Human trafficking in humans for the purpose of organ removal for transplant emerged in the 1980s when renal patients from the Gulf States began procuring transplants in India with kidney providers recruited from impoverished rural villages and urban slums. Although many of these early transplant experiments in black market kidneys failed to produce positive outcomes, the demand was great and the medical and financial rewards were great for the brokers, the surgeons. Sick people, stranded on dialysis, remained desperate for a solution, and the poor, the displaced and the disposable populations could always be recruited to sell a kidney for a pittance to feed their children, build a home, buy a car, or bury a parent. Both the buyers and the sellers are trafficked by brokers, and both are coerced by desperation or despair. Both are exploited – the recipients will often pay as much as $100,000 for an illicit transplant; the sellers will often receive as little as $6,000, far more than they were promised.

Criminal networks of human traffickers facilitating illicit transplant surgeries depend on the coordination of five populations: (1) renal patients willing to travel, to pay a great sum of money and face great insecurity and uncertainty in getting a commercialized and brokered kidney or part liver transplant from a paid stranger; (2) young and reasonably healthy kidney suppliers; (3) surgeons willing to break the law and violate their professional codes of medical ethics; (4) transplant brokers, some of whom are doctors with international connections to hospitals, transplant units, and surgical teams, and police protection or at least police indifference; (5) human traffickers and enforcers who recruit poor people into the scheme and often travel with them to make sure the transplant takes place. These illicit transplant transactions are complex and require expert teamwork among technicians in blood and tissue laboratories, surgical teams and nephrologists, and nurses. Travel, passports, and visas must be arranged, and bodies need to be prepared, prepped and often coaxed to go through with the plans once they arrive and see that the conditions are not quite what they had expected.

Despite the best efforts of the WHO, the EU, and UNDOC, the UN Office on Drugs and Crime, to document and count the trafficking in humans for organs, organ trafficking remains a largely covert, protected and intractable crime. A conservative estimate is that some 10,000 living kidneys are trafficked and sold each year. But this consensus of the WHO, the EU and Organs Watch is very incomplete. What is difficult to discern are statistics regarding organ and tissue trafficking from the bodies of enemies caught in war zones such as in Syria and in Kosovo at the end of the Kosovo War (Scheper-Hughes, 2017). Some are medically executed for the rapid removal of organs that can be quickly sent to brokers and hospitals, some of them private and unregistered in Turkey.

Human trafficking for organs is a relatively small, discreet and complex form of human trafficking and therefore it can be contained. Unlike other forms of human trafficking involving drugs, sex, or small arms, human trafficking for the purpose of organ removal can be dealt with efficiently and completely if there was the political will to do so. There are many outlaw transplant surgeons, but none quite as bold and immune to prosecution and convictions as such as the infamous Israeli-Turkish transplant surgeon and organ trafficker, Dr. Yusef Sonmez. I will use him as an example of their perfect impunity.

Sonmez is an escape artist, having been indicted and convicted without ever having gone to prison. He is wanted in Kosovo and Turkey among other countries. In 2014, Sonmez escaped immediately after his conviction in the Pristina District Court in Kosovo for organized crime, organ trafficking, and illegal surgeries conducted on Serbs and other ethnic minorities nationalities. Today, the outlaw surgeon is living comfortably in the Netherlands, which has refused requests for his extradition by the Office for War Crimes.

I have followed and published articles on the organ trafficking career of Dr. Sonmez since 2001. He is untouchable. As Director of Organs Watch I visited the hospitals and clinics where Sonmez and his Israeli partner, Dr. Zaki Shapira, former head of transplant at Beilinson/Rabin Medical Center, Petah Tikva. The team has collaborated in illicit transplants in Istanbul, Moldova, Kosovo, Azerbaijan, Israel and in the United States in the early years. I have interviewed his associates, clients, and victims. There are many documented cases of their surgical handiwork that were so haphazard that recipients as well as trafficked sellers died within the year following the illicit back door transplants. Others died more slowly from infections acquired during the transplant or rejection of the purchased kidney. I talked to one of his recipient victims, Mr. Tati in Israel, as he was dying in the hospital having been sent back to Israel by emergency airlift from Turkey. In Moldova I encountered a young kidney seller victim from rural Moldova who was just 19 years old when he was recruited into a Sonmez-Shapira scheme. Vladimir died a few years later, pale and emaciated, of kidney failure resulting from his botched nephrectomy (kidney removal).

