EDITORIALS
Progress towards national self-sufficiency in organ transplants
Luc NoëlI,*; Dominique MartinII
IDepartment of Essential Health Technologies, World Health Organization, 20 avenue Appia, 1211 Geneva 27, Switzerland
IICentre for Applied Philosophy and Public Ethics, The University of Melbourne, Melbourne, Vic., Australia
The federal shariat court of Pakistan recently upheld the country's 2007 Transplantation of human organs and tissue ordinance.1 A courageous campaign had originally established this legislation in Pakistan,2 a country in which poor people once received a pittance for selling their organs, while some organ brokers, doctors and hospitals became rich. The ordinance prohibits commercial organ donation, legalizes deceased donation, excludes donations to foreigners from unrelated Pakistani donors and establishes a human organ transplant authority to monitor transplantation activities and ensure transparency.
The transplant authority - at the Ministry of Health - must implement and enforce ethical practices and combat the resurgence of clandestine organ trafficking. Advocates of commercial transplantation and transplant tourism have openly sought to challenge the law. A society of transplant professionals interested in the sale of kidneys and the provision of transplantation services to tourists from abroad petitioned the federal shariat court on various grounds, including a claim that the prohibition against payment constituted a hurdle to the saving of human lives.
This petition exemplifies the persistent threats to ethical transplantation practice globally, highlighting the commercial appeal of paying vulnerable organ vendors to provide organs for distant elites. For example, patients from Saudi Arabia were regularly reported as clients of kidney transplantation clinics in Pakistan before the introduction of the 2007 ordinance. Saudi Arabia has since mirrored the Pakistani response to this threat, with both governments demonstrating that the pursuit of national self-sufficiency in human organs is the only way to progress towards equitable transplantation practice on a global level. The number of Saudi patients transplanted abroad has steadily decreased and donations from deceased donors increased to unprecedented levels in 2008.3 The Saudi authorities are clearly taking responsibility for meeting transplantation needs in the Kingdom, thereby minimizing the harmful effects of transplant tourism.
Other countries once recognized as transplant tourism destinations - such as Egypt and the Philippines - have recently adopted or are now considering draft laws banning commercial transplants.4,5 Countries that have previously resorted to transplant tourism have established - or are pursuing - self-sufficiency at the national or sub-regional level, for example in Israel, Japan and the Republic of Korea.6-8 Meeting transplantation needs at the national level avoids predatory behaviour at the expense of underprivileged populations in other countries. However, this goal can only be achieved by increasing deceased donations through efficient organ procurement organizations, as well as safely developing live-related kidney donation. The Member States of the World Health Organization were urged to do so in Resolution 57.18 of the 2004 World Health Assembly.9
Advocates of payment for living donation claim that altruism has been shown to be inefficient and insufficient, yet some countries, provinces and states have shown that self-sufficiency is within reach. Some countries have achieved success in the absence of paid donation, thus avoiding exploitative practices that shift the burden of organ donation to the poor.
The pursuit of national self-sufficiency in human material for transplantation is the collective responsibility of all citizens, inasmuch as they are necessary participants in the prevention and management of all diseases leading to the need for transplantation.
The shariat court judgment was a victory for the federal government and dedicated medical professionals in Pakistan seeking to establish and maintain ethical standards in organ procurement and transplantation. It was also a powerful affirmation of Islamic bioethics in harmony with the universal values expressed in the WHO guiding principles on human cell, tissue and organ transplantation and the Declaration of Istanbul.10,11
By putting a stop to the exploitation of vulnerable human beings and equipping the country with the legislation necessary to establish donation and transplantation services using organs from deceased donors, Pakistan has adopted the path to national self-sufficiency by which the health authorities invite citizens to donate organs after death. Potential donors are also reminded that they themselves may be potential beneficiaries of organs from deceased donors. In the pursuit of self-sufficiency, altruism, reciprocity and civic consciousness are the main motivations for donation. 
References
1. Askari SJ. Health experts hail FSC verdict on organ sale. The Nation 25 April 2009. Available from: http://www.nation.com.pk/pakistan-news-newspaper-daily-english-online/Regional/Karachi/25-Apr-2009/Health-experts-hail-FSC-verdict-on-organ-sale [accessed on 2 June 2009] .
2. Usmani AQ. From kidney bazaar to ethical practices in organ transplantation. Pak J Med Res 2007;46:56.
3. Saudi Centre for Organ Transplantation. 2008. Report available at http://www.scot.org.sa/eng-index.html [accessed on 2 June 2009] .
4. Torres T. Philippines says no to organ trafficking. INQUIRER.net 24 June 2009. Available from: http://globalnation.inquirer.net/news/breakingnews/view/20090624-212208/Philippines-says-no-to-organ-trafficking [accessed on 3 July 2009] .
5. McGrath C. Egypt: move to end organ trafficking. Global Issues 18 May 2009. Available from: http://www.globalissues.org/news/2009/05/18/1530 [accessed on 2 June 2009] .
6. Siegel-Itzkovich J. Knesset approves organ donation law. Jerusalem Post 24 March 2008. Available from: http://www.jpost.com/servlet/Satellite?cid=1205420767689&pagename=JPost%2FJPArticle%2FShowFull [accessed on 2 June 2009] .
7. Fukue N. Kids under 15 can give organs: upper house votes in new transplant law. The Japan Times on Line 14 July 2009. Available from: http://search.japantimes.co.jp/cgi-bin/nn20090714a2.html [accessed on 3 July 2009] .
8. Organ donation to be easier. The Korea Times 6 June 2009. Available from: http://www.koreatimes.co.kr/www/news/nation/2009/06/117_47008.html [accessed on 3 July 2009] .
9. Resolution WHA 57.18. Human organ and tissue transplantation. In: Fifty-seventh World Health Assembly, Geneva, 22 May 2004. Available from: http://www.who.int/transplantation/publications/en/ [accessed on 2 July 2009] .
10. WHO guiding principles on human cell, tissue and organ transplantation (updated edition). Geneva: World Health Organization; 2008. Available from: http://www.who.int/transplantation/TxGP08-en.pdf [accessed on 25 May 2009] .
11. Steering Committee of the Istanbul Summit. Organ trafficking and transplant tourism and commercialism: the Declaration of Istanbul. Lancet 2008;372:5-6 doi:10.1016/S0140-6736(08)60967-8 PMID:18603141
* Correspondence to Luc Noël (e-mail: noell@who.int).