Building a Public Health Response to Organ Transplant Abuse in China

  • Date: Oct 24 2020
  • Policy Number: 202010

Key Words: Global Code of Practice, Ethics

Organ transplants in China have been conducted on-demand for the past two decades despite the near-complete absence of organ donations for most of this period. While the Chinese government states that it stopped harvesting organs from executed death-row prisoners in 2015 and now relies entirely on voluntary donations, emerging evidence indicates that China performs far more transplants than officially reported, there remains a large gap of organs that cannot be accounted for by voluntary donations, and unethical organ procurement continues on a large scale from prisoners of conscience in extrajudicial killings. In response, the European Parliament and the U.S. Congress passed resolutions condemning these killings, and several countries have strengthened legislation against organ trafficking and illicit transplant tourism. Academic and professional organizations embargoed research from China on ethics grounds. However, Chinese officials’ subsequent promises of reform and claimed progress have led to a renewal of international collaboration with the Chinese transplant system. Because the latest evidence suggests that systemic abuses persist, the international community risks becoming complicit in these state-driven crimes against humanity through collaboration and trade. APHA recommends adoption of stronger measures by governments, medical bodies, and professional organizations to uphold established ethics standards. Proposed strategies include enacting legislation to reduce transplant tourism to China, educating patients on the risks of transplant tourism, expanding data reporting mechanisms to facilitate further research, enforcing ethics requirements more rigorously as prerequisites to academic collaboration and commercial transactions, and deterring individuals in China from participating in unethical organ procurement using existing legal mechanisms.

Relationship to Existing APHA Policy Statements
This policy statement is not related to previous statements.

Problem Statement
Organ transplantation in China grew exponentially starting in the year 2000 despite the absence of an organ donation system. Allegations first emerged in 2006 that the government of China forcibly harvested organs from prisoners of conscience, who were killed in the process. Subsequent investigations by David Matas and David Kilgour in 2007,[1] Ethan Gutmann in 2014,[2] Freedom House in 2016,[3] the China Organ Harvest Research Center in 2018 and 2019,[4,5] and the China Tribunal in 2019[6] have all concluded that forced organ harvesting from Falun Gong practitioners, Uighur Muslims, and other prisoners of conscience has been carried out on a large scale. The latest evidence indicates that the practice has not stopped despite China’s announcement that it has relied entirely on voluntary donations since 2015.

Transplants conducted on demand: While organ transplants around the world are conducted only as donors become available, in China even vital organs can be made available as needed. One hospital claimed to have “donors seeking matched recipients.”[4] Transplants in China are characterized by short waiting times, surgeries scheduled ahead of time, and procurement from living organ sources.[5]

Hospitals in China have routinely quoted wait times for organ transplants between days and weeks, including before 2010 (when China had no organ donation system) and after the claimed reform in 2015. The China Liver Transplant Registry reported that among 4,331 liver transplants performed in 2006, 1,150 (26.6%) were emergency transplants for which organs had to be located within 3 days. A transplant center stated that it could normally find a human leukocyte antigen–matched kidney donor in one week, with “the maximum time being one month.”[4] In October 2017, one of the largest transplant centers in China quoted organ wait times from days to weeks and offered expedited transplants in exchange for a monetary “donation.”[7] China also reported many cases of wait times of 1 day or less after 2017.[5]

Cases of prescheduled transplants provided to foreign recipients include that of an Israeli patient who traveled to China in 2005 for a heart transplant scheduled 2 weeks ahead of time. In August 2016, a Canadian patient received a kidney transplant in China after waiting for only 3 days. That November, an Australian senator was told that he could “go to Shanghai and for $150,000 get a new liver next week.”[5] It thus follows that the Chinese transplant system can guarantee a donor’s time of death.

A core ethical principle in transplantation of vital organs is the “dead donor rule,” which stipulates that organ donors must be dead prior to procurement and that the procurement itself must not cause the death of the donor. However, evidence shows that some organs were excised in China from living people who were killed in the process.[4]

Large volume of transplants conducted: The number of transplant centers in China grew from 150 before 1999 to 570 by the end of 2004. In 2007, more than 1,000 hospitals applied for government permits to continue performing transplants. The number of liver transplants in 2000 reached 10 times that of 1999; by 2005, the number had tripled further. All of these developments occurred when China had no organ donation system.

Even though these abuses attracted international scrutiny in 2006, organ transplantation in China has continued to grow. Overwhelmed medical teams procured organs and performed transplants around the clock. One hospital trained almost its entire staff of 100 general surgeons to conduct kidney transplants. Many transplant centers expanded with more beds and new wards, wings, and buildings.