I protested in many articles the absurd statements Sonmez gave to the media that all his donors signed a declaration confirming that they donated their kidney for humanitarian purposes. If they sold for ‘humanitarian’ reasons it was to save their families from hunger. Sonmez appeared uninvited at a meeting of the association of European Transplant Coordinators in 2008 where he presented a PowerPoint in which he claimed having transplanted more than 2,000 clients with kidneys procured for cash from the wretched of the earth. At that bizarre transplant meeting Sonmez advised his fellow transplant colleagues to opt out of the legal transplant regulatory system limited to deceased donor organs and altruistic living donors. It was more precise and scientific, he argued, to take fresh organs from living paid donors who are right in front of you, warm and breathing. No time on ice is necessary thus improving the quality of the ‘product’. Sonmez denied that tissue typing and even compatible blood types were necessary and could be over-ridden by massive doses of immune suppression drugs. When Dr. Igor Codreanu, the TTS (The Transplant Society) country leader for Moldova, questioned Sonmez about the post surgical risks of his kidney sellers, Sonmez flashed his audacious smile and replied: ‘They are not patients; they are paid suppliers and I have no responsibility for them. It was their choice’. The New York Times defended Sonmez (www.nytimes.com/2011/02/11/world/europe/11organ.html) who continues to give interviews to the newspapers and anthropologists like me.

There are brokers who are less rapacious like Gaddy Tauber, a 70+ year-old retired IDF military officer in Israel who teamed up with a retired Brazilian military officer, Ivan Bonifácio da Silva, in Recife where they operated large scheme to transport poor Brazilians to Durban, South Africa to provide kidneys to international transplant tourists, most of them from Israel. Tauber and da Silva were caught in Brazil and convicted under the UN Palermo Protocol against human trafficking for organs and given a stiff sentence of eleven years. I visited Gaddy in prison over two summers and found him to be a unique and thoughtful person who accepted his guilt but who argued rationally for a reasonable alternative of regulated kidney selling using Iran as his example.

In 2009 I received a telephone call from Tauber telling me that he was on parole and allowed to return to Israel. He gave me an address and phone number of his close friend ‘Suki’. I was delighted to visit Gaddy who was happy to be home in his seaside community. At that time I was working with Dan Rather and his crew on a TV documentary about organs trafficking, ‘Kidney Pirates’. Tauber refused an invitation to tell his story on screen again. He was done with organ trafficking, which he said he had always found very repulsive. But he argued that the opportunity to sell a kidney provided a small opportunity for the poor Brazilians he had recruited, some of whom took up the offer not so much for the small cash payment but for the opportunity to travel by air to South Africa. I found this to be true when I interviewed a dozen of Gaddy’s ‘boys.’

Gaddy refused to be separated from the kidney sellers when they were imprisoned, though briefly and he stayed in touch with them. It is true that some of the Brazilian sellers had taken their chances in the kidney trade to see the world, even if it was from a hospital bed in Durban. They came home with very little money but had a lot of stories and photos of semi-clad African dancers and wild animals like giraffes and rhinos. They liked African people but hated the food, although I told them that all they ate was hospital canteen food.

Gaddy and I chuckled about the resilience of the Brazilian sellers. But I should have been aware of the resilience of the Israeli brokers, dozens of whom I had met and interviewed, and one or two, like Gaddy and Shelly G, whom I found to be honest and forthright about their work, even if it was criminal. On our last visit in Israel, Gaddy warned me to stay away from the new generation of brokers who were cutthroats and dangerous, as our Dan Rather film team quickly learned after an incident where we were tackled to the ground and had our cameras broken. What I didn’t know, however, until a year later was that Gaddy Tauber had not been released by the Brazilian justice system and had in fact escaped while on parole. I saw his face appear on the nightly news in 2012 when he got caught by airport police in Rome when returning from a visit in the United States. He was extradited to Brazil, but no one seems to know where he is.

