Transplant Professionals and Transplant Commercialism in India: The Difficulty of Being Good

Following successful kidney transplantation in North America and Europe, India was one of the earliest amongst the newly liberated colonies of the Global South to initiate kidney transplantation. Though initial progress was slow, significant strides have been made in the last few decades. The number of transplants has increased and India now ranks third in terms of global volumes.¹ Deceased donor transplants regularly take place in some states and transplants of nonrenal organs, especially liver, are being performed in significant numbers with good outcomes.² There are more transplant centers across the country, and though their geographical spread is still skewed, hitherto underserved areas like the Northeast are witnessing activity.³ India is acknowledged as a major player in global transplantation and is reputed for high levels of expertise. The country’s transplants per million population remain very low,¹ which means access remains a big challenge and only a small privileged minority of those who need it get transplanted. The large majority of transplants are from live donors.

The growth was a result of several factors. The role of enhanced healthcare capacity, technology, and expertise across specialities is underappreciated but vital. The availability of tissue typing, preservative solutions, immunosuppressants, and anti-infectious drugs, including cheaper generics, also contributed.⁴ Clinicians trained in the West were returning to India bringing valuable expertise. But the contribution of an expanding private sector has also been a key driver. The proportion of transplants performed in the private sector in India is one of the highest in the world.

After independence, with the state focussing on primary care, tertiary care, especially high-end procedures, were restricted to few large public institutions. Despite policy commitments, universal healthcare was never seriously operationalized. The private sector occupied the vacuum in tertiary care by investing in technology and expertise fulfilling a felt need. Its entrepreneurial energy pushed rapid expansion. Also, transplants gave good returns. Although some private hospitals had charity as one of their stated aims, most strategized to seek profit through revenues. This trajectory of transplantation parallels that of speciality healthcare and is accentuated in transplants of extra renal organs like the liver and heart.

India’s economic liberalization of the 1990s saw the entry of for-profit private hospital chains and global capital in Indian healthcare. Trained specialists found a conducive and lucrative environment to utilize their expertise. Local experts and those working abroad were headhunted and offered high payouts. In a sense, it was a win-win situation. Medical tourism became a major revenue generator. The Indian government supports medical tourism as a source of national revenue and collective pride.⁵ India is a favored destination for foreigners seeking transplantation, and last year 10% of transplants were performed on foreigners, which is high by global standards and almost exclusively in the private sector.⁶ For those with limited or no access in their home country, transplantation in India is relatively cheap compared to high-income countries⁴ and their only hope. However, this has also thrown up the challenge of distinguishing between legitimate and unrelated commercial transplants. Recent reports reveal that an elaborate web of agents forge papers to bypass Indian regulations. A degree of complicity by hospitals is likely and higher revenue is the obvious driver.

With the demands of transplantation on investment, there is now a tendency toward monopolization by corporate chains. This has resulted in a severely monetized environment, which is intrinsically wired to overlook transgressions of ethical tenets and rules if they result in higher volumes and monetary returns. It’s vital to acknowledge this trajectory of the Indian transplantation, as it also offers part explanation for the intractable challenge of commercialism and collusion by professionals.

It wasn’t long back when the “kidney bazaar” had exploded in India. Foreigners, mainly from the Middle East, travelled to India in large numbers and paid for kidneys. There was lot of public outrage. Moreover the outcomes were poor and many recipients contracted serious viral infections like human immunodeficiency virus (HIV) and Hepatitis B.⁷ The promulgation of the Transplantation of Human Organs Transplant Act (HOTA) in 1994⁸ was aimed at two areas: to criminalise trading in organs and create a regulatory apparatus to oversee transplantation and to recognize brain stem death paving the way for deceased donation. For a period, commercial transplants In India went underground only to resurface in different forms.