No reliable data are available regarding the true number of organ transplants conducted in China due to widespread underreporting of official figures. However, a variety of sources suggest that the systemwide transplant volume is much larger than officially reported. Based on an analysis of minimum capacity requirements issued by the Ministry of Health, the 169 government-approved transplant hospitals have a combined capacity of over 70,000 transplants per year. Most government-approved transplant hospitals far exceed the minimum bed counts, including some with hundreds of dedicated transplant beds and utilization rates of greater than 100%. The same study showed that China’s official figures of 10,000 to 15,000 per year could be exceeded by just a few hospitals.[4]

Falsification and underreporting of transplant volume: There has been widespread falsification and underreporting of transplant volume due to “problems with organ sources” and financial interests. After the first international investigation reports were published in 2006, hospitals began to systematically delete data and other evidence. For example, a 2011 report showed that Tianjin First Central Hospital reported only seven liver transplants in 2010 despite its leading rank in the registry for more than a decade. In fact, this hospital had at least 500 transplant beds and operated at 100% to 131% occupancy, translating into a capacity of more than 8,000 transplants per year. After 2006, hospital Web sites also removed or stopped updating the number of transplants performed, including news reports of record-breaking feats (e.g., that of a hospital performing 17 transplants in 1 day). Transplant numbers that remained on hospital Web sites were deflated. Public access to transplant registry data was restricted. The Ministry of Health issued regulations in 2009 and 2010 to address underreporting of transplant figures, which indicated the widespread continuation of the practice.[4]

Volume not accounted for by official organ sources: The Chinese government has stated that organs were sourced from executed death-row prisoners and, later, voluntary donations. However, neither of the officially named sources has been able to account for the scale of transplants performed, and the claim that China was able to build up an organ donation and transplantation framework in just a few years is not supported by evidence.

The number of death-row executions in China is treated as a state secret but has been estimated at a few thousand each year, a rate that has decreased steadily since the year 2000.[8] Huang Jiefu, chair of the National Organ Donation and Transplantation Committee, wrote in 2016 that reliance on death-row organs was becoming “a stream without a source.”[4]

China first piloted a voluntary donation program in 19 provinces and cities in March 2010, but as of 2012 only 207 donated organs had been reported nationwide. Despite long-standing barriers to donation (including deeply rooted cultural views on keeping one’s body whole after death, lack of brain death legislation, and lack of trust in China’s medical system), China expanded the program nationwide in 2013. It later announced that 80% of organs in 2014 came from citizen donations[4] and that it stopped using organs from death-row prisoners in 2015.[9]

However, these announcements were not accompanied by substantive changes in unethical organ procurement practices. The 2015 announcement served to relabel the use of organs from prisoners as regular citizen donations.[10] China does not have legislation for brain death, transplantation, donation, or ethics that provides for organ transplantation in other countries. While a large portion of transplant organs in Chinese medical papers were listed as coming from brain-dead donors, standard criteria for determining brain death were either unknown to most doctors or not being followed in practice.[4]

In November 2015, Huang indicated that the organ donation system in China did not function in practice because the “National Organ Donation and Transplantation Committee…exists in name only. So far, no meeting has been held yet.” He later stated that as of 2017, China’s organ donation system had a high-level design but had yet to be implemented at lower levels, including branches for organ donation, procurement and distribution, transplantation, posttransplant registration, and supervision. In contrast to the 1,500 personnel overseeing organ donation and transplantation in the United States, China had only one person from the National Health and Family Planning Commission filling this role, which also lacked enforcement capability.[4]

The number of registered organ donors in China does not contribute substantially to the number of actual donations, which in reality relies on sourcing from intensive care units. China had 373,536 registered donors at the end of 2017. Based on the ratio of registered donors to actual donors in the United States, the number of registered donors in China would have yielded only a dozen actual donors.[4]

China started establishing organ procurement organizations (OPOs) at the end of 2012,[11] and its third OPO was established in 2013 after fulfilling the minimum requirement of 10 donations after cardiac death. A national OPO alliance was formed in November 2014 and was used to show that organ donation in China was “in line with international standards.”[4] However, these OPOs are established in ministry-approved transplant centers, include the same surgeons involved in unethical organ procurement, and operate without oversight. Given the time line of OPO development and lack of implementation, the claim that 80% of organs came from the donation system in 2014 is implausible.

A telephone survey of Chinese transplant centers ending in June 2017 revealed that most organs did not come from the national donation and allocation system (China Organ Transplant Response System, or COTRS), because hospitals could not access the system. That month, a hospital and a radio station held a joint promotion offering free liver transplants for the first 10 children to register; however, the Jilin Province Red Cross organ donation office stated that the livers did not come from its system.[4] Furthermore, a 2019 study produced statistical evidence that the Chinese government may have systematically misreported the number of voluntary organ donations.[12]

Organ sourcing from prisoners of conscience: The first recorded case of an organ being harvested from a political prisoner and being transplanted into the son of a senior Communist Party cadre took place in 1978.[13] In 1984, the Chinese government enacted regulations that allowed the use of organs and bodies of executed prisoners.[14] More cases of political prisoners being killed for organs were reported in Xinjiang in the 1990s, with many of the organs harvested while the prisoners were still alive.[2]