Although new laws have been passed in some countries like Egypt and Israel, to facilitate deceased donation and criminalize human traffickers, illicit transplant trafficking schemes remain robust, exceedingly mobile, resilient, and generally one-step ahead of prosecutors. The new generation of human traffickers for transplant is also more ruthless. The sites of illicit transplants have expanded within Asia, the Middle East, Central and Southeast Asia, Eastern Europe, Central and Latin America, Europe, and the United States.

Until recently questionable transplants between foreigners from different countries using a third country’s transplant units took place in plain view. Mr. Isaac Rosenbaum (see Scheper-Hughes, 2012), a real estate broker began brokering kidney sellers (described in his correspondence with the traffickers in Israel as ‘water filters’) found among the new immigrants to Israel from Moldova, Romania, Russia, and the Ukraine as well as among Arab minorities. The surgeons at many hospitals in New York, New Jersey, Philadelphia, welcomed Rosenbaum and Baltimore and he walked the floors of the transplant units dressed in scrubs and was invited to observe the transplants of his clients. Today, the brokers are aware of the possibilities of police stings and arrests and they have adjusted their modus operandi accordingly. They arrange new and very secret locations with short-term engagements, always prepared to flee to one of dozens of other sites that have been prearranged. As for the kidney sellers, they can be found in almost any nation. One crisis after another has supplied the market with countless unemployed and undocumented workers and political or economic refugees. They are recruited via deceptive tactics, and they are accompanied to the operating theatre by an enforcer who makes sure the seller does not escape.

Prosecutions are hindered when judges, prosecutors, crime detectives, or the police find it difficult to see male kidney sellers (the majority) as victims of trafficking. Sellers often admit that they wanted to sell a kidney, or as one of the Brazilian sellers trafficked to Durban in the Netcare case (see p. 2) told Judge Amanda during the trial of the organs traffickers and their associates in Recife, Brazil in 2004 that he did what he needed to do: ‘What father would not be willing to sell a kidney or a lung or part of his liver to save his wife and children from becoming homeless?’ (Scheper-Hughes, 2011). In rural Moldova the men who were recruited by local traffickers to sell a kidney abroad (Turkey, Russia) hid their stories of exploitation and humiliation. The shame was so great that they even refused to go to medical clinics or hospitals when suffering from problems of hypertension, pain, weakness, and suicidal ideation. Kidney selling is primarily a traffic in young and healthy men, especially in the Americas (Canada, US, Central America and South America), Eastern Europe (especially Moldova, Romania, Russia), the Middle East (Egypt, Turkey, Israel) and the Philippines.

In most of the prosecutions to date only a few culprits, usually the lower ranking brokers and kidney hunters, some of whom were former kidney sellers themselves are convicted. The surgeons, without whom no organs trafficking crimes could be facilitated, and hospital administrators escaped prosecution after claiming being unaware of the infiltration of international schemes and brokers in their hospital and surgical wards. In the South African Netcare Case the esteemed status of the surgeons and nephrologists involved in illegal transplants even influenced the prosecutors and the judge. A total of 109 illicit transplants were performed at Saint Augustine’s Hospital, including five cases in which the donors were minors. A well-planned police sting resulted in several plea bargains from various brokers and their accomplices. Netcare, the largest medical corporation in South Africa, pleaded guilty for having facilitated illegal transplants, paid a large penalty and saw their stock plummeting and caricatures of greedy transplant surgeons regularly appearing in political cartoons in the daily newspapers. The four surgeons and two transplant coordinators stuck to their not guilty plea, saying that they were mere technicians who had been deceived by the Netcare corporation and its lawyers. In December 2012, they were given a permanent stay of prosecution and the State was ordered to pay for their legal costs. It would be fair to say that rogue transplant surgeons operate with considerable immunity. This is an unfortunate state of affairs because the surgeons constitute the primary link in the transplant trafficking business.

During a meeting of a special WHO committee looking into the global traffic in organs, a frustrated British Interpol officer asked why the committee was focusing on kidney sellers and brokers rather than kidney buyers who also break the law and even more the key players in these illicit transplant scheme, the surgeons. ‘Who’s got the knife, mates?’, the officer asked. I thought it was a brilliant question to ask. I did once write an article on the role of surgeons in illicit transplant operations which was rejected by the editors of a special issue on human trafficking in the journal, Social Science & Medicine. The failure to identify and prosecute the outlaw surgeons and nephrologists involved in illicit transplant schemes remains the largest obstacle to eradicate the traffic in organs.  

