Human rights violations in organ procurement practice in China

Abstract

Background
Over 90% of the organs transplanted in China before 2010 were procured from prisoners. Although Chinese officials announced in December 2014 that the country would completely cease using organs harvested from prisoners, no regulatory adjustments or changes in China’s organ donation laws followed. As a result, the use of prisoner organs remains legal in China if consent is obtained. DiscussionWe have collected and analysed available evidence on human rights violations in the organ procurement practice in China. We demonstrate that the practice not only violates international ethics standards, it is also associated with a large scale neglect of fundamental human rights. This includes organ procurement without consent from prisoners or their families as well as procurement of organs from incompletely executed, still-living prisoners. The human rights critique of these practices will also address the specific situatedness of prisoners, often conditioned and traumatized by a cascade of human rights abuses in judicial structures. Conclusion
To end the unethical practice and the abuse associated with it, we suggest to inextricably bind the use of human organs procured in the Chinese transplant system to enacting Chinese legislation prohibiting the use of organs from executed prisoners and making explicit rules for law enforcement. Other than that, the international community must cease to abet the continuation of the present system by demanding an authoritative ban on the use of organs from executed Chinese prisoners.

Full text

D E B A T E Open Access
Human rights violations in organ
procurement practice in China
Norbert W. Paul
1
, Arthur Caplan
2
, Michael E. Shapiro
3
, Charl Els
4
, Kirk C. Allison
5*
and Huige Li
6*
Abstract
Background: Over 90% of the organs transplanted in China before 2010 were procured from prisoners. Although
Chinese officials announced in December 2014 that the country would completely cease using organs harvested
from prisoners, no regulatory adjustments or changes in China’s organ donation laws followed. As a result, the use
of prisoner organs remains legal in China if consent is obtained.
Discussion: We have collected and analysed available evidence on human rights violations in the organ procurement
practice in China. We demonstrate that the practice not only violates international ethics standards, it is also associated
with a large scale neglect of fundamental human rights. This includes organ procurement without consent from
prisoners or their families as well as procurement of organs from incompletely executed, still-living prisoners. The
human rights critique of these practices will also address the specific situatedness of prisoners, often conditioned and
traumatized by a cascade of human rights abuses in judicial structures.
Conclusion: To end the unethical practice and the abuse associated with it, we suggest to inextricably bind the use of
human organs procured in the Chinese transplant system to enacting Chinese legislation prohibiting the use of organs
from executed prisoners and making explicit rules for law enforcement. Other than that, the international community
must cease to abet the continuation of the present system by demanding an authoritative ban on the use of organs
from executed Chinese prisoners.
Keywords: Organ procurement, Prisoners, Human rights, Medical ethics, China
Background
Before a pilot organ donation program was introduced
in 2010, at least 90% of the transplanted organs in China
were procured from prisoners [1]. China is the only
country in the world that systematically uses organs
from prisoners for transplantation [2]. After decades of
denial, China finally admitted the practice in 2005 [3, 4].
However, organ procurement from executed prisoners
continued.
In December 2014, the Chair of the China Organ Dona-
tion and Transplant Committee and former Vice-Minister
of Health, Huang Jiefu, announced that the country would
completely cease the use of prisoner organs for transplant-
ation in China after 2015. Surprisingly, this announcement
has not been followed by any changes to China’s organ
donation laws or regulations (see website of PRC National
Health and Family Planning Commission: http://
en.nhfpc.gov.cn/regulations.html). The use of prisoner
organs remains legal, if so-called consent is obtained from
the prisoners [5, 6]. Such ‘consents’,however,eventhoseac-
tually signed by the prisoners, are not accepted by inter-
national organisations such as The Transplantation Society
(TTS) [7]. Because of the restrictions on liberty in a prison
environment, it is unlikely that prisoners are truly free to
make independent decisions and thus an autonomous
informed consent for donation cannot be obtained [7].
