EDITORIAL Transpl Int, 09 April 2024 https://doi.org/10.3389/ti.2024.13011

The shortage of organs for transplantations is increasing in Europe as well as globally. Many initiatives to the organ shortage, such as opt-out systems for deceased donation and expanding living donation, have been insufficient to meet the rising demand for organs. In recurrent discussions on how to reduce organ shortage, financial incentives and removal of disincentives, have been proposed to stimulate living organ donation and increase the pool of available donor organs. It is important to understand not only the ethical acceptability of (dis)incentives for organ donation, but also its societal acceptance. In this review, we propose a research agenda to help guide future empirical studies on public preferences in Europe towards the removal of disincentives and introduction of incentives for organ donation. We first present a systematic literature review on public opinions concerning (financial) (dis)incentives for organ donation in European countries. Next, we describe the results of a randomized survey experiment conducted in the United States. This experiment is crucial because it suggests that societal support for incentivizing organ donation depends on the specific features and institutional design of the proposed incentive scheme. We conclude by proposing this experiment’s framework as a blueprint for European research on this topic.

This study fills critical knowledge gaps into the organization of organ trade utilizing crime script analysis. Adopting a situational crime prevention approach, this article draws from law enforcement data to compare the crime commission process (activities, cast and locations) of 2 prosecuted organ trade cases: the Medicus case and the Netcare case. Both cases involved transnational criminal networks that performed kidney transplants from living donors. We further present similarities and differences between illegal and legal living donor kidney transplants that may help guide identification and disruption of illegal transplants. Our analysis reveal the similar crime trajectories of both criminal cases, in particular the extensive preparations and high degree of organization that were needed to execute the illegal transplants. Offenders in the illegal transplant schemes utilized the same opportunity structures that facilitate legal transplants, such as transplant units, hospitals and blood banks. Our results indicate that the trade is embedded within the transplant industry and intersects with the transport- and hospitality sector. The transplant industry in the studied cases was particularly found to provide the medical infrastructure needed to facilitate and sustain organ trade. When compared to legal transplants, the studied illegal transplant scripts reveal a wider diversity in recruitment tactics and concealment strategies and a higher diversity in locations for the pre-operative work-up of donors and recipients. The results suggest the need for a broader conceptualization of the organ trade that incorporates both organized crime and white collar crime perspectives.

Department of Internal Medicine, Erasmus MC Transplant Institute, University Medical Center Rotterdam, Rotterdam, Netherlands, School of Law and Social Justice, The Liverpool Law School, University of Liverpool, Liverpool, United Kingdom, Multi-Organ Transplantation Center, King Fahad Specialist Hospital-Dammam, Dammam, Saudi Arabia, Clinical Hospital Zan Mitrev, University “Sts Cyril and Methodius”, Skopje, North Macedonia

Criminal networks behind organ trade: a social network analysis of the Medicus case Though less well-known than for instance the narcotics or weapons trade, illegal organ trade is a lucrative business with yearly revenues estimated between 840 million and 1.7 billion USD. The most commonly reported form of organ trade is the trade in living donor kidneys. The current study maps the criminal network behind the illegal organ trade that took place in the Medicus clinic in Kosovo based on police files, indictments, transcripts of suspect and victim statements, court rulings and interviews. The Medicus case involved at least 27 living kidney donations. Operations were performed by eleven actors in teams of varying composition. The total criminal network consisted of 107 individuals and is characterized by a low density and features a number of central actors.

The human organ trade is proliferating globally. However, far fewer cases have been prosecuted than would be expected based on estimates of the crime. Research exploring the challenges to investigating and prosecuting organ trafficking cases is practically non-existent. Also no studies exist that explain these challenges utilizing a criminal justice framework. This article aims to explain the legal, institutional and environmental factors that affected the investigation and prosecution of two organ trafficking cases: the Netcare case, exposed in South Africa and the Medicus case, exposed in Kosovo. It analyzes these factors through a comparative, mixed-method design, utilizing a theoretical criminal justice framework. Both cases constituted globally operating criminal networks involving brokers and transplant professionals that colluded in organizing illegal transplants. Both cases contained human trafficking elements, however only the Medicus case was prosecuted as a human trafficking case. Legal uncertainty, a lack of institutional readiness and cross-border collaboration issues hampered investigation and prosecution of the Netcare case. The Medicus case also reported problems during cross-border collaboration, as well as a corrupt environment and institutional barriers, which impeded a successful case outcome. Recommendations to improve enforcement of organ trafficking include improving identification of suspicious transplant activity, strengthening cross-border collaboration and enhancing whistleblower protection laws.