Organ trafficking is by and large still a protected crime because it benefits some very sick people at the expense of other, more dispensable people. The result is that prosecutions are generally very weak and some state prosecutors and judges have treated the exploitation of sellers as a victimless crime. Such was the case in the Rosenbaum sentencing when the judge could not believe that academic and private hospitals and surgeons had been complicit with an international human trafficking scheme or that the young black Israeli kidney seller who testified at the hearing had been deceived, manipulated and coerced by Rosenbaum and his handlers. The judge saw the seller as a co-conspirator with the trafficker and his client. ‘You all got something out of this’, the judge concluded. The frightened and trafficked young African-American kidney seller who was living in a closed community of Black Hebrews in Israel and hauled into the Trenton federal court in 2012 confirmed that he had agreed to the donation but he had done so because he was desperate, unemployed, and alienated from his family and his Black Hebrew community. He began to lose faith in Israel, his adopted country, and hoped to do a meritorious act to improve his social standing. On arrival at the transplant unit, however, Mr. Quick had misgivings and asked the man who accompanied him (his ‘enforcer’) if he could get out of the deal because he had changed his mind. These were the last words he uttered before going under anesthesia.

Mr. Quick’s amazing testimony had no impact whatsoever on the judge. The Rosenbaum case was prosecuted as a felony but one that was a regulatory violation of the law against the US law 42 U.S. Code 274e, that prohibits ‘any person to knowingly acquire, receive, or otherwise transfer any human organ for valuable consideration for use in human transplantation if the transfer affects interstate commerce’. It was the kidney that was at stake, not the trafficked person who provided that kidney. Mr. Quick was quickly dispensed with and is still suffering the impact of his unfortunate decision and scorn by his family and friends. ‘I am treated like a pariah’. Meanwhile, Mr. Rosenbaum was cheered on by a court filled with supporters, including some who had flown all the way from Israel to praise his work on behalf of sick Israelis who could not find a living donor among their family or friends at home and who were too old and too sick to get a diseased donor organ. Obviously much more work must be done to educate law enforcement and the criminal justice system about the serious medical, social, and psychological effects and consequences of human trafficking for organs from living suppliers who are deceived, cheated and coerced with few defenders.

However, if we are talking about how to end the crime of human organ trafficking, brokers are not the key stakeholders to prosecute. Convicted brokers and their kidney hunters are easily replaced by other criminals – the financial rewards of their crimes ensure that. Hospitals and surgeons need to be held accountable in future prosecutions. In some cases this will require new laws informed by the knowledge produced by medical anthropologists, social scientists, legal scholars and criminologists. It will require a much needed change in international bodies like the UN and the EU so as to take concerted action on the new legal frameworks needed to prosecute the guilty parties in these international crimes.

Until then, the kidney will remain the ‘blood diamond’ of our times. Trafficking in humans for organs is one of the more egregious examples of pure exploitation where poor peoples’ bodies, their organs are trafficked to the benefit of those who are sick and often very old and willing and able to pay a small fortune for extend their lives.

There is another possibility that has often come my way: ‘Don’t criticize, legalize’. There are many bioethicists, economists and policy-makers who argue that the sale of organs is the best rational solution to the perennial shortage of organs, a term that turns my stomach, in so far as it implies that our second kidney, or lung is superfluous and a new ethical mandate – the obligation to give up a so called spare kidney. ‘You want my kidney? But I am still using it!’. But if it should come to that – and I hope it does not – we need a few basic principles. Let me suggest some.

Transplantation must be based on values of fairness, dignity, solidarity and transparency. Nations should strive for organ self-sufficiency and not look to poor nations for the supply of fresh organs. Kidney transplants between living non-blood relatives should be contained within national borders to prevent the tragedy of human trafficking for organ procurement.

If compensated kidney donation is something a democratic nation’s people can live with, then each nation, or each state, must create its own regulated system (similar to that of Iran) in which living, unrelated organ providers are compensated for an act of kindness and solidarity for another citizen. The system should be aware of vulnerable individuals who should be screened out of selling: the homeless, the mentally fragile or incompetent, the black sheep of the family or community looking for validation, the hopeless, the hapless and the unhappy, as well as those who have been trafficked from abroad or are political refugees, new immigrants or guest workers.

