The organization of the human organ trade: a comparative crime script analysis

Abstract

This study fills critical knowledge gaps into the organization of organ trade utilizing crime script analysis. Adopting a situational crime prevention approach, this article draws from law enforcement data to compare the crime commission process (activities, cast and locations) of 2 prosecuted organ trade cases: the Medicus case and the Netcare case. Both cases involved transnational criminal networks that performed kidney transplants from living donors. We further present similarities and differences between illegal and legal living donor kidney transplants that may help guide identification and disruption of illegal transplants. Our analysis reveal the similar crime trajectories of both criminal cases, in particular the extensive preparations and high degree of organization that were needed to execute the illegal transplants. Offenders in the illegal transplant schemes utilized the same opportunity structures that facilitate legal transplants, such as transplant units, hospitals and blood banks. Our results indicate that the trade is embedded within the transplant industry and intersects with the transport- and hospitality sector. The transplant industry in the studied cases was particularly found to provide the medical infrastructure needed to facilitate and sustain organ trade. When compared to legal transplants, the studied illegal transplant scripts reveal a wider diversity in recruitment tactics and concealment strategies and a higher diversity in locations for the pre-operative work-up of donors and recipients. The results suggest the need for a broader conceptualization of the organ trade that incorporates both organized crime and white collar crime perspectives.

Full text

Vol.:(0123456789)
Crime, Law and Social Change (2023) 80:1–32
https://doi.org/10.1007/s10611-022-10068-5
1 3
The organization ofthehuman organ trade: acomparative
crime script analysis
FrederikeAmbagtsheer1 · RoosBugter2
Accepted: 8 November 2022 / Published online: 29 November 2022
© The Author(s) 2022
Abstract
This study fills critical knowledge gaps into the organization of organ trade utilizing
crime script analysis. Adopting a situational crime prevention approach, this article
draws from law enforcement data to compare the crime commission process (activi-
ties, cast and locations) of 2 prosecuted organ trade cases: the Medicus case and the
Netcare case. Both cases involved transnational criminal networks that performed
kidney transplants from living donors. We further present similarities and differ-
ences between illegal and legal living donor kidney transplants that may help guide
identification and disruption of illegal transplants. Our analysis reveal the similar
crime trajectories of both criminal cases, in particular the extensive preparations
and high degree of organization that were needed to execute the illegal transplants.
Offenders in the illegal transplant schemes utilized the same opportunity structures
that facilitate legal transplants, such as transplant units, hospitals and blood banks.
Our results indicate that the trade is embedded within the transplant industry and
intersects with the transport- and hospitality sector. The transplant industry in the
studied cases was particularly found to provide the medical infrastructure needed to
facilitate and sustain organ trade. When compared to legal transplants, the studied
illegal transplant scripts reveal a wider diversity in recruitment tactics and conceal-
ment strategies and a higher diversity in locations for the pre-operative work-up of
donors and recipients. The results suggest the need for a broader conceptualization
of the organ trade that incorporates both organized crime and white collar crime
perspectives.
Keywords Organ trafficking· Organized crime· White collar crime· Crime script
analysis· Situational crime prevention· Organ trade
* Frederike Ambagtsheer
j.ambagtsheer@erasmusmc.nl
1 Department ofInternal Medicine, Erasmus MC Transplant Institute, University Medical Center
Rotterdam, Dr. Molewaterplein 40, 3015GDRotterdam, TheNetherlands
2 Triodos Bank, Zeist, TheNetherlands
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F.Ambagtsheer, R.Bugter
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Introduction
The growing scarcity of human organs has led to an illegal organ market that is
proliferating globally (Moniruzzaman, 2019; Columb, 2020). This market fulfils
the demand that legal organ procurement systems fail to fulfil (Yousaf & Pur-
kayastha, 2015). Although reliable figures of the trade’s scope are lacking, the
World Health Organization (WHO) has estimated that approx. 5000 illegal trans-
plants are performed annually (WHO, 2007). The organ trade is reported to rank
in the top 5 of the world’s most lucrative international crimes with an estimated
annual profit of $840 million to $1.7 billion (May, 2017). While illegal organ
transplants have been reported to take place in countries across the globe, knowl-
edge of the trade’s operational features remains scarce (Pascalev et al., 2016).