This article presents the results of a qualitative interview study amongst 41 Dutch transplant professionals. The overarching aim was to acquire in-depth understanding of transplant professionals' experiences with and attitudes towards patients who purchase kidneys. We found that transplant professionals occasionally treat patients who are suspected of kidney purchases abroad. However, they turn a blind eye to their patients' suspected purchases. Secrecy and silence function as a tacit agreement between patients and their caregivers that keeps the subject of kidney purchase at a safe distance and allows transplant professionals to ignore its suspected occurrence. They thus participate in the building of walls of secrecy and silence in the organ trade.

This paper addresses ethical, legal, and psychosocial aspects of Global Kidney Exchange (GKE). Concerns have been raised that GKE violates the nonpayment principle, exploits donors in low- and middle-income countries, and detracts from the aim of self-sufficiency. We review the arguments for and against GKE. We argue that while some concerns about GKE are justified based on the available evidence, others are speculative and do not apply exclusively to GKE but to living donation more generally. We posit that concerns can be mitigated by implementing safeguards, by developing minimum quality criteria and by establishing an international committee that independently monitors and evaluates GKE's procedures and outcomes. Several questions remain however that warrant further clarification. What are the experiences and views of recipients and donors participating in GKE? Who manages the escrow funds that have been put in place for donor and recipients? What procedures and safeguards have been put in place to prevent corruption of these funds? What are the inclusion criteria for participating GKE centers? GKE provides opportunity to promote access to donation and transplantation but can only be conducted with the appropriate safeguards. Patients' and donors' voices are missing in this debate.

Patienten reizen wereldwijd voor niertransplantaties. Zorgverleners in Nederland krijgen te maken met deze patienten, voor en na de transplantatie. Wij presenteren de resultaten van een enquete onder Nederlandse transplantatieprofessionals over hun ervaring met patienten die in het buitenland zijn getransplanteerd. Vervolgens beargumenteren wij dat zorgverleners illegale transplantaties zouden moeten rapporteren. 100 van de 241 ondervraagde professionals behandelden patienten die buiten de EU waren getransplanteerd: 31 professionals wisten zeker dat de nier gekocht was en 65 hadden vermoedens. De meerderheid ervoer een conflict van plichten. Zorgverleners kunnen een rol spelen bij het signaleren en melden van orgaanhandelnetwerken. Het doel van het melden is tweeledig. Ten eerste kan deze informatie leiden tot meer kennis over de werkwijze van orgaanhandelaren. Ten tweede kunnen politie- en justitiediensten onderzoeken of daadwerkelijk een crimineel netwerk is betrokken bij het faciliteren van deze transplantaties. Op deze manier kunnen degenen worden berecht die orgaanhandel faciliteren, zodat uitbuiting van donoren wordt voorkomen. Orgaanhandel komt overal in de wereld voor. Steeds vaker verschijnen er berichten over arme donoren die hun nier op de zwarte markt verkopen. Volgens deze berichten verkopen zij hun nieren veelal aan buitenlandse patienten.1,2 Onlangs bleek uit een systematische literatuurstudie dat van ruim 6000 patienten gerapporteerd is dat zij tussen 1970 en 2013 naar een ander land reisden voor een orgaantransplantatie.3 De meest genoemde transplantaties betroffen levende nierdonaties van genetisch niet-verwante donoren. China, Pakistan en India waren de populairste bestemmingslanden. Er wordt meestal verondersteld dat deze patienten hun nier hebben verkregen van donoren die daarvoor zijn betaald of uitgebuit. Patienten die in het buitenland zijn getransplanteerd lopen een significant hoger risico op infectie en afstoting dan patienten die binnen de landsgrenzen zijn getransplanteerd.

Patients travel worldwide to undergo kidney transplantations. Care providers in the Netherlands encounter these patients, both before and after the transplantation. We present the results of a survey that was distributed among Dutch transplant professionals about their experiences with patients who have undergone a kidney transplantation abroad. We propose that care providers should report illegal transplantations. Of the 241 surveyed professionals, 100 treated patients who travelled to a country outside the European Union for a kidney transplant. Thirty-one professionals were certain that patients purchased their kidney, and sixty-five had suspicions that it had been purchased. The majority reported a conflict of duties. Professionals can help prevent organ purchase by detecting and disclosing information about organ trafficking networks. The aim of reporting is two-fold. Firstly, such disclosure can lead to increased knowledge and information about organ trafficking. Secondly, it can support the police and law enforcement agencies to investigate if networks are involved in facilitation of these transplantations. In this manner, those who facilitate organ trafficking can be prosecuted and exploitation of donors can be prevented.