Major growth in organ transplantation in China did not start until 2000, when the Chinese government started prioritizing organ transplantation in its national strategy and investing heavily in research, development, industrialization, and personnel training.[4] This exponential rise in organ transplants without a donation system exactly paralleled the Communist Party’s campaign against Falun Gong, which was also included in China’s Five-Year Plan.[15] Falun Gong is a meditation and spiritual discipline based on the principles of “truthfulness, compassion, and tolerance.”[1] Since July 1999, Falun Gong practitioners all over China have been systematically arrested, detained, and tortured in forced labor camps, detention centers, black jails, prisons, psychiatric hospitals, extrajudicial “legal education” (brainwashing) centers, and secret military detention facilities for refusing to renounce their faith.[4] Foreign observers estimated that at least half of the 250,000 officially recorded detainees in China’s reeducation-through-labor camps were Falun Gong practitioners.[16]

Prisoners of conscience, including Falun Gong practitioners, House Christians, Uighurs, and Tibetans, have been forcibly given medical examinations and blood tests related to organ function, both while incarcerated and at home. These tests were not administered to other prisoners.[1,2,4] The results of these examinations were not communicated to the prisoners, nor have they led to medical treatment, suggesting that they were not performed to benefit the prisoners’ health. China’s public security system built a national database of more than 40 million individuals before 2017, when the government collected DNA samples and blood type information from 19 million Uighurs in Xinjiang under the guise of a public health program.[17] International experts have raised concern over the purpose of these mass screenings, which authorities have characterized as a crime-fighting tool.[18] Furthermore, telephone investigations have yielded admissions from hospital staff in China that organs were sourced from Falun Gong practitioners, a group targeted for inclusion in the national database.[1]

Continued availability of organs on demand after 2015: Huang Jiefu attributed the limiting factor for transplant volume not to organ availability but rather to a lack of qualified hospitals and experienced doctors. He has expressed the desire to increase the number of qualified transplant hospitals from 169 to 300 or 500. He also promoted platforms to make organs available to regions outside of mainland China with the “cheapest cost, most accessibility, and high quality,” suggesting that the organ supply available in China has not decreased. Huang further predicted that China would perform the most transplants in the world by 2020.[5]

After Chinese officials stated that transplants for foreign patients were strictly forbidden and completely stopped, transplant tourism to China continued to thrive. Journalists found in October 2017 that one of China’s largest transplant centers operated dedicated wards and hotel facilities for international patients from the Middle East, South Korea, and other regions.[7] Patients who traveled there for transplants were not told about organ sources.

In November 2017, the China Organ Transplantation Development Foundation signed an organ sharing and allocation agreement with the Macau health ministry. Training for medical personnel in Macau began in January 2018. Wang Haibo, the director of COTRS, stated that 519 Hong Kong residents and 50 Macau residents received organ transplants in mainland China as part of COTRS between 2010 and the end of 2017.[4]

International response: The European Parliament passed a resolution in 2013 citing “persistent and credible reports of systematic, state-sanctioned organ harvesting from non-consenting prisoners of conscience in the People’s Republic of China, including from large numbers of Falun Gong practitioners imprisoned for their religious beliefs, as well as from members of other religious and ethnic minority groups.”[19] The U.S. House of Representatives passed a similar resolution in 2016.[20]

The Transplantation Society (TTS) developed an ethics policy in November 2006 limiting membership to doctors who signed a statement agreeing to conduct clinical practice according to TTS policies; it also prohibited collaboration with experimental studies involving material from illicit sources.[21] The transplant organization NATCO adopted a position statement on organ tourism in 2008, citing China’s procurement of organs from “live prisoners who are then killed after donation.”[22] A 2009 study showed that less than 4% of transplant professionals surveyed believed organ procurement practices in China to be ethically sound.[23] The journals Liver Transplantation and the American Journal of Transplantation stated in 2007 and 2011, respectively, that they would exclude manuscripts containing data derived from organs obtained from executed prisoners.[24,25] In July 2014, 35 Chinese participants were excluded from the World Transplant Congress in San Francisco for ethics reasons. In addition, many international experts declined to attend a 2014 transplant conference in Hangzhou, China.[26] In 2016, Chinese state media took the TTS conference being held in Hong Kong as a sign that the Chinese transplantation system was accepted by the international community, but the assertion was rebutted by TTS.[27] In February 2017, the journal Liver International retracted a study from Chinese surgeons after determining that the hospital could not have obtained 564 livers from donors after cardiac death as claimed in the study.[28]

In February 2017, the Pontifical Academy of Sciences invited Huang Jiefu to its summit on organ trafficking. Huang presented a blueprint of the “Chinese mode” of organ donation and transplantation, which the chancellor of the academy promoted as one that could be used across the world. The model was also endorsed by representatives of the World Health Organization and the Declaration of Istanbul Custodian Group. Some governments and institutions outside of China have thus renewed their collaboration with Chinese government agencies and transplant institutions. For example, TTS invited COTRS director Wang Haibo and Zheng Shusen, whose paper was retracted by Liver International, as featured speakers at its 2018 conference.[4]

Other ethics concerns relate to the sale of products to Chinese transplant institutions, the funding and performance of clinical trials and medical experiments in China, and the training of Chinese transplant surgeons. Western biotechnology and pharmaceutical companies invested heavily to nurture China’s organ transplant industry at a time when almost all organs were sourced from prisoners.[29] A recent study named at least 20 Western companies that have reportedly profited from supplying China with materials, drugs, technology, and technical expertise to develop organ transplantation.[30]

Given the lack of legislative changes prohibiting the use of prisoner organs, the lack of enforcement of existing organ procurement laws,[9] and emerging evidence that the harvesting of organs from prisoners of conscience in China continues on a large scale, international institutions are ethically obligated to conduct further investigation and substantive verification of organ sources before continuing their collaboration with Chinese transplant institutions.

Evidence-Based Strategies to Address the Problem
Recommended strategies include (1) enacting legislation outside of China to reduce transplant tourism for the purpose of obtaining an organ from an illegal or unidentified source; (2) educating patients about the medical, ethical, and legal risks of transplant tourism; (3) expanding data reporting mechanisms to facilitate research into transplant tourism and organ trafficking; (4) enforcing ethics requirements more rigorously in academic collaborations and commercial transactions; and (5) deterring individuals in China from participating in unethical organ procurement using existing legal mechanisms.

Reduce transplant tourism to China through legislation: Following the 2008 Declaration of Istanbul, which calls on governments to increase deceased organ donations and remove obstacles and disincentives for such donations,[31] several countries amended legislation to reduce outbound transplant tourism and increase domestic organ donations.[32] Israel passed the Organ Transplant Act in 2008 to ban the sale, purchase, and brokerage of organs both in Israel and abroad, including the performance of transplants in other countries if the operations contravene Israeli law. The law also prohibits reimbursement for transplants involving illegal organ procurement or trade and has stopped the health insurance system from funding such transplants.[33] A unique clause of the law prioritizes organ allocation to candidates who are registered donors or have previously donated the organ.[34] Follow-up research has shown that “[b]ecause of the implementation of the law, annual numbers of patients undergoing kidney transplantation abroad have dramatically declined from 155 in 2006 to 43 in 2013.” The legislation also increased living organ donation within Israel by reimbursing donors for lost earnings, transportation, recovery, health and life insurance, and psychological consultations.[35]

Israel, Spain, Italy, Taiwan, Norway, and Belgium have also strengthened legislation to restrict organ trafficking and transplant tourism. In 2015, Taiwan amended its Human Organ Transplantation Act to require legal proof of the source of organs obtained in other countries, ban the use of organs from executed prisoners, and impose prison time for those engaged in organ brokering, trading, or tourism regardless of foreign laws or lack thereof.[36] Spain amended its criminal code in 2010 to impose prison time for those who promote or facilitate illegal organ procurement or trafficking. The same penalties extend to those who receive an organ with knowledge of its illicit origin.[37] Italy passed a similar bill in 2015 that also punishes doctors who assist patients with travel to obtain an organ illegally with lifetime disqualification for violating medical ethics.[38]

Educate patients on the risks of transplant tourism: In addition to other strategies outlined, health care providers should educate patients in pretransplant counseling on the medical, ethical, and legal risks of traveling abroad to receive organs from illicit sources, as recommended by the Canadian Society of Transplantation and the Canadian Society of Nephrology.[39] A study of Canadian end-stage renal disease patients revealed that “those willing to travel and purchase a kidney were…less knowledgeable about the risks and legality of transplant tourism” and that “the majority of patients were less willing to travel when presented with safety or legal concerns.”[40] The study also showed that “33% were willing to travel even if they knew the donor was an executed prisoner, but only 4% admitted they were willing to break the law to obtain a transplant overseas,” indicating a need to distinguish between “executed prisoners” (convicted criminals lawfully sentenced to death, the use of organs from whom can be argued to be morally acceptable[41]) and prisoners of conscience who are killed extrajudicially. In addition, a substantial proportion of transplant tourists pursue transplant tourism before the start of dialysis or referral for transplant assessment, indicating a need to educate patients before the development of end-stage disease and to educate “non-transplant health professionals, including nephrologists, allied health care workers, and primary care physicians.”[42]

Patients whose individual survival instincts may override ethical considerations may be dissuaded by education on medical risks. A meta-analysis of 39 original studies showed higher incidences of cytomegalovirus, HIV, hepatitis B, and wound infection associated with obtaining an organ from other countries (including China). One‐year graft and patient survival rates are lower among transplant tourists than among domestic transplant patients.[43] Moreover, transplant tourists may bring unusual or resistant infections to their home countries, posing a public health threat.[44,45] Two medical centers have independently reported higher incidences of acute rejection and severe infectious complications among organ transplantation tourists.[46,47]

Expand data reporting to facilitate research: More comprehensive reporting requirements and transparency are needed to promote accountability, protect public health, and support continued research into organ transplant abuses. Efforts to document the scale and characteristics of transplant tourism from the United States have been hampered by incomplete and inaccurate data in published sources. For example, a study that examined the Scientific Registry of Transplant Recipients database for removals of patients from the U.S. transplant waiting list after foreign travel for transplantation was unable to obtain information about countries to which some patients traveled; the study also identified data entry errors concerning transplants performed at a different center.[48] Capturing the true extent of transplant tourism thus requires more comprehensive and accurate data to be recorded for patients who receive transplants in another country. In 2012, the Taiwan legislature began to require major medical institutions and physicians to record information from hospitals and surgeons on any patient receiving an organ transplant in a foreign country, making such information required for patients to receive postoperative health insurance payments.[36] The U.S. Department of State amended its nonimmigrant visa application (DS-160) in 2011 to bar individuals involved in the coercive transplantation of human organs or bodily tissue.[24] Expanding on these initiatives, other national governments and their transplant data reporting agencies should require that residents returning to their home countries declare whether they have received an organ transplant while abroad. As more national legislatures seek to amend their human and organ trafficking laws and adopt treaties such as the Council of Europe Convention against Trafficking in Human Organs, nongovernmental organizations and policy institutes focused on human trafficking, medical ethics, and international affairs should include mandatory reporting of transplant tourism in their advocacy initiatives.

Enforce ethics guidelines: The need remains for ethics guidelines to be enforced as a precondition for professional and academic engagement with Chinese transplant personnel, including training of transplant surgeons and participation in and recognition of research in international publications and forums by Chinese transplant personnel. Most conferences require a written declaration from authors that their abstracts comply with ethics guidelines, including the Declaration of Istanbul and the Declaration of Helsinki. However, these declarations lack substantive verification, and a number of abstracts have been accepted that involved the use of organs from years in which almost all organs in China were sourced from executed prisoners.[14] Furthermore, a 2018 study showed that almost all research papers on organ transplantation in China published in peer-reviewed English-language journals between 2000 and 2017 failed to meet international ethical standards banning publication of research involving biological material from executed prisoners.[49] In contrast, the International Society for Heart and Lung Transplantation stipulated that “abstracts related to transplantation and involving either organs or tissue from human donors in China [would] not be accepted for consideration for the 2017 Annual Meeting.”[50]

A 2009 study revealed that 66% of transplant professionals would support an embargo on scientific reports from countries suspected of unethical organ procurement practices; 56% would refrain from participating in training of liver transplantation physicians and surgeons who intended to practice in such countries.[23] Due to the history of falsified data and continued lack of transparency in China’s organ procurement system, medical and academic institutions outside China should adopt and enforce stricter ethics policies requiring independent verification that all human organs used in studies are sourced from voluntary donors before engaging in collaboration with a Chinese transplant institution.

Hold human rights violators accountable: Existing legal mechanisms can be used to enforce accountability of and deter officials, medical professionals, and other individuals involved in the killing of prisoners of conscience for organs. For example, the Global Magnitsky Human Rights Accountability Act provides for the denial of entry to and imposition of property sanctions on foreign individuals responsible for “extrajudicial killings, torture, or other gross violations of internationally recognized human rights committed against individuals in any foreign country who seek…to obtain, exercise, defend, or promote internationally recognized human rights and freedoms.”[51] In 2017, the act was used to sanction two Chinese public security officials for their responsibility in the torture and death of a human rights activist in 2014.[52] American and international firms may be prevented from entering into business transactions with sanctioned individuals. The United Kingdom, Estonia, Canada, and the European Parliament have passed or are considering passing similar legislation regarding international human rights violators.[53]

Opposing Arguments/Evidence
Favoring collaboration over condemnation: A main opposing argument favors engaging rather than isolating Chinese transplant professionals so that outside experts can help China develop a system that meets internationally accepted ethics standards.[54] For example, TTS has emphasized the need to work with Chinese transplant officials directly to effect long-term change[21] and engagement with Chinese officials who are willing to support reform.[55] When confronted with the question of whether physicians should provide on-site training at foreign transplant centers, some ethicists have suggested that physicians’ “commitments to beneficence and the welfare of all patients, including organ failure patients in distant lands with questionable legal practices, dictate that medical expertise should be shared when patients stand to benefit.”[41]