Meanwhile, even in the rest of the world, several “hotspots” for organ trafficking emerged. India was considered one of them. In 2008, transplant professionals, ethicists, and policy-makers under the umbrella of the Transplantation Society and International Society of Nephrology with support from the World Health Organization (WHO) formulated the “Declaration of Istanbul” (DOI).⁹ Although the declaration focusses on organ trafficking and transplant tourism, it is a comprehensive document which promotes self-sufficiency and highlights the autonomy of donors. It’s a call to professionals and their organizations to encourage ethical transplantation and oppose commercialism. The “Declaration of Istanbul Custodian Group,” led by transplant professionals, was created to keep the document “alive.”¹⁰

Whilst commercialism, transplant tourism, and organ trafficking in India are much discussed, the role of transplant professionals is less analyzed. This is necessary not only because professionals are key players without whom transplants cannot happen but more importantly because they can resist unethical activities. A significant number of transplant professionals in India could be described as ambivalent on commercialism and punitive action. Whilst there is a small number who participate in illegal acts and have even been arrested, there are many more who put forward arguments that amount to defence of their colleagues.¹¹ There is another section which believes that professionals have to do their job and that issues like organ trading are outside their purview. There is a section that believes payments to the poor to donate organs are not wrong and, in fact, deliver justice to the donor or the family who gain nothing from donation. Whether this reflects ideological disagreement over Indian law and global ethics guidance, an acknowledgment of their complicity or just groupthink is difficult to say. But a distressing “dual loyalty,” where employers are subtly pushing for unethical transplantation while self-image, law, and global peer pressure pull in the opposite direction, is common.

Whilst officially endorsing global principles, including the DOI, professional organizations in India have stayed away from publicly condemning or investigating colleagues who have been charged. However, such inaction is not restricted to transplantation. Professional organizations have remained silent in the face of public scandals around unethical practices involving colleagues. The state has hence been forced to create special laws. The promulgation of the HOTA was a response to the scandals around kidney trafficking in previous years.

There are professionals in countries like the USA who openly argue for a regulated market in organs. They propose a transparent, monitored, system of monetary compensation for unrelated donors.¹² Whilst the feasibility of a regulated market is debatable, these proposals are somewhat different from what we witness in India where the socially vulnerable are duped or coerced into selling their organs. If there are professionals who support a regulated market, they have as yet not articulated it cogently and openly. It is worth remembering that given severe social divides and grinding poverty, monetary compensation for donation is coercion in another form.

There are several reasons advanced for high levels of transplant commercialism in certain regions of the world. These include a very wide demand-supply gap worsened by a lack of deceased donation, financial vulnerability, and inadequate regulation. But the role of an increasingly monetized health system which co-opts professionals is underestimated. Transplant professionals are paid well above their colleagues. The co-option maybe out of conviction, benign neglect, pressure to deliver volumes, or personal monetary gain, which is socially admired.

The predicament of the Indian transplant professional is real and likely to increase. Market medicine values volumes and revenues for its growth. Most citizens cannot afford transplantation and referrals are monetized through commissions. There is severe interinstitutional competition, with everyone competing for the same pie. Given the pressure of monetary targets, it’s tempting to cross scientific and ethical boundaries and preferentially transplant the wealthy and foreigners—and to look away from illegal practices. Conversely, with social and regulatory consensus against organ trading, periodic scandals break out and professionals are punished, shamed in the media and even arrested. This is sought to be blamed on fraudulent paperwork, but the fact that certain institutions and certain cities like Kolkata are repeatedly in the news for commerce suggests complicity.

The political economy and social fault lines that impact the conduct of transplantation are not of our making. But we are key players. Recognizing the forces at play and developing a collective will autonomous from market forces is necessary. Some of our senior global colleagues recently publicly challenged us by suggesting that transplantation in India is “not for the common good.”¹³ The best way to respond is by proving them wrong. That will not be easy, but our profession has a legacy of taking up difficult challenges as part of our commitment toward science and society. Transplantation tests that more than other areas of healthcare. It’s indeed difficult to be good.