The trade in human organs is considered a major international concern. In 2007, the World Health Organization (WHO) estimated that approximately 6000 kidney transplants are performed illegally each year. More recently, the Council of Europe declared that organ trade constitutes a “major threat to public health” and that it is growing worldwide due to the “greed of unscrupulous traffickers”. [...]

The international transplant community portrays organ trade as a growing and serious crime involving large numbers of traveling patients who purchase organs. We present a systematic review about the published number of patients who purchased organs. With this information, we discuss whether the scientific literature reflects a substantial practice of organ purchase. Between 2000 and 2015, 86 studies were published. Seventy-six of these presented patients who traveled and 42 stated that the transplants were commercial. Only 11 studies reported that patients paid, and eight described to what or whom patients paid. In total, during a period of 42 years, 6002 patients have been reported to travel for transplantation. Of these, only 1238 were reported to have paid for their transplants. An additional unknown number of patients paid for their transplants in their native countries. We conclude that the scientific literature does not reflect a large number of patients buying organs. Organ purchases were more often assumed than determined. A reporting code for transplant professionals to report organ trafficking networks is a potential strategy to collect and quantify cases.

Background: Patients travel worldwide for paid kidney transplants. Although transplantations abroad are not always illegal, they are commonly perceived to be illegal and unethical involving risks. Aim: We aimed to describe the motivations and experiences of patients who traveled abroad for paid kidney transplantations and to examine how these transplantations were facilitated. Methods: We interviewed 22 patients who traveled from Macedonia/Kosovo, the Netherlands, and Sweden for paid kidney transplantations between years 2000 and 2009. Results: Patients traveled because of inadequate transplant activity in their domestic countries and dialysis-related complaints. However, 6 patients underwent preemptive transplantations. Cultural factors such as patients’ affinity with destination countries, feelings of being discriminated against by the health-care system, and family ties also help explain why patients travel abroad. Seven of the 22 patients went to their country of origin. They were able to organize their transplantations by arranging help from family and friends abroad who provided contacts of caregivers there and who helped cover the costs of their transplants. The costs varied from €5000 to €45 000 (US$6800-US$61 200). Seven patients paid the hospital, 5 paid their doctor, 4 paid a broker, and 6 paid their donors. Conclusion: Research should include interviews with brokers, transplant professionals, and other facilitators to achieve a full picture of illegally performed transplantations.

Organ Trade: Knowledge, Awareness, and Nonlegislative Responses Frederike Ambagtsheer, LLM, MSc and Willem Weimar, MD, PhD Links [A] http://www.osce.org/secretariat/ 103393 [B] http://www.declarationofistanbul.org/ [C] https://wcd.coe.int/ViewDoc.jsp?id= 2214787&Site=DC&BackColorInternet= F5CA75&BackColorIntranet= F5CA75&BackColorLogged=A9BACE [D] https://www.politie.nl/binaries/content/ assets/politie/documenten-algemeen/ onderwerpteksten/trade-in-human-organsand-trafficking-in-human-beingsan-exploratory-study-into-the-involvementof-the-netherlands-and-europe.pdf [E] http://hottproject.com/home.html [F] http://www.who.int/bulletin/volumes/85/ 12/06-039370/en/ [G] http://www.gfintegrity.org/wp-content/ uploads/2014/05/gfi_transnational_crime_ high-res.pdf [H] https://www.unodc.org/documents/ human-trafficking/2015/UNODC_ Assessment_Toolkit_TIP_for_the_Purpose_ of_Organ_Removal.pdf [I] http://hottproject.com/userfiles/ HOTTProject-TraffickinginHumanBeings forthePurposeofOrganRemovalAComprehensiveLiteratureReviewOnlinePublication.pdf [J] http://hottproject.com/userfiles/Reports/ 2ndReportHOTTproject-OrganRecipients WhoPaidForKidney TransplantsAbroad.pdf [K] http://hottproject.com/userfiles/Reports/ 3rdReportHOTTProjectTraffickinginHumanBeingsforthePurpose ofOrganRemoval-ACaseStudyReport.pdf The trade in human organs is a hot topic that receives increasing scrutiny from international organizations [A], the transplant community [B], researchers, and the popular press. According to the Council of Europe, the trade is growing worldwide [C]. Governments, international organizations, and transplantation societies are establishing new laws against organ trade or tightening existing regulations. Organ trade however receives little consideration from law enforcement authorities, and only few successful convictions have taken place [D]. In addition, there are no partnerships between transplant professionals and law enforcement. The HOTT project (2012-2015) is a European Union-funded international research that addresses “trafficking in human beings for the purpose of organ removal.” The project has 3 objectives: to increase knowledge, raise awareness, and improve the nonlegislative response. The project is coordinated by Erasmus MC in collaboration with 3 cobeneficiaries and more than 10 associate partners [E]. This article collates online resources with relevance to the readership of Transplantation providing guidance on the current state of organ trade. In 2007, the World Health Organization estimated that 5-10% of the approximately 60 000 kidney transplants performed annually around the globe occur via organ trade [F]. In 2011, the Institute, “Global Financial Integrity” ranked organ trade in the top 10 of the world's most profitable crimes, with an estimated annual illegal profit of US $614 million to US $1.2 billion. [G].How exactly these figures were established or validated is unclear. The World Health Organization indeed recognizes that the current state of organ trade remains obscure because of scarce data and acknowledges that figures should be regarded as “provisional and tentative.” The United Nations Office on Drugs