Collaborating with Chinese transplant professionals in an effort to end unethical organ sourcing may be tenable if the government of China truly intends to regulate its organ donation system and enforce the policies it has enacted on paper. But while previous engagements have led to highly visible promises of reform, the government of China continues to deny extrajudicial killings of prisoners despite being presented with evidence to the contrary. Existing policies continue to be openly violated, including the ban on transplant tourism.[4,7] Furthermore, with regard to the killing of Falun Gong practitioners for organ procurement, prominent leaders in China’s transplant system have personally published hate speech against the victim group and led government agencies tasked with eradicating Falun Gong while simultaneously performing large numbers of transplants in the absence of voluntary donations.[4] There continues to be a lack of transparency and independently verifiable data in China’s donation and transplantation system, including registries. In over a decade of international cooperation and dialogue with Chinese officials, the harvesting of organs from prisoners of conscience has not stopped. Because leaders in charge of reforming China’s transplant system continue to cover up rather than address systemic abuses, continuing to engage as partners would pose an ethical risk of knowingly helping to facilitate illicit transplants.

Interference in internal affairs: Another opposing argument considers the regulation of organ transplantation as an internal affair with which other countries should not interfere. However, the abuses in China’s organ transplantation system have amounted to crimes against humanity, to which the international community is obligated to respond under the Responsibility to Protect principle adopted by the United Nations.[56] Furthermore, because the international medical community is actively engaged in training, collaboration, publication of research, and other activities that have contributed to the development of organ transplantation in China, such transplant abuse cannot be considered an internal affair, and the international community is obligated to promote and independently verify the ethical sourcing of organs in China.

Action Steps
As a result of the conditions and risks associated with the practices described in this policy statement, APHA urges:

  1. National governments to prohibit travel
  2. Heads of state and national legislatures
  3. The United States to seek the inclusion
  4. The U.S. Department of State to recommend
  5. Governments and private organizations to fund research
  6. The Scientific Registry of Transplant Recipients
  7. Medical schools, continuing education programs
  8. The U.S. Congress to authorize funding
  9. Health care providers to educate potential
  10. Medical and academic institutions and associations
  11. International organizations including the United Nations and the World Health Organization to facilitate independent investigations into organ procurement practices in China.