Furthermore, all organ trade cases that have been exposed to date, reveal that
legal institutions including blood banks, hospitals, clinics and their staff were
directly or indirectly involved in facilitating illegal transplants (Ambagtsheer,
2019; Columb, 2017a; De Jong, 2017; OSCE, 2013). Nonetheless, the popular
discourse depicts organ trade as an underground, mafia-like crime that exists sep-
arately from the medical sector and other legal industries (Council of Europe,
2014; López-Fraga etal., 2014). Consequently, attention is diverted away from
the complicity of legal businesses and their staff.
At the time of writing, only 16 convictions involving organ trade have been
reported to the case law database of the United Nations Office on Drugs and
Crime, which is far less than would be expected based on global estimates of
the problem (UNODC, 2022). The Organization for Security and Co-operation
in Europe (OSCE) has reported 9 additional cases (OSCE, 2013). All reported
cases had cross-border features and most involved the facilitation of living donor
kidney transplants. Charges included e.g. fraud, brokering, trafficking in human
beings for the purpose of organ removal (THBOR), severe bodily injury, organ-
ized crime, assault, unlawful exercise of medical authority and abuse of author-
ity (OSCE, 2013; UNODC, 2022). A closer look at these cases reveals that suc-
cessful convictions of hospitals, medical staff and other legal actors are virtually
absent (Ambagtsheer, 2019, 2021; OSCE, 2013). Law enforcers report having
limited awareness and knowledge of how and where to identify and disrupt illicit
transplant activities (Ambagtsheer & Weimar, 2016a; Capron etal., 2016).
The underlying study aims to fill knowledge gaps into the organization of
the organ trade utilizing crime script analysis (CSA). CSA involves the decon-
struction of a crime commission process using a step-by-step approach. It high-
lights the sequence of decision points the offender goes through, as well as the
resources required at each step to successfully commit the offence (Cornish &
Clarke, 2002). For each stage, the crime script identifies the actors, the actions
they need to carry out to successfully further the commission of the crime, and
the opportunities they need to have available to do so (Borrion, 2013). Further-
more, CSA enables the identification of disruption points (Wortley & Townsley,
2016). CSA has been applied to a wide range of offences (Dehghanniri & Bor-
rion, 2019), but has not yet been applied to the organ trade.
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The organization ofthehuman organ trade: acomparative crime…
This study is the first to utilize law enforcement data to deconstruct and com-
pare the crime commission process of 2 prosecuted organ trade cases: the Netcare
-and Medicus case. Both cases involved transnational criminal networks that per-
formed illegal kidney transplants from living donors. These cases were also selected
because law enforcement authorities involved in the investigation and prosecution of
these cases were willing to host the research team during on-site visits and they pro-
vided access to case materials. Comparing criminal cases allows for a richer under-
standing of the ways in which organ trade is organized and provides insight into the
differences and similarities of the modus operandi of criminal groups and the social
and geographic contexts within which they operate. This study addresses the follow-
ing questions: What are the stages in the crime commission process of organ trade
networks? Who are involved in the facilitation of illegal organ transplants? Where is
the crime prepared and carried out? To identify underlying opportunity structures,
we also address occupational factors, transplant resources and the wider legal, medi-
cal, and geo-political context within which the illegal transplant operations in both
cases took place. Finally, to improve identification of illegal transplant activity, we
explore where and how illegal transplants divert from legitimate transplants and
identify disruption points.
This article first describes what is known about the organ trade, including its
organizational features. Then, we present the theoretical and methodological frame-
work. Next, to highlight where and how illegal transplants divert from legitimate
transplants, we present a script of a legitimate living donor kidney transplant proce-
dure. Subsequently, we present the crime scripts and highlight the scenes, cast and
locations of the studied cases. We also highlight how and where the scripts overlap
and diverge. Finally, we identify the opportunities that facilitated the illegal trans-
plant schemes, we explain how and where criminal transplant trajectories differ from
legal transplant scripts and we offer recommendations for disruption of the crime.
The human organ trade
Organ trade constitutes the sale and purchase of organs for financial or material gain
(WHO, 2010). Organ trade becomes human trafficking if an individual is threatened,
coerced, deceived or otherwise exploited for the removal of his/her organs (UNODC,
2016). THBOR was first prohibited in the 2000 United Nations Trafficking in Per-
sons Protocol (hereafter, Palermo Protocol) (United Nations, 2000). This definition
includes three key elements: 1) an action being recruitment, transportation, transfer,
harboring or receipt of persons; 2) a means by which that action is achieved: threat
or use of force, or other forms of coercion, abduction, fraud, deception, abuse of
power or abuse of a position of vulnerability, and the giving or receiving of pay-
ments or benefits to achieve consent of a person having control over another person;
and 3) a purpose of the intended action or means: exploitation. All three elements
must be present to constitute trafficking in persons (United Nations, 2000).