The trade in human organs is a hot topic that receives increasing scrutiny from international organizations [A], the transplant community [B], researchers, and the popular press. According to the Council of Europe, the trade is growing worldwide [C]. Governments, international organizations, and transplantation societies are establishing new laws against organ trade or tightening existing regulations.1,2 Organ trade however receives little consideration from law enforcement authorities, and only few successful convictions have taken place [D]. In addition, there are no partnerships between transplant professionals and law enforcement. The HOTT project (2012-2015) is a European Union-funded international research that addresses “trafficking in human beings for the purpose of organ removal.” The project has 3 objectives: to increase knowledge, raise awareness, and improve the nonlegislative response. The project is coordinated by Erasmus MC in collaboration with 3 cobeneficiaries and more than 10 associate partners [E]. This article collates online resources with relevance to the readership of Transplantation providing guidance on the current state of organ trade. In 2007, the World Health Organization estimated that 5-10% of the approximately 60 000 kidney transplants performed annually around the globe occur via organ trade [F].3 In 2011, the Institute, “Global Financial Integrity” ranked organ trade in the top 10 of the world's most profitable crimes, with an estimated annual illegal profit of US $614 million to US $1.2 billion. [G]. How exactly these figures were established or validated is unclear.4 The World Health Organization indeed recognizes that the current state of organ trade remains obscure because of scarce data and acknowledges that figures should be regarded as “provisional and tentative.” The United Nations Office on Drugs and Crime also affirms that “due to an absence of reliable information, the global scale remains unknown” [F, H]. Estimated numbers of unknown cases are an inherent part of crime research: with the prohibition of a particular act, numbers often drop. Noteworthy, this relationship is not linked to a decline but rather to the development of a black market. As a result, real numbers remain hidden from law enforcement authorities. The scale of the human organ trade will thus be unknown as long as it remains prohibited.5 Links [A] http://www.osce.org/secretariat/103393 [B] http://www.declarationofistanbul.org/ [C] https://wcd.coe.int/ViewDoc.jsp?id=2214787&Site=DC&BackColorInternet=F5CA75&BackColorIntranet=F5CA75&BackColorLogged=A9BACE [D] https://www.politie.nl/binaries/content/assets/politie/documenten-algemeen/onderwerpteksten/trade-in-human-organs-and-trafficking-in-human-beings-an-exploratory-study-into-the-involvement-of-the-netherlands-and-europe.pdf [E] http://hottproject.com/home.html [F] http://www.who.int/bulletin/volumes/85/12/06-039370/en/ [G] http://www.gfintegrity.org/wp-content/uploads/2014/05/gfi_transnational_crime_high-res.pdf [H] https://www.unodc.org/documents/human-trafficking/2015/UNODC_Assessment_Toolkit_TIP_for_the_Purpose_of_Organ_Removal.pdf [I] http://hottproject.com/userfiles/HOTTProject-TraffickinginHumanBeingsforthePurposeofOrganRemoval-AComprehensiveLiteratureReview-OnlinePublication.pdf [J] http://hottproject.com/userfiles/Reports/2ndReportHOTTproject-OrganRecipientsWhoPaidForKidneyTransplantsAbroad.pdf [K] http://hottproject.com/userfiles/Reports/3rdReportHOTTProject-TraffickinginHumanBeingsforthePurposeofOrganRemoval-ACaseStudyReport.pdf For these reasons, the HOTT project did not aim to establish how often organ trade occurs. Instead, we began our research by conducting a literature review on actors involved. The review, entitled, ‘Trafficking in human beings for the purpose of organ removal: a comprehensive literature review’ is based on a search of 5 databases in addition to screening more than 10 000 records. The review presents over 200 references on patients, donors, brokers, transplant professionals, hospitals, service providers, translators, and corrupt law enforcement officials who are involved in the network under which organ trade proliferates. The review describes, among others, how brokers recruit patients and donors, how much profit is made, where they travel to and from and to what extent organ sales constitute trafficking in humans. The review presents knowledge gaps due to a lack of ethnographic research into the experiences and motivations of patients that purchase organs and the modus operandi of trafficking networks. The authors conclude that “the scholarly research in this area is not well-developed” [I]. Subsequently, we conducted interviews with 22 patients from Sweden, The Netherlands, and Macedonia/Kosovo who purchased kidney transplants abroad. The aim of this study was to describe their motivations and experiences and to assess how their transplantations were facilitated. To date, this is the largest group of patients that has been