The hazards of transplant tourism.

I n the November issue of the CJASN, Jagbir Gill et al. present a University of California Los Angeles (UCLA) series of 33 patients that underwent kidney transplantation in a foreign country and returned to the United States for post-transplant care. “Transplant tourists” are traveling to established destinations to obtain readily accessible organs for transplantation, available from the poor of that destination country who sell mostly kidneys, but in some instances, a lobe of the liver or a cornea. These practices have been well known for more than a decade. In 2004, the World Health Assembly (WHA) issued a resolution urging member states “to take measures to protect the poorest and vulnerable groups from transplant tourism and the sale of tissues and organs, including attention to the wider problem of international trafficking in human tissues and organs.” Although the WHA 2004 resolution was unambiguous in its objection to trafficking and transplant tourism, a comprehensive description of these unethical practices was still needed. To address the concerns of the WHA, a Summit Meeting of more than 150 international representatives of scientific and medical bodies, government officials, social scientists, and ethicists was held in Istanbul, Turkey from April 30 to May 2, 2008. The result of these deliberations was the Istanbul Declaration on Organ Trafficking and Transplant Tourism. Gill describes the transplant tourist as a resident of the United States who underwent transplantation outside the United States and then returned for follow-up care. The UCLA group makes no conclusion regarding the ethical propriety of this practice, disclaiming social circumstances that may have propelled these patients to travel for transplantation. The Istanbul Declaration, however, distinguishes travel for transplantation from transplant tourism by means of the following: “travel for transplantation is the movement of organs, donors, recipients or transplant professionals across jurisdictional borders for transplantation purposes. Travel for transplantation becomes transplant tourism if it involves organ trafficking and/or transplant commercialism or if the resources (organs, professionals and transplant centers) devoted to providing transplants to patients from outside a country undermine the country’s ability to provide transplant services for its own population.” The practical basis for concern arises when the destination country places its own resident patient population at disadvantage for gaining access to the list because lucrative arrangements for patients from the client countries simultaneously claim an allocation priority. Meanwhile, in the client country, readily available access to organs (in the destination country) prevents deceased-donor programs from gaining widespread support. Nevertheless, not all recipient travel for transplantation in a foreign country is unethical. The Istanbul Declaration provides additional guidance that travel for transplantation may be ethical if the following conditions are fulfilled: