Since June, two kidney rackets have been busted in two prominent private hospitals in Delhi and Mumbai, raising questions over the illegal trade of organs in the country and whether doctors, state health authorities and hospitals are equipped, or even willing, to tackle this problem.
The Transplantation of Human Organs and Tissues Act, 2011, governs the transplantation of organs and tissues in India. It has laid down strict procedures to verify if organ donors are genuine, and are not donating in exchange for payment, which is forbidden.
It is no wonder then that Dr Tarun Seem, secretary, health and family welfare, Delhi government, seemed genuinely puzzled at how the racket at Delhi’s Apollo hospital, which was busted in June, was operating.
“It is like the perfect murder,” he said.
Similarly, last week, in Mumbai, the police busted another illegal kidney transplant racket at the LH Hiranandani Hospital after a tip-off.
High demand, less supply
According to the transplant law, organs for transplants can be retrieved in the following ways:
- Through cadavers or brain dead patients, with the consent of their families
- From living donors who include spouse and blood relations above the age of 18.
- From living donors who donate out of love and affection for the patient, without any commercial motive.
- Swap donors in which a willing close-relation donor, who is incompatible with the patient, exchanges his or her kidneys with another donor and recipient pair. For instance, in a swap case, patient A’s wife X donates a kidney to patient B, and patient B’s husband Y donates his kidney to patient A.
Organ donation in India
India has a very poor organ donation rate with just 0.26 per million as compared to America’s 26, Spain’s 35.3, and Croatia’s 26.5 per million, according to a report released by the Chennai-based Mohan Foundation in association with Delhi’s Parashar Foundation – both non-profit organisations that focus on organ donation in India.
Organ donation scams are often attributed to the desperation of people in need of transplants.
In India, nearly 2 lakh people need a kidney every year, and about a lakh need a new liver. In Mumbai, there are more than 2,000 patients waiting for a cadaver transplant.
The number of organ transplant surgeries in the country is between 3,500-4,000 each year, a small percentage of which are cadaver transplants (India does not have a national registry recording this information yet.)
In comparison, in the United States, in the last six months, 62% of organ donations are from cadavers.
In a 2009 paper in the Indian Journal of Medical Ethics, Dr Sunil Shroff of the Mohan Foundation argued that the high demand for organs in India had led to “its commodification”, which was more prevalent in countries that had weak regulatory bodies and a large proportion of the population below the poverty line.
Painstaking verification procedure
In Delhi, there were four cases of illegal transplants, Dr Seem said.
Two were disguised as regular cases of donation – where a close relative donates, while the other two were the more complex swap cases.
According to the law, cases of regular donation are decided by a committee at the hospital level itself. The committee comprises the hospital management, its doctors (other than those treating the prospective organ recipient) and a member of the Directorate of Health Services.
The committee looks at all documentary evidence related to the relationship – birth certificates, marriage certificates and photos. Sometimes, it even orders a DNA test if there is suspicion that the donor is not a close relative.
Swap cases, as well as living donations made by unrelated persons out of love and affection for the patient, are decided by state-level authorisation committees, which include members of the Directorate of Health Services, social workers, and legal experts.
In case of donations made out of love and affection, the committee is supposed to interrogate the donor and the patient on the attachment between the two. It has to examine that there is no commercial transaction between the recipient and donor, and an explanation has to be sought about the circumstances that led to the offer of donation being made.
The donor-recipient may also have to provide evidence of their relationship, such as photographs. The donor’s financial status is examined to check for any disparity between the financial status of the donor and patient to rule out the possibility of it being a commercial transaction. Even relatives of the donor are examined to check if they are in agreement about the donation.
The proceedings of these committees are video-recorded.
Forgery an issue
In both the Delhi and Mumbai cases, the documents submitted to prove that there was a relationship between the donor and the patient were forged, said the police.
For instance, in the Mumbai case, the patient had allegedly found a willing donor for payment and forged documents to show that the donor was his wife.
According to The Indian Express, the hospital insisted that it was not responsible for verifying documents submitted by donors.
Dr Sujit Chatterjee, the chief executive officer of the hospital, told The Indian Express: “Notaries [affidavits] have been submitted. Now, who are we to contest these items? The government should also check how to streamline this… We go by exactly each letter of the law.”
Hospitals and doctors unaware?
But is it really that easy to fool hospital administrations and committees?
“Usually, the hospital can identify the donor,” said Dr Sujata Patwardhan, general secretary of the Zonal Transplant Coordination Committee, Mumbai, who has conducted transplant surgeries. “We usually know the patient for 3- 6 months before the transplant takes place. If it is a false donor, we would know. It is not so easy to fool us.”
Earlier, there were several cases in which the unrelated live donor was found to be a poor person willing to sell his or her kidney, but that has reduced in recent years.
“I think it is more stringent as compared to earlier,” said Dr Sanjay Nagral, a liver transplant surgeon who practices in Mumbai. “The committees are more careful. I used to sit in the Jaslok Hospital [Mumbai] Committee earlier, and in my view, it is not difficult to find out if the donation is made by a genuinely close relative or someone else.”
Dr Amar Jesani, the editor of the Indian Journal of Medical Ethics, pointed to the conflict inherent in private hospitals approving cases for donation as it is these cases that get them more transplant surgeries, which is income for hospitals.
Who takes responsibility?
In the Delhi and Mumbai kidney scams, the appropriate authority under the Transplantation of Human Organs and Tissues Act were the health authorities of the respective state governments.
The transplantation Act confers upon health authorities the powers of a civil court. This means they can summon persons who can inform them about illegalities related to the Act, or even issue a search warrant for any place where persons are suspected to be indulging in unauthorised organ retrieval and transplant.
But despite being thus empowered, both the Delhi and Mumbai cases were detected by the police, not by health authorities.
The doctor’s community is a closed one, and it is usually the medical fraternity itself that is more likely to know of such illegalities as compared to the police.
At the national level too, there is not much accountability.
When asked about action that could be taken after the Delhi kidney racket was busted, Dr Anil Kumar, national programme officer, National Organ and Tissue Transplant Committee said: “We read that story in the newspaper. It is under the jurisdiction of the Delhi government. We do not come in the picture at all. We only work on the policy level.”
And does the body get any information about doctors and hospitals involved in any such illegalities? “We do not have machinery to deal with that,” said Dr Kumar. “If we do get a complaint we forward it to the Prime Minister’s Office.”
A few years ago, the National Organ and Tissue Transplant Committee managed to shut down a website that openly offered patients donors for a price. But though the committee wanted to take action, it was unable to do so. “We do not have any machinery to do that,” said Dr Kumar.
With almost all parties – hospitals, doctors and state health authorities – passing the buck, the question is: who will take responsibility for the illegal trade of organs in the country?