In 2014 the Council of Europe established a new convention against ‘Traffick-
ing in Human Organs’ which calls for a broad prohibition of virtually all commer-
cial dealings in organs. Accordingly, sales that occur with the consent of donors are
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F.Ambagtsheer, R.Bugter
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considered to be ‘trafficking’ regardless of the circumstances involved (Council of
Europe, 2015). At the time of writing, this convention has been ratified by 14 states
(Council of EuropeTreaty Office, 2022). Payments for organs and THBOR are pro-
hibited in almost all countries (Amahazion, 2016; UNODC, 2016). Iran is the only
country that has adopted a semi government-controlled kidney transplant program
that rewards living donors for their kidney donations (Fry-Revere, 2014). Despite an
almost-universal ban, the trade1 occurs in all corners of the world, inflicting harm on
the world’s most vulnerable populations (Columb, 2017b; Tong etal., 2012).
Organ trade is driven by an ever-increasing demand for organs. The trade in liv-
ing donor kidneys is the most commonly reported form of organ trade (Tong etal.,
2012). Due to the ageing of populations and the growth of diabetes and vascular
diseases, the number of people with organ failure is growing exponentially (ISN,
2017). Of all organs, kidneys are highest in demand (Shafran etal., 2014). Approx-
imately 10% of the world’s population suffers from chronic kidney failure (Rees,
Paloyo, et al., 2017). An estimated 2–7 million deaths occur annually because
patients suffering from kidney failure lack access to adequate treatment (Rees,
Paloyo, etal., 2017). Over 200.000 patients are registered on kidney transplant wait
lists worldwide (ISN, 2017). Roughly 75.000 (38%) of these patients receive a kid-
ney transplant annually (Council of Europe, 2019a). The total number of transplants
performed worldwide is estimated to be less than 10% of the global need (Council
of Europe, 2019a). Average wait times are 3–5years and annual mortality rates are
estimated to lie between 15–30% (Council of Europe, 2019a).
Because of the shortage of deceased donor kidneys, living kidney donation has
become the most important alternative to fulfill demand. The need to increase the
living kidney donor pool has been recognized by the global transplant community
(LaPointe etal., 2015). Due to advancements in transplant technology and excellent
results in living kidney donation, the living donor pool has expanded over the last 3
decades from genetically related donors to spouses, friends, acquaintances, neigh-
bors and anonymous donors (Matas etal., 2000; Slaats etal., 2018). By the end of
2018, living kidney donors accounted for 37% of all reported kidney transplantation
worldwide (Council of Europe, 2019a). The worldwide increase in legitimate living
donor kidney transplants has coincided with an illegal trade in living donor kidney
transplantations.
Despite growing attention for the organ trade, scholarly enquiry into this issue
remains scarce. Existing research predominantly describes the detrimental out-
comes associated with kidney sales on the black market (Budiani-Saberi etal.,
2014; Lundin, 2015; Tong etal., 2012; Yea, 2010). Only few studies focus on
other aspects of organ trade such as organ purchases, organ brokering and other
organizational features (Ambagtsheer & VanBalen, 2020; VanBalen etal., 2016;
Columb, 2017a; Pascalev etal., 2016).
1 In this article, we use ‘organ trade’ as an umbrella term to denote payments for organs, organ traffick-
ing and human trafficking for the purpose of organ removal.
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The organization ofthehuman organ trade: acomparative crime…
Organ trade’s organizational features
The OSCE was the first organization to offer insight into the organ trade’s opera-
tional aspects (OSCE, 2013). Analyzing data of 11 criminal cases, the OSCE high-
lighted the instrumental role of international brokers. These brokers lead the crimi-
nal network, identify transplant surgeons and locate hospitals and clinics. They hire
local brokers to recruit donors and recipients. The recruitment process involves
blood testing and cross-matching donors and recipients. The OSCE further iden-
tified ‘minders’ as playing a vital role in escorting donors and recipients, inform-
ing and instructing them about the transplant process and taking care of travel and
accommodation. Other facilitators include nephrologists, anesthesiologists, nurses,
medical facilities and administrative staff (OSCE, 2013). The OSCE also empha-
sizes the trade’s coercive and fraudulent nature (OSCE, 2013). Its report underpins
the crime’s cross-border dimensions, highlighting that recipients and donors are
often recruited from countries other than the countries where the transplants takes
place (OSCE, 2013).
