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A Closer Look at the Iranian Model of Kidney Transplantation a

Kiarash Aramesh a

Tehran University of Medical Sciences Published online: 17 Sep 2014.

To cite this article: Kiarash Aramesh (2014) A Closer Look at the Iranian Model of Kidney Transplantation, The American Journal of Bioethics, 14:10, 35-37, DOI: 10.1080/15265161.2014.947044 To link to this article: http://dx.doi.org/10.1080/15265161.2014.947044

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Kidney Vendors in Regulated Organ Markets

sold a kidney. Buyers regularly publish organ classifieds in major newspapers for soliciting organs, and brokers have expanded their networks from local to national to international levels. Such profound violence, exploitation, and suffering would be rife in the regulated or rampant commerce of organs. In sum, after selling their vital organs, the health of sellers is compromised, their economic situation has worsened, and their social status has declined (Moniruzzaman 2012). The outcomes of organ selling are invasive, harmful, and devastating. As seller Koliza said with regret, “I donated my liver lobe to: i) live better, ii) save a life, and iii) satisfy God. In the end, my recipient died after a month and I could not escape the clutches of poverty. If I had a second chance in life, I would not sell my body parts, nor let others die inside out from it.” It can therefore be argued that a regulated organ market is not the solution, but rather, the strict criminalization of the organ trade is ethically and pragmatically essential. As Koplin notes, a regulated organ market would improve vendors’ well-being or minimize their harms lack evidential warrant. Such a system does not speak to the lives of the economic underclass, but rather seriously discriminates against them. It promotes the value of individual autonomy, but puts minimal emphasis on beneficence and justice to organ sellers. We ought to oppose the organ market in order to curb this illicit practice. &

The Daily Star. 2014. Killed for kidneys. May 01, Dhaka, Bangladesh. Available at: http://www.thedailystar.net/killed-forkidneys-22349 Delmonico, F. 2008. The development of the declaration of Istanbul on organ trafficking and transplant tourism. Nephrology, Dialysis, and Transplantation 23(11): 3381–3382. Hamdy, S. 2012. Our bodies belong to God: Organ transplants, Islam, and the struggle for human dignity in Egypt. Berkeley, CA: University of California Press. Koplin, J. 2014. Assessing the likely harms to kidney vendors in regulated organ markets. American Journal of Bioethics 14(10): 7–18. Moazam, F., R. Zaman, and A. Jafarey. 2009. Conversations with kidney vendors in Pakistan: An ethnographic study. Hastings Center Report 39(3): 29–44. Moniruzzaman, M. 2012. “Living cadavers” in Bangladesh: Bioviolence in human organ bazaar. Medical Anthropology Quarterly 26 (1): 69–91. Muzaale, A., A. Massie, M. Wang, et al. 2014. Risk of end-stage renal disease following live kidney donation. Journal of the American Medical Association 311(6): 579–586. Scheper-Hughes, N. 2011. The body in tatters: Dismemberment, dissection, and the return of the repressed. In A companion to the anthropology of the body and embodiment, ed. F. Mascia-Lees, 172– 206. Malden, MA: Wiley-Blackwell. Titmuss, R. 1970. The gift relationship: From human blood to social policy. London, UK: New Press.

REFERENCES Cohen, L. 2003. Where it hurts: Indian material for an ethics of organ transplantation. Zygon 38(3): 663–688.

Zargooshi, J. 2001. Quality of life of Iranian kidney “donors”. Journal of Urology 166:1790–1799.

A Closer Look at the Iranian Model of Kidney Transplantation Kiarash Aramesh, Tehran University of Medical Sciences In his arguments against the claim that “kidney sellers would benefit from paid donation under a properly regulated kidney market,” Koplin (2014) has presented the Iranian model of kidney transplantation (IMKT) as an example of regulated system for donor compensation. In the past 8 years, through my engagement in the field of medical ethics in Iran, I have been in close contact with the IMKT. Although this model was successful in providing vital care for thousands of desperate patients, it has always been surrounded by ethical controversies and debates (Aramesh 2009). A huge body of literature has

been created by the proponents and opponents of this model, including some descriptive studies. As Koplin mentioned, some degrees of discrepancy exist in the published results of these studies. I believe that parts of both the critics and defenders have been influenced by their general views toward the Iranian health system at its large scale; even descriptive reports do not seem to be free of such influences. For example, the most cited article against the IMKT that has been conducted in a city in a western province of Iran has used a lot of banned newspapers as its references (Zargooshi 2001). While reports with more

Address correspondence to Kiarash Aramesh, Tehran University of Medical Sciences, Medical Ethics and History of Medicine Research Center, 16 Azar St., No.23, 4th floor, Tehran, Iran. E-mail: [email protected]