Organ harvesting from executed prisoners violates inter-
national principles of medical ethics [8]. The compromised
autonomy of all prisoners as an ethical restriction regarding
the process of informed consent had historically been de-
rived from a thorough analysis of crimes against humanity
performed by physicians during the German Nazi regime
mostly on prisoners in German concentration camps. In
Asia, crimes against humanity performed during World
WarIIwereshamefullynotprosecutedinasimilarwayas
* Correspondence: alli0001@umn.edu;huigeli@uni-mainz.de
5
School of Public Health, University of Minnesota, Minneapolis, USA
6
Department of Pharmacology, Johannes Gutenberg University Medical
Center, Obere Zahlbacher Strasse 67, 55131 Mainz, Germany
Full list of author information is available at the end of the article
© The Author(s). 2017 Open Access This article is distributed under the terms of the Creative Commons Attribution 4.0
International License (http://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, and
reproduction in any medium, provided you give appropriate credit to the original author(s) and the source, provide a link to
the Creative Commons license, and indicate if changes were made. The Creative Commons Public Domain Dedication waiver
(http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated.
Paul et al. BMC Medical Ethics (2017) 18:11
DOI 10.1186/s12910-017-0169-x
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the Nuremberg Military Tribunals. The vivisections and
experimental atrocities performed by Japanese biological
warfare Unit 731 against occupied Chinese and prisoners of
war in Manchuria were not raised, addressed nor prose-
cuted during the Tokyo Trials [9, 10].
The unethical practice of organ procurement from
executed prisoners in China has lasted for decades [5].
Moreover, this practice is associated with large scale abuse
and severe human rights violations. In part, the transgres-
sion of ethical boundaries in the case of organ harvesting
is triggered by an ever growing local and global demand
for transplantable organs associated with the emergence
of a global (black) market [11–13]. This heavily impacts
human rights, ethics and justice far beyond ideas calling
for regulated markets for organs [14].
In a prior publication, we explored the historical develop-
ment and status of organ procurement from death-row pris-
oners in China [5]. In the present article, we more closely
examine transgressions of human rights (mainly focusing on
legal considerations of human rights), contradictory frames
offered in justification, conditions claimed for consent of this
most vulnerable of populations, issues of brain death criteria
in the context of China, and several specific examples.
Organ procurement from executed prisoners
without consent
From the 1970s, organs were simply taken from executed
prisoners in China without asking for the permission of
the prisoners or their families. In 1984, the first “Interim
Rules on Using the Body or Organs of Executed Crimi-
nals”[15] (also translated as “Provisional Regulation on
the Use of Dead Bodies or Organs from Condemned
Criminals”[16]) officially allowed, for the first time, organ
harvesting from executed prisoners, under the condition
that either the body is not claimed; or the prisoner volun-
teers for organ donation; or the family consents.
As prescribed by the 1984 Rules, “the use of the dead
bodies or organs from condemned criminals must be kept
strictly confidential. […] the operation vehicles from
medical institutions can be allowed entry into the execu-
tion grounds to remove organs, but vehicles with the logo
of medical institutions are not to be used, and white clinic
garments are not to be worn. The execution ground
should be guarded against before the operation is com-
pleted. After the dead bodies are used, the crematory shall
assist the [medical] units in timely cremation”[16]. In
many cases, the families receive only the cremains without
being informed what has happened with the body of their
loved ones.
Recently, it has been repeatedly admitted by Chinese
transplant officials that organs from executed prisoners
had been procured without consent [17–19]. For ex-
ample, a Chinese medical official admitted in 2013 that
“previously, authorities used executed criminals’organs
without their consent, while permission has been re-
quired in recent years”[17]. In 2014, when Hong Kong
newspaper Mingpao asked the question whether
prisoners and their families are informed and consent
obtained before organ procurement, Huang Jiefu admit-
ted that “we have not been able to achieve this, but we
will soon”[18]. In 2015, Huang Jiefu admitted that the
problem with China’s organ transplantation system was
that the laws were not obeyed: “Although the law
provides that the use of prisoner organs must be from
voluntary donation, but there are still loopholes in the
law enforcement”[19]. All of these statements strongly
suggest that organs were procured in China largely with-
out consent of the prisoners or their families.
Although organ procurement without consent is illegal
according to Chinese laws, the practice appears to be
tolerated by the authorities in China.