De Jong (2017) deconstructs the trade through a human trafficking frame, ana-
lyzing its activities according to the ‘acts’ (recruitment, transport, transfer, harbor-
ing) and ‘means’ (coercion, fraud, etc.) as defined in the Palermo Protocol (De Jong,
2017; United Nations, 2000). She depicts the crime’s organizational model as highly
sophisticated, involving flexible combinations of criminal networks and actors that
join forces to facilitate illegal transplants on a global scale (De Jong, 2017). Columb
corroborates the loose and fluid structure of organ trade networks, but points out
that the organ trade is better understood as an informal economic activity that is
embedded within the transplant industry as opposed to a human trafficking offence
(Columb, 2020; Columb, 2015). He concludes, amongst others, that the expansion
of the transplant industry and the emergence of the organ market are interlinked
(Columb, 2020). The organ market constitutes a subsystem of the transplant industry
where the lines between the ‘legitimate’ and the ‘illegitimate’ are blurred (Columb,
2020).
While these studies offer new insights into the trade’s organization, no stud-
ies exist that systematically deconstruct the trade’s crime commission process in a
grounded way and that highlight physical, social and medical factors that facilitate
and sustain organ trade. Crucially, a theoretical and methodological approach is
lacking that conceptualizes the criminal stages of the organ trade process, decon-
structs the locations where the crime is prepared and conducted and helps to under-
stand the trade’s underlying opportunity structures. The next paragraph presents the
theoretical and methodological framework that guides this study.
Theoretical andmethodological guidance
Situational crime prevention andcrime script analysis
This study adopts a situational approach to crime. A situational crime prevention
approach understands crime as being shaped by the interplay between the physical
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F.Ambagtsheer, R.Bugter
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and socio-economic environment, the routines of actors and the combination of
facilitators and limitations, which combined determine the opportunity for crime
(Van deBunt & Schoot 2003; Clarke, 1995;Von Lampe, 2011). We define ‘oppor-
tunity’ as access to a suitable environment in order to pursue certain goals (Cloward
& Ohlin, 1960). The criminological opportunity theories grounded in a situational
approach (e.g., routine activity, rational choice theory) offer a useful framework
to systematically capture and understand the modus operandi of organized crimes
using CSA (Kleemans etal., 2012; Von Lampe, 2011; Levi & Maguire, 2004; Lord
etal., 2017).
CSA helps to understand criminality as rational, goal-oriented and purposive
behavior. Furthermore, it allows for a detailed identification and understanding
of a criminal activity into functionally, spatially, and temporally defined events
(Cornish, 1994). Criminal involvement includes a sequence of stages in which a
potential offender chooses to desist from or continue with crime (Bie etal., 2015;
Brantingham & Brantingham, 1993). CSA enables an in-depth examination of
these different stages or ‘scenes’, which may reveal procedural aspects of crimi-
nal activity and underlying opportunity structures (Bie etal., 2015). ‘Scenes’ can
consist of different ‘tracks’ that constitute the different ways in which criminal
behaviors can be accomplished. By understanding the crime’s procedural aspects,
intervention points can be identified (Lord etal., 2017).
In this study, we utilize CSA to identify opportunities for organ trade
through the deconstruction of scenes, actors (‘cast’) and locations (Cornish,
1994). CSA further helps to explore convergence of legal and illegal struc-
tures, in particular opportunities for co-offending (Felson, 2006;Von Lampe,
2011). Organ transplants require the involvement of specialized medical staff
including nephrologists, anesthesiologists and transplant surgeons. Illegal
organ transplants involve collaboration of these occupations with recruit-
ers, brokers and minders to recruit paid donors and recipients. Organ trade
thus involves a range of ‘legal’ and ‘illegal’ actors who co-offend to recruit
donors and recipients, perform the nephrectomy (the removal of the kidney
from the donor) and the transplantation (the implantation of the kidney into
the body of the recipient) and distribute profits (De Jong, 2017; Ambagt-
sheer, 2017; Columb, 2020). Applying CSA to organ trade within a situa-
tional crime approach can help reveal the social, medical and legal infra-
structures that networks rely upon to sustain and conceal illicit transplant
activity. Furthermore, it can shed light on the trade’s intersections with the
medical sector and other legal industries. Utilizing CSA within a situational
crime prevention framework also guides the identification of measures that
can help prevent or disrupt organ trade activity (Edwards & Levi, 2008; Von
Lampe, 2011).