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promising and optimistic results are usually authored by proponents of the IMKT, some of them have been practically engaged in different aspects of the IMKT (Malakoutian et al. 2007). Therefore, part of the discrepancies among reports and results originating from inside Iran can be attributed to such influences and even biases. According to the formal formulation of the IMKT, every patient who is diagnosed as a candidate for getting a kidney transplant and every person who wants to donate (actually, sell) his or her kidney should register at the Iranian Patients’ Kidney Foundation. In Iran, the word that is used for kidney vendors is “donor”; therefore, in this article, in describing the IMKT I use the same word although the donors are actually vendors. After initial evaluations and obtaining the related consents, the foundation introduces each matched pair (recipient and donor) to each other, and they negotiate the amount of money the recipient should pay (Mahvadi-Mazdeh 2012). After the transplantation is completed, a nongovernmental organization (NGO) named the Charity Foundation for Special Diseases is responsible for providing monetary compensation (namely, the gift for altruism, which is provided by the government) and a 1-year medical insurance for donors, which is an addition to the informal payment agreed upon beforehand in the mentioned negotiations. All the transplantation centers in the country are located at university hospitals and are under the scrutiny of the Ministry of Health and Medical Education. One of the main differences between the IMKT and other models based on organ market in developing countries is that in the IMKT, the medical team has no share from the money paid by the recipient to the donor (Mahdavi-Mazdeh 2012). As a regulated model, the IMKT has always been proud of its own advantages, including the following: 1. Elimination of the waiting list for kidney transplantation, which can be considered the most prominent achievement of the IMKT (Ghods and Savaj 2006). Although other reports have called this claim into question, (Griffin 2007), it is obvious that candidates for kidney transplantation get the required organ shortly after registration in the official waiting list, provided that they can pay enough money to find an organ donor, which, given the relatively low prices, is affordable for most patients in need (Malakoutian et al. 2007). 2. Elimination of kidney black market, which is one of the main features that makes the IMKT different from the other kidney transplantation programs in the developing countries mentioned by Koplin. This claimed elimination of brokers in the domestic market is owed to the role played by the Iranian Patients’ Kidney Foundation in introducing the potential recipients and donors to each other for face-to-face negotiation; there is almost no place for brokers in this system (Larijani et al. 2004), although recently some unproven reports onf kidney brokers have appeared in journals. Also, it is impossible to transplant a kidney from an Iranian donor to a foreigner recipient because according to law, if any

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foreigner person wants to get a kidney transplant in Iran, his or her donor must be of the same nationality (Mahdavi-Mazdeh 2012). The IMKT also has its own widely discussed disadvantages; among them are: 1. Commercialization and commodification: The direct monetary relation between kidney donors and recipients is the most debated ethical issue of the IMKT (Griffin 2007). Some authors argue that the demonstrated similarity of socioeconomic status of donor and recipient populations in Iran proves that the exploitation of the poor by the wealthier part of the society does not occur in the IMKT (Mahdavi-Mazdeh 2012). Ethically speaking, however, merely this similarity does not exclude the ethical concerns; it just keeps the price of organ low! 2. Exploitation of the poor: In the absence of financial desperation, nobody wants to sell his or her kidney. Therefore, the burden of commercialization of the human kidney is placed on disadvantaged social groups and the poor. In some cases, families encountering a financial problem expect the husband or father (and sometimes other members of the family) to sell his kidney to solve or alleviate the problem (Zargooshi 2001). Although informed consent is obtained from all donors, nobody can ignore that the main drive behind kidney donation in IMKT is financial. 3. Stigmatization of donors: Organ donors are considered organ vendors with no honor; therefore, they tend not to reveal their true identity and address to the hospital’s administration, which makes their medical follow-ups almost impossible (Zargooshi 2001), which, at the end of the day, shapes a major disadvantage of the IMKT (Mahdavi-Mazdeh 2012). 4. Suppression of altruistic donation: The loved ones of patients who need kidneys for transplant prefer to buy a kidney for their patients rather than donate their own kidneys. Also, the stigmatization surrounding the organ donors as organ vendors lowers the rate of altruistic donation in the society (Zargooshi 2001). The IMKT is an established model of regulated nonrelative live-donor kidney donation, and is obviously superior to its market-based counterparts in other developing countries. It shows that establishing a regulated market can eliminate or alleviate some major flaws attributed to market-based organ transplantation models. However, as Koplin describes, this model still has its own ethical disadvantages, which makes it less than credible for being proposed as a perfect model for other countries. The IMKT, however, should not be considered the only possible model for regulated market for organ transplantation, since at least some of its imperfections can be attributed to factors that are not inherent to the model of regulated market but are results of general economical and social (and subsequent cultural) issues that exist in a developing country. These issues include general shortcomings and