Compensated donors should be treated with respect and receive proper medical surveillance before, during and after surgery. There needs to be an organ providers’ bill of rights. Patients must be informed of the potential long-term risks – medical, social, economic and psychological. They need to be protected from being treated like living cadavers, containers of recyclable biological and medical material and energy to be siphoned off to the highest bidder.

Even a regulated system will have to rely on ‘matchmakers’ and intermediaries. Hospitals and transplant teams should not be the organ brokers in the legally mandated paid donation of living people’s organs. Transplant teams in the US have failed to identify cases where force, coercion and fraud have motivated seemingly willing and informed consent to forfeit an organ. Public committees should approve compensated kidney donors following strict government guidelines.

Beyond that, compensated kidney providers need independent advocates as guardians of their bodies. These advocates should have nothing to do with the medical or financial aspects of the organ transplants, and can verify that the compensation is equitable, just, voluntary and there are no other social, material or psychological reasons for prohibiting the sale. Kidney sellers constitute the poorest, weakest and most vulnerable stakeholders with little or no bargaining power. They need unions and collective bargaining. They will all require adequate medical insurance – for the rest of their lives.

If, in the meantime, you are still determined to pay someone for a kidney (or for a liver lobe) then, before looking for a stranger from a foreign land, look closer to home and pay someone you know, someone you care about, someone you will be in contact with should his health fail. You cannot put a price on life, but you can exchange money within a regulated system that acknowledges the need for mutuality, trust and care. People do this within their families and friendships. Anthropologists call it open-ended reciprocity and it is what makes social life possible and meaningful. The money is not the issue; it is the downgrading of the donor from a life-sharer or lifesaver to a commodity, a living body providing spare parts.

Present Options and Futures

A current option is the universal donation of organs and tissues at death unless one actively opts out – with a guarantee of equal access regardless of socio-economic background. This ‘green’ option requires re-imagining the deceased body as a commons, a site of compassionate social solidarity that has been trampled over by the dominant market-oriented view of the body as commodity.

What else can we hope for? Stem-cell research that will lead to the development of artificial kidneys, xenotransplantation – kidneys from pigs, although unsuccessful so far. Experimental new biotechnologies that could lead to artificial, 3-D copy kidneys.

But don’t forget that the real answer to kidney disease is a strong public health system that identifies and provides early intervention for diseases like type-2 diabetes that are simultaneously ‘epidemic’ and preventable. Providing support in the poor parts of the wealthy world, where kidney disease is caused by polluted water supplies, contact with toxic waste, and environmental degradation. Clean water is a primary necessity for healthy kidneys, as is universal healthcare and early diagnosis.

Kidney buyers have it right – kidneys are a valuable human resource without which the end-stage kidney patient is adrift in an existential hell. They deserve compassion and best medical care available. Transplantation is a valuable but last resort treatment. So I have suggested an organ donor’s bill of rights.

The Organ Donors Bill of Rights

1. All humans have the right to bodily integrity.
    
2. Organ harvesting should be considered in terms of a post-Cartesian notion of the person. Not ‘I think, therefore I am’ but ‘I am self-consciously embodied, therefore I am’.
    
3. Recognize organs as one’s birthright, one’s bodily inheritance.
    
4. Recognize that there are no ‘spare’ organs.
    
5. Green donation (deceased donors) should be the default system. Red donation (living donors) should be viewed as the exception, not the rule. Living donation should be acknowledged as a major sacrifice and not as a moral imperative.
    
6. Establish safeguards that recognize the existence of vulnerable donor populations – young people, the unemployed, prisoners, the mentally ill, guest workers, the uninsured, economic and political refugees, those in debt.
    
7. Establish a principle of solidarity with the weak, the frail, the sick and the existentially shaken, both kidney patients and kidney sellers.
    
8. Recognize that the consequences and scars of kidney selling are often hidden. Living unrelated donors – paid or unpaid, altruistic and family members – can feel used and ignored, deprived and worthless and empty, following kidney removal and partial liver donation.
    
9. While altruistic living donation is permissible and ethical, an independent donor advocate should represent the living donor.
    
10. No living organ donation by persons without medical insurance.

References

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