Organ procurement from incompletely executed
prisoners
At a European Parliament hearing on 29 January 2013,
Enver Tohti testified that he was ordered in 1995 to harvest
organs from an incompletely executed, still-living prisoner
in China [20]. More details were revealed in his interviews
with ABC [21], BBC [22] and journalist Ethan Gutmann
[23, 24]. When Enver Tohti got the body of the ‘executed’
prisoner, he noticed, however, that the prisoner was not
dead. “The gunshot, gun wound was on his right chest. So,
I guess that was deliberately to make this prisoner not die
immediately to allow some time for us to remove that
organ when he is still alive”[21]. When Tohti kept making
attempts to follow normal procedure –sterilize, minimal
exposure, sketch the cut - the chief surgeon told him to
hurry up. “No anesthesia, no life support”,“we are working
against time”. Finally, Tohti extracted the liver and the
kidneys from the still-living prisoner [23, 24].
Unfortunately, this was not the only case reported. An
early case has been documented in the book “China’seyes”
[25]. In 1978, Zhong Haiyuan, a schoolteacher from the
Jiangxi Province, was sentenced to death for her “counter-
revolutionary”thoughts. The execution was performed by
three officers from the People’s Armed Police Forces on
April 30, 1978. Two officers fixed Zhong while the third
officer put the gun against her back on the right side and
fired the bullet [25]. Years later, one of the officers told the
books’author that the order was not to kill Zhong imme-
diately. “The kidneys must be harvested before she dies”,
because the army doctors wanted high quality kidneys,
“kidneys from a living person”[25].
More recently, Mr. Wang, who currently lives in
Canada, revealed that he was once a member of a team
extracting organs from a still-living person. The incident
happened in the 1990s when Wang was an intern doctor
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at the urology department of the Shenyang Military
General Hospital in Liaoning Province [26].
In March 2015, Jiang Yanyong told to Hong Kong jour-
nalists that corruption, illegal transplantation and organ
trade were common in military hospitals [27, 28]. Jiang
elaborated on the case of Li Shiyong, director of the
Department of General Surgery of the Beijing Military
General Hospital. With no prior experience in transplant-
ation and without asking for permission of the hospital
director, Li founded a liver transplantation center in 2005
and appointed himself as the director. Because Li had
found ways to obtain donor livers, he could serve as the
director (see Additional file 1: Table S1).
In the same TV interview, Jiang also revealed that many
of the prisoners used for organ harvesting were shot but
not completely killed [27, 28]. The purpose was for organ
harvesting while the prisoners were still alive in order to
keep the warm ischemic time of the sourced organs as
short as possible (see Additional file 1: Table S1).
Jiang as a source is, we contend, credible based on his
personal story within the Chinese medical system. He was
a chief physician of the 301 Military Hospital (People’s
Liberation Army General Hospital) in Beijing where he
witnessed the results of the trauma inflicted on the
students during the Tiananmen Square Massacre of 1989.
Jiang was also the person who publicized the cover-up of
the Severe Acute Respiratory Syndrome (SARS) epidemic
by the Chinese government in 2003.
Unfortunately, the strength of these examples is con-
strained by the fact that the number of executions and
the detailed techniques used are state secrets in China;
empirical data cannot be generated. There are no statis-
tics available on the incidence of the practice of incom-
plete executions in China. A systematic international
investigation into this issue is needed in the interest of
(overdue) justice for the victims.
The medical and ethical function of brain death
and its implementation in China
In most Western cultures, treating a person only as a mere
means to an end of another is a challenge to core concepts
of human dignity as Immanuel Kant and other 18th cen-
tury philosophers argued [29]. Even from a contemporary
perspective, ethicists have always argued that transferring
organs to another person either from a living donor or
from post mortem procured organs must be contextualized
in a way that a) human dignity, b) autonomy and c) social
justifiability in the light of shared values are not endan-
gered [30, 31].
Here, human dignity is understood to be an applied
concept. Based on the notion of phenomenological dignity
it is cognition that enables humans to identify themselves
and to perceive others as human beings which are to be
treated with the same respect (dignity) that one would
expect for oneself. This concept is fostered by a reflexive
mode of dignity in which the constant (re-)evaluation and
adjustment of actions is put in place by relating both,
intentions and consequences to commonly accepted
values, like those which constitute our understanding of
human rights. Finally, the mutual appreciation of humans
together with a value based evaluation and adjustment of
interaction turn dignity into a relational concept which
ought to be the guiding principle of human coexistence.
Especially the relational dimension of dignity is addressed
in discourses on brain death when it comes to evaluations
of those values, moral concepts and needs which need to
be reflected for both, donors and recipients of organs [32].