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Kidney Vendors in Regulated Organ Markets

deficiencies in social welfare, questions about the validity and comprehension of the obtained informed consents, and some inadequacies in observing patients’ rights (especially for the poor and minorities) in health care facilities in developing countries like Iran (despite the major steps taken forward in recent years, like compiling and formal announcement of the Charter of Patients’ Rights by the Iranian Ministry of Health). Designers of the IMKT have tried to deal constructively with some of these issues. For example, in an attempt to make the donation a consensus decision of the family, and as a unique feature of the IMKT, consent is being taken from both the donor and his or her spouse in the case of married donors (Mahvavi-Mazdeh 2012), which, of course, does not resolve the issue of financial coercion. As a final conclusion, given the major advantages of the INKT and the possible attributing of part of its ethical flaws to general conditions of a developing economy, one can argue that a revised and improved version of the IMKT can still be considered as a solution for long waiting lists of organ transplantation in developed countries. For instance, developing a model of indirect and regulated payment from recipients to donors can be considered as a possible solution for the future. &

REFERENCES Aramesh, K. 2009. Iran’s experience on religious bioethics: An overview. Asian Bioethics Review 1(4): 318–328. Ghods, A. J., and S. Savaj. 2006. Iranian model of paid and regulated living-unrelated kidney donation. Clinical Journal of the American Society of Nephrology 1:1136–1145. Griffin, A. 2007. Kidney on demand. British Medical Journal 334:502–505. Koplin, J. 2014. Assessing the likely harms to kidney vendors in regulated organ markets. American Journal of Bioethics 14(10): 7–18. Larijani, B., F. Zahedi, and E. Taheri. 2004. Ethical and legal aspects of organ transplantation in Iran. Transplantation Proceedings. 36:1241–1244. Mahdavi-Mazdeh, M. 2012. The Iranian model of living renal transplantation. Kidney International. 82:627–634. Malakoutian, T., M. S. Hakemi, A. A. Nassiri, et al. 2007. Socioeconomic status of Iranian living unrelated kidney donors: a multicenter study. Transplantstion Proceedings 39:824–825. Zargooshi, J. 2001. Iranian kidney donors: Motivations and relations with recipients. Journal of Urology 165:386–392.

The Truth About Iran Sigrid Fry-Revere, Stop Organ Trafficking Now! Koplin’s article is well written but unfortunately suffers from numerous factual and conceptual errors. In this piece I will concentrate on two: his failure to understand the limitations of the data he relies upon to support his thesis and his failure to include the most recent literature on Iran. I will also briefly set the record straight on some major points about the Iranian system of compensated donation. Koplin relies primarily on the work of Javaad Zargooshi who did most of his research in the 1980s and 90s and whose data are limited to the region of Kermanshah. Koplin’s strong reliance on Zargooshi’s work is a fatal flaw because Zargooshi collected his data before Iran became a regulated market. The kidney sellers Zargooshi interviewed were people who had donated before the Iranian government began to regulate kidney sales (Fry-Revere, 2014, pp.176-178). As a result, Koplin is comparing a black market to a legal, but unregulated market. If that is the comparison (an illegal market vs. an unregulated market) then, I, for one, agree – there really isn’t much difference between the two as far as compensated donors are concerned. It would be far more meaningful to compare black market kidney sales in Pakistan, India, or the Philippines

to the way in which compensated donation is currently done in the Iranian provinces of Isfahan and Razavi Khorasan (the province where Mashhad is located). Those provinces not only have the legal protections Iranian law provides all compensated donors, but also take their obligations to donors so seriously that they provide donors with all the same types of services available to recipients. Koplin fails to disclose that Zargooshi’s donor data are more than 20 years old or that Zargooshi draws all his data exclusively from a severely economically depressed part of Iran. Relying on Zargooshi’s limited data to describe the current Iranian system of compensated donation is like generalizing about the state of healthcare in the United States today based on data collected twenty years ago in rural Alabama. Koplin neglects to cite the dozen or more works written specifically about living organ donation in Iran since 2008. Although he mentions a few Iranian authors other than Zargooshi, Koplin fails to point out, that although these authors are somewhat critical of the Iranian system, their conclusions are generally positive. Koplin might have mentioned to his advantage articles by Fallahzadeh,

Address correspondence to Sigrid Fry-Revere, Stop Organ Trafficking Now!, 1433 Longfellow Street NW, Washington, DC, 20011, USA. E-mail: [email protected]

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A closer look at the Iranian model of kidney transplantation.

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