interviewed on this issue. The patients provided information about their motivations for going abroad (eg, long wait time, dialysis-related complications, absence of a transplant programme, no living donor in domestic country, affiliations with destination countries, and so on). Practical arrangements that preceded their transplants mainly consisted of help from friends and family at home and abroad. The vast majority of recipients were satisfied with the care they received in the destination country. Nonetheless, 10 patients experienced severe complications ranging from a rupture of the bladder and perineal hematoma necessitating reexploration, severe rejections and infections (sepsis, Hepatitis C, tuberculosis and an infected kidney stone). Recipients, however, shared little information about whether their donors were paid and/or exploited. Thus, although this study has shed light on patients' motivations and experiences, we were not able to determine the potential illegal nature of their transplantations [J]. Therefore, we organized a case study research to acquire information about the modus operandi of organ trafficking networks and the facilitation of illegally performed transplants. We studied prosecuted cases in South Africa, Kosovo, Israel, and the United States by performing 37 interviews with 49 persons (police, prosecutors, lawyers, transplant professionals, government representatives, and so on). The aim was to describe how police and prosecution discovered each case, how they performed their investigations, what the modus operandi of the networks were, under what laws the prosecutions took place, what the successes and obstacles of law enforcement authorities were, and what the judgment in each case was. This study revealed, among others, sophisticated and subtle methods that trafficking networks use to recruit patients and donors facilitating illegal transplants. This case study also illustrated the difficulties that police and prosecutors experience in convicting networks and in proving that donors were exploited. They in particular encountered difficulties with prosecuting transplant doctors [K]. We presented the project's research results at its international symposium which was held at Europol's headquarters in The Hague, The Netherlands, in November 2014. The event was attended by more than 230 participants. We invited police and prosecutors from the United States, Kosovo, South Africa, and Israel to share their prosecution experiences. One day before the symposium, we organized a “Writers' Conference” where we invited 40 experts to formulate recommendations to improve the nonlegislative response to the crime. Experts convened in 4 groups and developed recommendations that addressed ethical and legal obligations of health care providers,6 the protection of victims,7 strengthening cross-border collaboration in criminal cases,8 and stimulating partnerships between transplant professionals and law enforcement.9 These recommendations highlight, among others, the need for transplant professionals to collaborate more closely with law enforcement. In particular, the transplant community can help improve the nonlegislative response by reporting organ trafficking networks to law enforcement authorities.10 The project's final report is a list of indicators for transplant professionals, law enforcement, and victim support workers based on the project's empirical data. Indicators aim to differentiate legal from illegal transplant activities and to support data collection and identification of trafficking in human for organ removal. The report identifies legal and illegal services provided for each step of the criminal process: recruitment, transport, entrance, documents, housing, transplant, aftercare, and finance.11 The project's reports have been sent to over 1000 of its stakeholders. They have also been posted on the project's website and will be published in a book of which 1000 copies will be distributed. In conclusion, the HOTT project has contributed to an increase in knowledge and awareness of trafficking in humans for organ removal among law enforcement and transplant professionals. Yet, creating awareness among these groups can only be done by ensuring that evidence-based information about the crime is made easily accessible and readily available. Moreover, an effective nonlegislative response cannot be successfully established if transplant professionals and law enforcement authorities do not collaborate. In addition to scholarly literature, a set of valuable online resources exist on the topic.

Frederike Ambagtsheer Erasmus MC University Hospital Rotterdam, The Netherlands Martin Gunnarson Lund University, Sweden Linde van Balen Erasmus MC University Hospital Rotterdam, The Netherlands Ninoslav Ivanovski University of St. Cyril and Methodius, Macedonia Susanne Lundin Lund University, Sweden Ingela Byström Lund University, Sweden Willem Weimar Erasmus MC University Hospital Rotterdam, The Netherlands