Ethics and Policy: Organ Bazaars in Bangladesh

A kidney seller's scar

Monir Moniruzzaman doesn't spend a lot of time debating the finer points of medical ethics. He has little doubt about the morality of the medical practice that he researches, which is trafficking in human organs.

His problem is what to do about it.

The Underground Market

"I've been working on the underground organ market since 2000," said Dr. Moniruzzaman. "Commercialization of medicine and increasing inequality have had a huge impact on the transplant enterprise. Organ transplants have boomed since the 1970s. In the West, waiting lists can be six to seven years, so wealthy people go overseas to get it done. In the East, people live in excruciating poverty, so they sell their body parts to get by. It started with kidneys. Later, livers became new commodities."

Many doctors and hospitals are co-conspirators, as Moniruzzaman found out when he undertook a year-long study in Dhaka in 2005. "Hospitals don't look at where organs come from," he said.

"The first three months I asked around in hospitals...the doctors denied it exists in Bangladesh. They said it was just a problem in India. I started talking to recipients, but they made up stories when I asked to talk to their donors: 'He lives in a remote village, there's no phone,' and so on. They pretended the donor was a family member."

Then a friend said he knew a recipient who had purchased a kidney from a slum dweller. That contact paid off with a confidential seven-hour interview about how the market operates. "The sellers are not connected," said Moniruzzaman. "You can only find them through brokers."

Approaching the brokers, however, was difficult and dangerous. "I approached four brokers. Once I met a broker in a back alley; he came along with thugs and denied his involvement in organ trafficking. Finally, I convinced one broker who agreed to help," said Moniruzzaman.

Once plugged into the brokers' network, what he found was even worse than expected. Most of the sellers, severely impoverished to begin with, were worse off than before. Many were never paid what they were promised, and none received any post-operative care. For most, the money soon ran out and they were unable to go back to work because of lingering health issues from their surgeries.

And, commented Moniruzzaman, "it was difficult to find the data because nobody wants to tell that he sold his organs. It's shameful. It's humiliating. There is stigma involved, and it's illegal on top of that."

But he persisted, and did succeed in infiltrating the market, and in 2012 was able to testify before the Congressional Tom Lantos Human Rights Commission and the Senate Foreign Relations Committee with hard-won data from the first ever in-depth study of its kind. He also published the study results in Medical Anthropology Quarterly.^[1]

Stopping the Exploitation

The village tea stall is a typical meeting place where organ brokers prey on the poor.

Having verified and to some degree quantified the problem, Moniruzzaman has now turned his attention to how this brutal and horrific form of human exploitation might be stopped.

"The biggest problem in Bangladesh is the poverty," he said. "The inequality is massive here." For this reason he disagrees with those who want to legalize and regulate the market: "There are some people who still want to legalize it, arguing that the donors will get paid and cared for. They fail to understand that an organ market simply prolongs the lives of the affluent few at the severe cost of bioviolence, exploitation, and suffering inflicted against the poor. We cannot legalize a market that promotes bodily inequality; the poor have every right to keep their body parts intact."

Over the past decade a growing world-wide community has begun to converge around the issue.

In 2004, the World Health Assembly (the decision-making body of WHO) urged its member states to take measures against transplant tourism and address the wider problem of international organ trafficking.

Poverty in Dhaka

In 2006, representatives from two medical societies, the Transplantation Society and the International Society of Nephrology, met to discuss the idea of developing a formal declaration that would unite and speak for all those engaged in combating unethical practices in organ transplantation.

They laid the foundations for this mission to be carried out two years later at the Istanbul Summit, where 152 representatives from scholarly and medical societies, governments, the Vatican, organ transplantation experts, ethicists, anthropologists, sociologists, legal scholars, and others met to draft the Declaration of Istanbul on Organ Trafficking and Transplant Tourism.2 The Declaration was published in 2008 in the Lancet and has since been republished in numerous medical journals and translated into more than a dozen languages.

Moniruzzaman serves as a "custodial" or core member of the Istanbul group, which now examines organ trafficking and promotes ethical guidelines for practice in organ donation and transplant. Since its inception, over 100 countries have strengthened or adopted their laws against organ trafficking. He is also in the process of launching the Organ Union, a non-governmental organization in Dhaka. The Union will map out, monitor, and mitigate the organ trafficking, as well as support the organ sellers, in Bangladesh.

"There are many people who still want to legalize organ selling. The argument is the donors will get paid and cared for. But it's bodily inequality. The commodification of organs is bioviolence."

Monir Moniruzzaman

Based on Moniruzzaman's research, MSU faculty members Sue Carter (Journalism), Troy Hale (Telecommunication, Information Studies and Media), and Geri Alumit Zeldes (Journalism) are making a documentary film to create awareness on this issue.

Dr. Francis L. Delmonico, who is executive secretary of the Declaration of Istanbul Custodian Group (DICG), president of the Transplantation Society, and advisor for human transplantation to the World Health Organization, said that "Dr. Moniruzzaman has been a vital member of the DICG and has made a unique contribution in the exposure of organ trafficking in Bangladesh. It is the collaboration of professionals such as Dr. Moniruzzaman that has enabled DICG to be effective in combating transplant tourism and organ trafficking throughout the world."

Moniruzzaman believes that the solution lies in local action, supported by global policy declarations. "The UN took a recent initiative for putting it under human trafficking. But these agreements are international. Local governments are where changes have to be implemented. In Bangladesh, the Minister of Health is taking the initiative to tighten the laws and ensure that papers are not fake, the donor and recipient are actually related, and so on. Almost every country prosecutes organ trafficking, but it goes on. That's where we are working."

Sources

1. Moniruzzaman, M. (2012). "Living cadavers" in Bangladesh: Bioviolence in the human organ bazaar. Medical Anthropology Quarterly, 26, 69-91.