Only this clarification could lead to a situation in which
the concept of brain death established the medical basis
and justification to switch from life-sustaining care setting
to considering a deceased person as a cadaver organ donor.
Ethically, brain death is the fine line on which dignity of a
living and acting person changes into the dignity of a de-
ceased person, and respecting autonomy of a living person
shifts over into respecting an advanced directive or declared
will to donate organs. In this context, the justifiability of
organ procurement is derived from the fact that the brain-
dead person can donate organs without suffering from vital
consequences caused by organ removal (e.g. pain and
death), since he or she is already dead. Intensive care is pro-
vided only to protect the organs of the deceased.
It is this integration of medical and ethical functions of
brain death which makes organ procurement a widely ac-
cepted practice in Western culture. This is especially true
because of the potential for other procurement strategies,
such as procurement from non-heart-beating donors (Do-
nation after Circulatory Death - DCD), which require
careful, detailed and transparent protocols, in order to as-
sure the avoidance of even the potential for conflict of
interest regarding treatment, and verification of the death
of the donor [33, 34]. Circulatory death is, if not clearly
defined as the irreversible cessation of cardiovascular
circulation, potentially reversible. Furthermore, it can be
prognostically highly dependent on a number of arbitrary,
concomitant circumstances (time, temperature, cause),
thus requiring strict protocols, including electrocardiog-
raphy and blood pressure monitoring to assure death has
occurred, and is permanent. DCD donation may also lead
to decreased quality of recovered organs, because of
prolonged ischemia, or reduced number of organs that
can be procured. It thus has to be seen as a procedure
only applicable in an environment with reliable clinical
standard operating procedures (SOPs) which have to be
implemented in an evidence-based mode by well-trained
medical personnel [34, 35].
However, there is yet no brain death legislation in
China and circulatory death is the legal standard despite
the absence of evidence-based and reliable SOPs [36].
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China lacks any state issued official guidelines to diag-
nose brain death.
In 2003, the Ministry of Health drafted “Brain Death
Determination Criteria”and “Brain Death Determination
Technical Specifications”(comment drafts). In 2009, the
Ministry of Health revised the two documents. In March
2012, the National Health and Family Planning Commis-
sion (NHFPC, the former Ministry of Health) assigned
Xuanwu Hospital of Capital Medical University as the
Brain Injury Quality Control Evaluation Center. In 2013,
the Center further revised and combined the two docu-
ments into “Brain Death Determination Criteria and
Technical Specification (Adult Quality Control Version)”
[37]. These Criteria and Technical Specifications repre-
sent a suggested medical standard; it is not a standard
procedure, a mandatory guideline for medical practi-
tioners or an administrative regulation. Above all, the
standard is not legally binding. As stated in the Editor’s
Note accompanying its publication, “the Center has re-
vised and improved the above-mentioned documents on
the basis of 10 years of clinical practice and research on
brain death determination, and hopes that the new
document serves as the medical standard to promote
the brain death determination in our country to develop
orderly and normatively”[37].
The first documented brain death diagnosis in China was
performed on 25 February 2003, in Wuhan, Hubei Province
[38]. The brain death determination was carried out ac-
cording to the published 2003 draft. In November 2003, the
kidneys of a boy diagnosed as brain dead were used for
transplantation with the consent of the parents [39]. Both
events were considered breakthroughs in Chinese trans-
plant medicine. Both were nominated by major Chinese
media to be among the top 10 medical stories of 2003 [40]
(Fig. 1). Since then, there have been reported increasing
numbers of organ donations after brain death, although “it
is illegal to take organs from the brain-dead for transplant
purposes”in China, as acknowledged by China Daily [41].
Even though no brain death legislation has been effectu-
ated in China, the Chinese Classification of Deceased
Organ Donation has been recently formulated as follows:
“China Category I: Organ donation after Brain Death;
China Category II: Organ Donation after Circulatory
Death; China Category III: Organ Donation after Brain
Death followed by Circulatory Death”[36]. The ambiguity
of this classification together with the absence of SOPs,
guidelines, regulations and legislation leads to a situation
in which legal, medical and ethical uncertainty continues.
Execution by organ explantation?
The medical journal Henan Medical Research published
a research paper titled “The experience of homologuous
orthotopic heart transplantation”(Fig. 2). The operation
was allegedly performed in a hospital of the People’s
Armed Police Force in 2001 and the paper published in
2003 [42]. The 32-year-old male recipient died from
infection 46 days after the heart transplantation [42].