Data sources andanalytical strategy
Data was gathered under auspices of the ‘HOTT project’, a research project funded
by the European Commission, that aimed to increase knowledge, raise awareness
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The organization ofthehuman organ trade: acomparative crime…
and improve responses to THBOR (Ambagtsheer & Weimar, 2016b; HOTT Project,
2012-2016). Data pertaining to the Netcare –and Medicus cases was collected in
South Africa, Kosovo, United Kingdom and Israel.
The collected materials predominantly consisted of law enforcement data, i.e.
charge sheets, indictments, closing statements, judgments, victim and witness tes-
timonies, legislation, international arrest warrants, notes and summaries of court
proceedings, defense statements and affidavits. This data was supplemented with 36
anonymous in-depth, semi-structured interviews that F.A. and other team members
of the HOTT project held with 45 respondents, most of whom were involved in the
investigation and prosecution of these cases. We additionally interviewed offenders’
defense lawyers, patients, nephrologists, surgeons, nurses, transplant coordinators,
social workers, representatives of international organizations, government officials
and human trafficking experts. The case materials and respondents are enclosed as
Appendixes 1 and 2.
The data was analyzed using qualitative content analysis. Coding of the data was
‘data-driven’ (Gibbs, 2007). Qualitative data analysis software (NVivo-QSR 12) was
used to classify the data, to construct coding structures and to run coding queries.
Because of the crime’s complexity and knowledge gaps, we organized our results in
accordance with Thompson and Chainey’s simplified, universal script which con-
sists of 4 components: ‘preparation’, ‘pre-activity’, ‘activity’, and ‘post-activity’
(Tompson & Chainey, 2011). First, we (F.A. and R.B) each separately classified the
data (totaling 1726 pages) according to the 4 components of this universal script
and deconstructed the data into ‘scenes’. We performed this procedure separately
for each case, thereby generating 4 coding structures (2 for each case). We coded
all scenes prior to the entry of the transplant destination country under ‘prepara-
tion’. All activities that took place after arrival in the destination country prior to
the transplants, was coded under ‘pre-activity’. The nephrectomies and transplanta-
tions were coded under ‘activity’ and activities that took place after the transplanta-
tions were coded under ‘post-activity’. To identify underlying social and physical
opportunity structures, we coded the actors and location(s) for each scene. Given
the cases’ transnational dimensions, we coded the places (i.e. airport, hospital,
hotel) and the countries where the activities took place under ‘location’. To identify
broader opportunities for organ trade, we also coded contextual factors that help to
explain why the offenders chose these locations. Our grounded approach allowed
us to identify overarching themes that emerged from the data which help to further
conceptualize and explain our findings.
After completing the first round of coding, we discussed differences in the coded
data and fine-tuned scenes. Then, we merged the coding structures into 2 coding
schemes (1 for each case) and classified the scenes into scripts during various dis-
cussion rounds. During these discussions, we subjected our scripts to Borrion’s qual-
ity criteria to ensure completeness and accuracy of the scripts (Borrion, 2013). We
also asked a colleague (not involved in this study) to verify the clarity of the scripts.
To comparatively analyze differences and similarities in the crime commission pro-
cess between both criminal cases, we conducted matrix coding queries at scene -and
script level. The crime scripts are presented in Figs.2 and 3. The detailed descrip-
tive scripts including tracks and cast are enclosed as supplementary materials.
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Finally, to explore which features differentiate the crime scripts from a legal
transplant script, we constructed a script of a legitimate living donor kidney trans-
plantation. We developed this script based on transplant protocols and we refined the
script during discussion rounds with the transplant team at Erasmus MC’s Depart-
ment of Nephrology and Kidney Transplantation. We then conducted coding queries
using NVivo-QSR 12 to identify similarities and differences between the legal trans-
plant script and the crime scripts. The stages of a living donor kidney transplanta-
tion are presented in Fig.1. The detailed script including tracks, cast and locations is
enclosed as supplementary materialin Appendix 3.
Limitations
Our analysis revealed gaps in the data. For example, the data did not always spec-
ify which actor(s) conducted the identified criminal activities. Of some activities it
is also unclear in which locations they took place. These gaps are recognizable by
fields in Appendixes 4 and 5 that have been left intentionally blank.
