The Declaration of Istanbul and its Global Impact on Organ Transplantation

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In 2004, prompted by an increase in organ trafficking and the advent of transplant tourism, the World Health Assembly urged United Nations member states to implement national oversight of organ transplantation to protect poor and vulnerable individuals from being coerced into selling their organs. Four years later, more than 150 professionals from 78 countries and a variety of backgrounds and religious traditions gathered in Istanbul, Turkey, to address the rampant global problem of organ trafficking and transplant tourism. The situation had deteriorated to the point that transplant tourists were departing and going to the United States.

Convened by The Transplantation Society (TTS) and the International Society of Nephrology (ISN) the conference participants drafted the Declaration of Istanbul on Organ Trafficking and Transplant Tourism, which was simultaneously published in several medical journals including the official journals of the TTS, ISN, and the American Society of Nephrology (ASN), and distributed electronically as a Lancet web appendix.

The Declaration consists of: 1) clear definitions of organ trafficking, transplant commercialism, and transplant tourism; 2) a set of principles to guide professional conduct and government policy; and 3) a series of proposals applying those principles to particular problems in transplantation. In addition, the Declaration was a forerunner of the corresponding World Health Organization (WHO) Guiding Principles adopted by the 63rd World Health Assembly in 2010.

Since its release, the Declaration’s principles have been spread across the world by the Declaration of Istanbul Custodian Group (DICG)—an assembly of dedicated professionals from across the globe. The DICG’s current mission is to promote ethical practices of organ donation and transplantation, so that national self-sufficiency can be achieved and transplant tourism and organ trafficking curtailed.

Much has been accomplished since the Declaration was released. Starting in 2008, the DICG targeted governmental authorities to align national policies with the Declaration and the WHO Guiding Principles. The DICG has achieved success in India, Pakistan, the Philippines, Eastern Europe, Latin America, China, as well as the United States.

For example, China has agreed to change its policy of using organs from executed prisoners, although this remains a work in progress. The DICG leadership unraveled transplant tourism in Costa Rica and have worked to protect Central America from this menace. The Council of Europe engaged DICG to support the development of a convention prohibiting organ trafficking. A fundamental WHO Guiding Principle to achieve transparency of transplantation activity has been adopted by the United Network for Organ Sharing (UNOS). UNOS will now collect data on candidates who are neither U.S. citizens nor residents who have travelled to the United States for the purpose of transplantation.

Yet more must be done in the United States to address the plight of those waiting for kidney transplants. As a first step, removing the considerable financial disincentives and obstacles to organ donation, rather than eliminating the federal ban on payment to donors, would be something the entire community could enthusiastically support. These expenses include the costs of being evaluated as a potential donor, of transportation, dependent care, and lost wages during the period from pre-donation screening to postoperative recovery. Insurance against the risks of donation should also be provided. Medical complications that may not be covered by the donor’s health insurance should be paid for. In addition, the death of a donor without life insurance and loss of financial support would be disastrous for any family. This cost coverage would ultimately reduce the cost to health insurance companies and the federal government because enabling patients to undergo kidney transplantation would not only extend and improve their lives but also save the cost of dialysis.

A second step would be to eliminate the 3-year limitation on Medicare coverage of the immunosuppressive medications that are essential to prevent organ rejection. This shortsighted policy has resulted in hundreds of patients losing their transplanted kidneys, necessitating a return to dialysis while they await another transplant.

A third step would be to increase the supply of organs from deceased donors. About 500 kidneys are recovered from deceased donors each year in the United States and discarded even though they are medically suitable for transplantation. Moreover, efforts must be undertaken to continue developing the practice of donation after circulatory death.

The highly successful kidney paired donation programs should be made available to all recipients with biologically incompatible living donors.

The DICG greatly values the support of the ASN and the kidney community. Continued cooperation is sought to serve our patients not only in North America, but throughout the world.

The Declaration of Istanbul’s website provides information on organ trafficking, and the DICG welcomes the interest of professionals and stakeholder members of society to visit at www.declarationofistanbul.org