In the section 2.1 of this research paper, the “major
points of donor heart removal”included: “systemic
heparinization (2 mg/kg); delivery of cold cardioplegia to
the heart through the aortic root until the heart stopped
beating; cut of the superior vena cava at 4 cm above
right atrium …” (Fig. 2). Besides blood type and heart
weight, no other information about the donor was pro-
vided in the paper.
The fact that systemic heparinization was performed
and heart beating was stopped by cold cardioplegia im-
plies that the blood was circulating and the heart was
functional before the explantation procedure. Logically,
one of the following two scenarios are applicable to
describe the heart explantation: (i) the donor was a brain
death patient and a brain death diagnosis was performed
as it would have in most confirmatory brain death diagno-
ses based on neurological standard operating procedures
(e.g. in the EUROTRANSPLANT region); (ii) the donor
was not a brain death patient and the cardiac death was
induced by the cold cardioplegia delivered by the medical
professionals.
In this context, it is important to re-emphasize that
there is no brain death legislation in China and circula-
tory death is still the legal standard in China [36]. As
mentioned above, the first brain death determination in
China was performed in 2003 (Fig. 1) [38]. The heart
transplantation in this publication, however, was per-
formed in 2001 and the concept of “brain death”is not
mentioned. This therefore raises the question as to
whether the donor was brain dead, especially given that
the paper was published at a time where the diagnostic
procedure alone would have captured the attention of
the Chinese medical community and would have con-
tributed positively to the scientific impact of the paper.
It is thus reasonable to assume that the delivery of cold
cardioplegia served the purpose of execution and
explantation at the same time.
Human rights: grounding and violations
On 26 June 1945 in San Francisco, the Republic of
China (ROC), first in suffering Axis aggression, was also
first to sign the United Nations Charter and Statute for
the International Court of Justice, which entered into
force on 24 October, establishing the United Nations.
The latter date followed the Double Tenth Agreement
(10/10/1945) between Chaing Kai-Shek and Mao
Zedong wherein the Chinese Communist Party (CCP)
acknowledged the Republic’s Kuomintang government
as legitimate and the Kuomintang the CCP as a legitim-
ate opposition party. Full scale civil war resumed 26
June 1946. Before Mao proclaimed the People’s
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Republic of China on 1 October 1949, the ROC en-
dorsed the Universal Declaration of Human Rights (10
December 1948). The mainland People’sRepublicwas
not a party to UN human rights instruments before
1971 but reaffirmed the UN Charter and UDHR after
the Republic of China was unseated. The PRC is now
party to at least 17 international instruments [43].
The United Nations Office of High Commissioner for
Human Rights characterizes universal human rights as “in-
terrelated, interdependent and indivisible”often expressed
Fig. 1 The first brain death determination in China. Shown is an Expert Opinion paper published in National Medical Journal of China (Zhonghua
Yi Xue Za Zhi), a top medical journal in China, by Chen & Qiu [40]. Text in left box: ‘At the beginning of 2003, the drafting group of the Ministry
of Health completed the “Brain Death Determination Criteria (for adults)”. According to these criteria, the Brain Death Coordinating Group of the
Tongji Hospital at the Tongji Medical College, Huazhong University of Science and Technology, completed the first brain death determination
and treatment cessation in China on 25 February 2003’. Text in right box: ‘The animal model of brain death, the first brain death determination in
adults, and the first brain death in children followed by unpaid organ donation –these three pioneering works were nominated by 10 major
Chinese media to be among the top ten medical news of 2003, ranking from 3 to 7, respectively’
Paul et al. BMC Medical Ethics (2017) 18:11 Page 5 of 9
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in treaties, customary international law (i.e. implicit norms)
or general principles. Documents comprise moral declara-
tions, which implicitly presuppose a concept of human
flourishing, and derivative binding treaties (covenants, con-
ventions, protocols). The troika of the 1948 UDHR and the
complementary international covenants on Economic, So-
cial and Cultural Rights (ICESCR) and Civil and Political
Rights (ICCPR), respectively opened for signature in paral-
lel in 1966, comprise the so-called ‘Bill of Human Rights’,
with others building upon them.