1. Matas D, Kilgour D. Bloody harvest: revised report into allegations of organ harvesting of Falun Gong practitioners in China. 2007. Available at: http://organharvestinvestigation.net/report0701/report20070131.htm#_Toc160145147. Accessed December 30, 2017.
2. Gutmann E. The Slaughter: Mass Killings, Organ Harvesting, and China’s Secret Solution to Its Dissident Problem. Buffalo, NY: Prometheus Books; 2014.
3. Freedom House. The battle for China’s spirit: Falun Gong. Available at: https://freedomhouse.org/sites/default/files/FH_2017_BattleForChinasSpirit_Falun_Gong_0.pdf. Accessed January 6, 2018.
4. China Organ Harvest Research Center. Transplant abuse in China continues despite claims of reform. Available at: https://www.chinaorganharvest.org/app/uploads/2018/06/COHRC-2018-Report.pdf. Accessed February 5, 2020.
5. China Organ Harvest Research Center. Documenting Genocide: The extrajudicial killing of prisoners of conscience for organs in China and the campaign to eradicate Falun Gong. Available at: https://www.chinaorganharvest.org/app/uploads/2019/04/COHRC-Factual-Findings-Report.pdf. Accessed February 5, 2020.
6. Independent Tribunal Into Forced Organ Harvesting from Prisoners of Conscience in China. Judgment. Available at: https://chinatribunal.com/wp-content/uploads/2020/03/ChinaTribunal_JUDGMENT_1stMarch_2020.pdf. Accessed August 10, 2020.
7. Kim H, Shin D. Video: investigation into organ transplant tourism to China. Available at: https://vimeo.com/250087127/37c9aedd40. Accessed January 8, 2018.
8. Hood R. Abolition of the death penalty: China in world perspective. Available at: https://deathpenaltyinfo.org/documents/RHoodOnChina.pdf. Accessed December 30, 2017.
9. Allison KC, Caplan A, Shapiro ME, Els C, Paul NW, Li H. Historical development and current status of organ procurement from death-row prisoners in China. Available at: https://bmcmedethics.biomedcentral.com/articles/10.1186/s12910-015-0074-0. Accessed January 3, 2018.
10. Allison KC, Paul NW, Shapiro ME, Els C, Li H. China’s semantic trick with prisoner organs. Available at: http://blogs.bmj.com/bmj/2015/10/08/chinas-semantic-trick-with-prisoner-organs/. Accessed December 30, 2017.
11. Transplantation Society. Haibo Wang, People’s Republic of China. Available at: http://confman.tts2018.org/mobis/bio/24231. Accessed January 30, 2018.
12. Robertson MP, Hinde RL, Lavee J. Analysis of official deceased organ donation data casts doubt on the credibility of China’s organ transplant reform. BMC Med Ethics. 2019;20:79. 
13. Human Rights Watch. China organ procurement and judicial execution in China. Available at: https://www.hrw.org/reports/1994/china1/china_948.htm#_1_3. Accessed January 30, 2018.
14. Trey T, Sharif A, Schwarz A, Fiatarone SM, Lavee J. Transplant medicine in China: need for transparency and international scrutiny remains. Am J Transplant. 2016;16:3115–3120. 
15. Zhu R. Report on the outline of the 10th Five-Year Plan for National Economic and Social Development. Available at: http://en.people.cn/features/lianghui/zhu10.htmlOriginal. Accessed January 30, 2018.
16. U.S. Department of State. International religious freedom report 2007—China (includes Tibet, Hong Kong, and Macau). Available at: https://www.state.gov/j/drl/rls/irf/2007/90133.htm. Accessed February 6, 2020.
17. Human Rights Watch. China: minority region collects DNA from millions. Available at: https://www.hrw.org/news/2017/12/13/china-minority-region-collects-dna-millions. Accessed January 22, 2018.
18. Fan W, Khan N, Lin L. China snares innocent and guilty alike to build world’s biggest DNA database. Available at: https://www.wsj.com/articles/china-snares-innocent-and-guilty-alike-to-build-worlds-biggest-dna-database-1514310353. Accessed January 26, 2019.
19. European Parliament. Resolution on organ harvesting in China. Available at: http://www.europarl.europa.eu/sides/getDoc.do?pubRef=-//EP//TEXT+MOTION+P7-RC-2013-0562+0+DOC+XML+V0//EN. Accessed December 30, 2017.
20. U.S. Congress. H.Res.343—114th Congress. Available at: https://www.congress.gov/bill/114th-congress/house-resolution/343. Accessed December 30, 2017.
21. Transplantation Society. TTS Ethics Committee policy statement: Chinese transplantation program. Available at: https://www.tts.org/images/stories/pdfs/StatementMembs-ChineseTXProg.pdf. Accessed January 2, 2017.
22. NATCO. Position statement—organ tourism. Available at: http://www.natco1.org/Advocacy/files/Organ%20Tourism.pdf. Accessed January 3, 2018.
23. Biggins SW, Bambha K, Terrault N, Inadomi J, Roberts JP, Bass N. Transplant tourism to China: the impact on domestic patient-care decisions. Clin Transplant. 2009;23:831–838. 
24. Danovitch GM. Testimony before the House Foreign Affairs Committee on Oversight and Investigations. Available at: http://www.declarationofistanbul.org/index.php?option=com_content&view=article&id=344:testimony-before-the-house-foreign-affairs-subcommittee-on-oversight-and-investigations-washington-dc-september-12-2012&catid=50:articles-relevant-to-the-declaration&Ite. Accessed January 1, 2018.
25. Rakela J, Fung JJ. Liver transplantation in China. Liver Transplant. 2007;13:182. 
26. Chinese Transplant Congress response to the foreign media. Available at: http://archive.is/ro86V. Accessed January 7, 2018.
27. Tatlow DK. Chinese claim that world accepts its organ transplant system is rebutted. Available at: https://www.nytimes.com/2016/08/20/world/asia/china-hong-kong-organ-transplants.html. Accessed January 7, 2018.
28. Davey M. Medical journal to retract paper after concerns organs came from executed prisoners. Available at: https://www.theguardian.com/world/2017/feb/09/medical-journal-to-retract-paper-over-concerns-organs-came-from-executed-prisoners. Accessed January 6, 2018.
