelled by money from wealthy first-world buyers.
Organ markets are built on mutual desperation, feeding on a paucity of money in one place and organs in another. Patients who either can't stand the wait for a suitable donor or can't get on the waiting list at all can pay brokers in countries like India or Brazil to set them up with crooked surgeons and sellers so desperate that they are willing to part with kidneys or liver lobes for cash.
These illicit surgeries are not one-off, apocryphal horror stories of people waking up in bathtubs full of ice minus their kidney; since organ transplantation surgeries have become routine, the commodification of the body by organ-selling syndicates has become big business. In 2012, the World Health Organisation estimated that around 10,000 transplants a year were being performed using organs that had been illegally bought and sold, with recipients paying tens or hundreds of thousands of dollars to jump the queue (of which the donor is likely to see only a few thousand).
But knee-jerk distaste aside, so long as the seller gets paid, what's so wrong with the organ market? If you have the fortune not to have been born into extreme poverty, the idea of carving out a kidney or a liver lobe for money seems unconscionable. But that's a far cry from the situation of a would-be organ seller from a Bangladeshi slum. If it's a choice between someone losing their home or losing their kidney, who are you to tell them they're better off on the street with two kidneys than under a roof with one? The problem is, people who are driven to sell parts of themselves to strangers might technically be making a choice, but not one that's informed. Selling an organ is, Michigan State University Assistant Professor of Anthropology Monir Moniruzzaman tells me, "a false choice."
"Most of the [organ sellers] don't know what a kidney is," says Professor Moniruzzaman. "[They don't know] what the liver is and what its function is in the body. They are persuaded by these village brokers who tell them that losing one kidney is not a problem, or that selling a liver lobe is a win-win situation: a noble, lucrative act that can save a life and is harmless and safe."
The donor's recovery and the long-term consequences of his or her "donation" are not discussed, even though in the poorest, most underdeveloped areas of the third world (the hunting ground of the organ broker), they are the most terribly pronounced: donors here can't pay for post-operative care (if they can even reach a hospital capable of providing it), and the common physical side-effects they experience—weakness, pain, dizziness, fatigue—make going back to manual labour difficult. According to Moniruzzaman, the money that an organ seller receives almost always runs out "in just a few months."
Could a legitimate system work as a safeguard? More likely, according to Moniruzzaman, legalising the trade in organs would actually coerce more people into selling off parts of themselves when times are hard, with the profits going to the same (now legitimised) groups and individuals as before.
"Most of the [organ sellers] don't know what a kidney is"
"This corruption and manipulation and trickery is not going to change with a market," he says. "They're going to exist in exactly the same form, but it's going to be legalised, so there are going to be more and more people trying to entice this vulnerable population [into selling their organs], by telling them that this is a legal thing... Moneylenders could force these poor people [to sell], by telling them, 'You can sell your organs. It's legal. So why don't you sell [one] and pay me my money back?'"
The syndicates are practiced at keeping their claws in donor communities. The money sellers receive rarely provides the kind of escape from poverty they're so desperately hoping for—something that syndicates on the lookout for new recruiters regularly take advantage of. The most harrowing results are sometimes referred to as "kidney villages": places where neighbours encourage each other to sell to the brokers until the telltale scar left from surgery becomes a community's defining feature. These villages are breeding grounds for new recruiters, and so the cycle continues.
"They're lied to, always, about how much they're going to get," says Professor Scheper-Hughes, of the sellers in the current system. "The people who made out better were not those who just sold their kidneys, but people who became part of the syndicate. People would come back and say, 'I got $5,000 [for my organ], but it really didn't help get me out of my troubles with my family,' and then [the recruiters] would say, 'Then you can recruit other people [for us].'"
"Sellers are bargaining in terms of their immediate needs"
There is one country in the world where paying people for body parts is a regulated business, providing a dispiriting model of what legitimate global trade might look like: Iran.
"The [Iranian] government has said, 'We're not allowing people to sell organs in Iran, we are simply giving you an honorarium,'" says Scheper-Hughes. "Some of the sellers see it as a kind of blood money. They say, 'OK, selling a kidney is like damaging somebody at work or a culpable accident. You can be paid for that. So what we're giving you is money to compensate for the loss of your organ. Or to pay for the pain that you've suffered.'"
But regulated or not, those poor and desperate people still face one of Moniruzzaman's "false choices".
"Sellers are bargaining in terms of their immediate needs," Scheper-Hughes continues. "But still people are trying to be kind to each other: one is saying, 'Look, my father is dying and we're not wealthy people, we can't really give you more than $2,000.' And the [seller] says, 'But if I don't have $3,000 I'm being thrown out of my apartment.'"
The idea of organs being bought and sold like second-hand cars—with both buyer and seller hashing out terms that suit their individual needs—might seem seductively simple at face value. But slough off the surface ideals of free trade and autonomy and you're left with poor people being dismembered for the benefit of the rich. Or, as Scheper-Hughes puts it, "a social tragedy."
"The moral question is, could we cut off the leg of a poor person and tell them that one leg is enough for them?" asks Moniruzzaman. "Or cut off a head of a poor person who is willing to sell that? There are poor people who are desperate to sell anything."
"I interviewed at least 70 people [in Bangladesh] who had sold their organs, including kidneys, liver [lobes] and in one case I found a seller who wanted to sell one of her corneas… Is that the right [system to have]?"