China is a full party to the ICESCR (signed 1997, rati-
fied 2001); the Convention against Torture and Other
Cruel, Inhuman or Degrading Treatment or Punishment
(CAT, ratified 1988); the Convention on the Prevention
and Punishment of the Crime of Genocide (signed 1949,
ratified 1983); and the United Nations Convention
against Transnational Crime (ratified 2003) whose con-
cerns include organ trafficking (albeit patients rather
than prisoner organs have comprised the transnational
element in China).
Fig. 2 Questionable heart explantation. The operation was performed on 19 October 2001 in the hospital of the People’s Armed Police Forces in
Zhengzhou City, Henan Province. That was two years before the first documented brain death determination was performed in China. Underlined
text: ‘Major points of donor heart removal: systemic heparinization (2 mg/kg); delivery of cold cardioplegia to the heart through the aortic root
until the heart stopped beating’. The first page of the publication by Guo et al. in the medical journal Henan Medical Research is shown [42]
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China also signed, but has not ratified, the ICCPR in
October 1998. While formally not bound by ICCPR provi-
sions until ratification or accession, China is obliged not to
defeat its general purpose. Per the Foreign Ministry at the
time, China’s 1998 signature “demonstrates its firm deter-
mination to promote and protect human rights”as well as
concretely commemorating the UDHR’s 50th anniversary,
acknowledging a coherence bridging moral and legal rights.
It also emphasized flexibility in prioritization: “the principle
of the universality of human rights must be respected, but
the specific conditions of each country must also be taken
into consideration in observing this principle,”highlighting
economic development successes against poverty. The tone
markedly contrasts more recent ideological tightening con-
tra “Western ideas”, expressly against universal values of
human rights, parallel to an anticorruption campaign short
on procedural protections [44].
China domestically has circulated “alternatively phrased”
translations of signed human rights conventions rather
than the UN’s official Chinese text, according to one
source providing an interpretive buffer while also impri-
soning those who ask for the ICCPR to be ratified [45].
Legally binding, however, are the official UN language
versions, not CCP state paraphrases.
Human rights violations ending in organ harvesting from
prisoners are, like human rights, also interrelated and inter-
dependent. Violation cascades –one violation increasing
probability of another given the substantive interrelationship
of rights - increase vulnerability cumulatively whether in a
specific person or in a targeted population. Rights violations
via detention schemes and a death penalty regime subject to
manipulation with lack of sufficient representation or appeal
[46] precondition the subsequent act of forced organ extrac-
tion: risk accumulates to a specific subject and identifiable
population. In this sense, the implication of the title of this
paper is extensive and systemic, not simply perioperative.
De jure and de facto factors, frequently in violation of inter-
national human rights standards, lead to and condition the
supply of prisoners being solicited before execution or
simply exploited in the first instance.
Specifically concerning the death penalty, variability
includes bringing charges across 46 potentially capital of-
fenses; death sentences and executions waxing and waning
during ‘strike hard’campaigns; and executions increasing
before the new year. Furthermore, judges in China are not
unaware that executees are the mainstay of transplantation.
Beyond the design of preserving public order and social
control through execution is added the exogenous influ-
ence of medical demand for execution as the chief gateway
to a social good (organs for transplantation), at times
indirectly abetted by the international community (e.g. The
Transplantation Society’spolicysupportingprovidingtrain-
ing to Chinese transplant surgeons under the banner of in-
fluencing eventual reform while simultaneously expanding
capacity, as in the TTS Ethics Committee Letter of 6 No-
vember 2006 to TTS members [47]). It is notable that the
initial 1984 Rules officially allowing organ harvesting from
executed prisoners cited the initiative of medical personnel,
not the state, as seeking to exploit this context for organ
sourcing [16].
The practice of organ procurement in China that we
have described violates freedom from torture and other
cruel, inhuman or degrading treatment or punishment
(UDHR, CAT, ICCPR Art. 7). Nowhere is an individual
as subject to state power than in prison, and nowhere in
prison than when awaiting execution. However, it is the
contiguous context, not merely local ‘choice’
, that is
proper object of the human rights critique, exposing the
step-wise cumulative vulnerability of prisoners at risk of
being exploited in and through execution. This is aided
and abetted by medical demand by an occupation that
first pushed for exploiting execution for organ harvest-
ing, and by a citizen population willing to rely upon,
benefit from, and exploit the bound population - evident
from ongoing reticence to participate in voluntary donor
registration, yet seeking transplantation surgeries.