29. Jia Y. Foreign immunosuppressant manufacturers invest heavily in Chinese market. Available at: http://www.yyjjb.com/html/2010-09/20/content_121831.htm. Accessed January 7, 2018.
30. Porubiak P, Kudlacek L. The economics of organ harvesting in China. Available at: https://theirccdotorg.files.wordpress.com/2019/12/the-economics-of-organ-harvesting-in-china-ircc-2019-1.pdf. Accessed February 5, 2020.
31. Declaration of Istanbul Custodian Group. The Declaration of Istanbul on Organ Trafficking and Transplant Tourism. Available at: http://multivu.prnewswire.com/mnr/transplantationsociety/33914/docs/33914-Declaration_of_Istanbul-Lancet.pdf. Accessed January 1, 2018.
32. Danovitch GM, Al-Mousawi M. The Declaration of Istanbul—early impact and future potential. Available at: https://www.researchgate.net/publication/221722732_The_Declaration_of_Istanbul-early_impact_and_future_potential. Accessed January 1, 2018.
33. Declaration of Istanbul Custodian Group. Israel Transplant Law—Organ Transplant Act, 2008. Available at: http://www.declarationofistanbul.org/index.php?option=com_content&view=article&id=267:israel-transplant-law-organ-transplant-act-2008&catid=83:legisl%20ation&Itemid=130. Accessed January 1, 2018.
34. Lavee J, Ashkenazi T, Stoler A, Cohen J, Beyar R. Preliminary marked increase in the national organ donation rate in Israel following implementation of a new organ transplantation law. Am J Transplant. 2013;13:780–785. 
35. Ashkenazi T, Lavee J, Mor E. Organ donation in Israel—achievements and challenges. Transplantation. 2015;99(2):265–266. 
36. Taiwan Ministry of Justice. Human organ transplantation regulation. Available at: http://law.moj.gov.tw/LawClass/LawAll.aspx?PCode=L0020024. Accessed January 1, 2018.
37. Boletín Oficial del Estado. Real decreto 1723/2012. Available at: http://www.ont.es/infesp/Legislacin/BOERD1723-2012.pdf. Accessed January 1, 2018.
38. Senate of the Republic of Italy. Introduzione nel codice penale del reato di associazione finalizzata al traffico di organi destinati al trapianto. Available at: http://www.quotidianosanita.it/allegati/allegato4671710.pdf. Accessed January 1, 2018.
39. Gill JS, Goldberg A, Prasad GVR, et al. Policy statement of Canadian Society of Transplantation and Canadian Society of Nephrology on organ trafficking and transplant tourism. Transplantation. 2010;90(8):817–820. 
40. Gill J, Gill G, Joffres Y, et al. Willingness of Canadian ESRD patients to consider transplant tourism. Available at: https://atcmeetingabstracts.com/abstract/willingness-of-canadian-esrd-patients-to-consider-transplant-tourism/. Accessed January 21, 2019.
41. Rhodes R, Schiano T. Transplant tourism in China: a tale of two transplants. Am J Bioeth. 2010;10(2):3–11. 
42. Gill J, Diec O, Landsberg D, et al. Opportunities to deter transplant tourism exist before referral for transplantation and during the workup and management of transplant candidates. Kidney International. 2011;79(9):1026–1031.
43. Anker AE, Feeley TH. Estimating the risks of acquiring a kidney abroad: a meta-analysis of complications following participation in transplant tourism. Clin Transplant. 2012;26(3):E232–E241.
44. Morris MI, Muller E. Infectious complications of transplant tourism. Curr Infect Dis Rep. 2019;21(10):36.
45. Dominguez-Gil B, Danovitch G, Martin DE, et al. Management of patients who receive an organ transplant abroad and return home for follow-up care: recommendations from the Declaration of Istanbul Custodian Group. Transplantation. 2018;102(1):e2–e9.
46. AlBugami MM, AlOtaibe FE, Alabadi AM, et al. Transplant tourism following the Declaration of Istanbul: poor outcomes and nephrologist dilemma. Nephrology (Carlton). 2018;23(12):1139–1144.
47. Gill J, Madhira BR, Gjertson D, et al. Transplant tourism in the United States: a single-center experience. Clin J Am Soc Nephrol. 2008;3(6):1820–1828.
48. Merion RM, Barnes AD, Lin M, et al. Transplants in foreign countries among patients removed from the US transplant waiting list. Am J Transplant. 2008;8(4):988–996.
49. Rogers W, Robertson MP, Ballantyne A, et al. Compliance with ethical standards in the reporting of donor sources and ethics review in peer-reviewed publications involving organ transplantation in China: a scoping review. BMJ Open. 2019;9:e024473. 
50. International Society for Heart and Lung Transplantation. Call for abstracts, Thirty-Seventh Annual Meeting and Scientific Sessions. Available at: http://www.ishlt.org/ContentDocuments/ISHLT_Call4Abstracts_2017.pdf. Accessed January 1, 2018.
51. U.S. Congress. S.284: Global Magnitsky Human Rights Accountability Act. Available at: https://www.congress.gov/bill/114th-congress/senate-bill/284/text. Accessed January 1, 2018.
52. Reuters. Chinese officials targeted by human rights groups over 2014 death of activist, under expanded Magnitsky Act. Available at: http://www.scmp.com/news/world/united-states-canada/article/2111070/chinese-officials-targeted-human-rights-groups-over. Accessed January 1, 2018.
53. Human Rights Watch. The US Global Magnitsky Act. Available at: https://www.hrw.org/news/2017/09/13/us-global-magnitsky-act. Accessed January 1, 2018.
54. Millis JM. Engagement vs. isolationism: China’s transplant system. Hepatobiliary Surg Nutr. 2013;2(6):295–296. 
55. O’Connell PJ, Ascher N, Delmonico FL. The Transplantation Society believes a policy of engagement will facilitate organ donation reform in China. Am J Transplant. 2016;16:3297–3298. 
56. United Nations. Resolution adopted by the General Assembly on 16 September 2005. Available at: http://www.un.org/en/development/desa/population/migration/generalassembly/docs/globalcompact/A_RES_60_1.pdf. Accessed February 3, 2019.