In general, an alibi of system reform has been counte-
nanced too long. After over a decade of reform claims
and the redefinition of the status of prisoners, the ethical
outcome respecting human rights in China, here
conforming with international medical ethical standards,
is categorical cessation of organ sourcing from prisoners.
Practically, this would remove the perverse incentives
shared and relied upon by medical and judicial establish-
ments, and by the general population. Given the nature
of the violations and delay, justification of gradually real-
izing an ethical practice fails. This recognition should
hold for actors and institutions of influence outside of
China now in possession of over a decade of knowledge.
While human rights violations in China span systemic
structural preconditions, augmented by political whim,
the most proximate point of intervention still lies with
the medical community and professional societies.
Admitting the failure of gradualism, and increasing,
rather than decreasing, professional sanctions, may more
quickly realize the intent: Cessation of prisoner organ
sourcing generally; reducing perverse incentives in death
penalty demand (moral hazard); and confronting the
general population with two ethical alternatives: sup-
porting or declining voluntary organ transplantation as a
system, while bearing the cost of either choice.
Conclusion
The unethical practice of organ procurement from exe-
cuted prisoners in China is associated with a large scale
of abuse and a cascade of severe human rights violations,
including, we contend, organ explantation from still-
alive human beings, and, upstream, conditioning the
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supply of prisoners exploited per se or then solicited to
‘freely’offer organs as atonement for real or supposed
crimes. Those involved in organ harvesting from still-
alive prisoners must be prosecuted. The unethical prac-
tice of lethally procuring vital organs from the living
must be prevented by a law prohibiting use of prisoner
organs generally, supporting change in the practical
legal, medical and popular culture surrounding trans-
plantation in China. Finally, greater influence may be
exerted by international institutions through change of
strategy.
Additional file
Additional file 1: Table S1. Jiang Yanyong Interview in March 2015.
This additional file provides further information on Jiang Yanyong’s
statements (including English translation) in his interview by Hong Kong
journalists. (PDF 439 kb)
Abbreviations
CAT: Convention against torture and other cruel, inhuman or degrading
treatment or punishment; CCP: Chinese Communist Party; DCD: Donation
after circulatory death; ICCPR: International covenant on civil and political
rights; ICESCR: International covenant on economic social and cultural rights;
PRC: People’s Republic of China; ROC: Republic of China; SARS: Severe acute
respiratory syndrome; SOP: Standard operating procedure; TTS: The
Transplantation Society; UDHR: Universal declaration of human rights
Acknowledgments
We thank the BMC Medical Ethics reviewers and editors for their comments
and suggestions that helped us substantially to revise this article.
Funding
This work was partly supported by the grant Graduiertenkolleg (GRK) 2015/1
“Life Writing - Life Sciences”from the Deutsche Forschungsgemeinschaft
(DFG), Bonn, Germany.
Availability of data and materials
The datasets supporting the conclusions of this article are included within
the article and its additional file. Some reports (e.g. references [19] and [41])
are additionally archived on a publicly accessible server (https://archive.is).
The web addresses of the archived reports are provided at the end of the
references.
Authors’contributions
NWP drafted the manuscript and critically revised the manuscript. AC helped
to draft the manuscript and critically revised the manuscript. MES helped to
draft the manuscript and critically revised the manuscript. CE helped to draft
the manuscript and critically revised the manuscript. KCA drafted the
manuscript and critically revised the manuscript. HL drafted the manuscript
and critically revised the manuscript. All authors read and approved the final
manuscript.
Competing interests
The authors declare that they have no competing interests.
Consent for publication
Not applicable.
Ethics approval and consent to participate
Not applicable.
Author details
1
Institute for History, Philosophy and Ethics of Medicine, Johannes
Gutenberg University Medical Center, Mainz, Germany.
2
Division of Medical
Ethics, School of Medicine, New York University, New York, NY, USA.
3
Department of Surgery, Rutgers - New Jersey Medical School, Newark, USA.
4
Department of Psychiatry, University of Alberta, Edmonton, Canada.
5
School
of Public Health, University of Minnesota, Minneapolis, USA.
6
Department of
Pharmacology, Johannes Gutenberg University Medical Center, Obere
Zahlbacher Strasse 67, 55131 Mainz, Germany.
Received: 8 May 2016 Accepted: 24 January 2017
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