Terminology
The open-coding analysis generated a variety of actors, many of which were
termed differently within and between the criminal cases, despite the cohesive-
ness of their activities in the various scenes. In particular the terms, ‘brokers’,
‘fixers’ and ‘recruiters’ were interchangeably used without definition. Donors and
victims were also denoted differently. For example, in the Netcare case, donors/
kidney sellers were described as ‘suppliers’, whereas in the Medicus case they
were interchangeably depicted as ‘victims’ and ‘donors. Furthermore, many
actors adopted multiple roles. For example, transplant surgeons not only per-
formed transplant operations but also recruited, screened and escorted recipients
to the transplant-destination countries. Interpreters simultaneously took on the
role of minders/fixers, arranging for transportation and other logistics for recipi-
ents and donors next to providing translation services.
To enhance clarity of the terminology used, we created a node attribute list
of the actors in which their occupations, activities and double roles were high-
lighted. We then condensed this list into a table (Table1), where we define the
terms and roles of each actor and highlight which actors took on multiple roles.
We adopt many of these terms throughout this study. For example, we refer to
organ buyers as ‘patients’ or ‘recipients’ and to organ sellers as ‘donors’. We
specify double roles, by using a ‘/’ between the terms. For instance, transplant
surgeons who also escorted patients are denoted as ‘transplant surgeon/recruiter’.
Interpreters who also arranged logistics are denoted as ‘interpreter/fixer’. This
table is not intended to present universal definitions of actors in organ trade. Its
purpose is to avoid confusion and to clarify what is meant with the various terms
used throughout this study.
Throughout this article, we mention the full names of offenders who have
appeared in public court records, in the media and/or in publications. For those
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The organization ofthehuman organ trade: acomparative crime…
who have not appeared in public records, we only mention the occupations/roles
as presented in Table1.
The legality andillegality ofliving donor kidney transplantations
An understanding of illegal kidney transplants requires knowledge of how legal
living donor kidney transplants are performed and what factors differentiate them
from illegal transplants. Given the global expansion of living kidney donation,
the transplant community has formulated minimum standards and procedures
to ensure autonomy and safety of donors and recipients. For living donors these
include medical and psychosocial evaluation, informed consent, voluntariness,
long-term follow-up and registries, and the prohibition of using minors as donors
(Delmonico, 2005). Universal guidelines affirm that a living donation needs to be
performed in a manner that minimizes the physical, psychological and social risk
to the donor and that does not jeopardize the public trust within the healthcare
community (Council of Europe, 1997; Pruett etal., 2006; Steering Committee of
the Istanbul Summit, 2008). The donation decision should further be performed in
an environment that enables the potential donor to decide autonomously (Delmon-
ico, 2005; Pruett etal., 2006). The prohibition of payments for organs functions as
Table 1 Description of actors and their roles
Recipient The (prospective) recipient of an organ transplant. Also denoted as ‘patient’ or
‘organ buyer’
Donor The person who donates or sells an organ. Also denoted as ‘victim’, ‘supplier’
or ‘organ seller’
Recruiter Solicits / recruits recipients and donors
Escort Accompanies or ‘chaperones’ recipients and donors to, from and within coun-
tries
Broker Operates transnationally, handles payments, connecting figure between doctors,
recipients, donors and other actors in the scheme
Fixer Arranges transport, accommodation and other logistics for donors and recipients
in transit and destination countries. Also depicted as ‘minder’
Driver Transports donors and recipients from/between hotels, airports, hospitals and
other locations
Transplant coordinator Coordinates transplant logistics, schedules transplants
Nephrologist Medical doctor who specializes in treatment of kidney disease
Transplant surgeon Medical doctor who conducts the donor nephrectomy (organ removal) and
transplantation
Anesthesiologist Medical doctor who specializes in perioperative care, develops anesthetic plans
and administers anesthetics during surgery
Nurse Is trained to care for the sick
Matron A woman in charge of medical arrangements
Medical technician Assists with medical diagnoses by performing tests for physicians and hospitals
in a laboratory setting
Interpreter Provides translation services between donors, recipients and other actors
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F.Ambagtsheer, R.Bugter
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a safeguard in this respect, as its underlying rationale is that paid donors cannot
freely consent to their organ sale (Council of Europe,2015, 2019b; Hilhorst &
Van Dijk, 2007). The WHO was the first organization to introduce the prohibi-
tion of payment for organs in 1987, declaring that “organs should only be donated
freely, without any monetary payment or other reward of monetary value.” (WHO,
1987; WHO, 2010).
The principle of non-payment for organs is reiterated in numerous interna-
tional instruments (Council of Europe, 1997; Steering Committee of the Istanbul
Summit, 2008) and has been codified into the legislation of (almost) all coun-
tries that run transplantation programs (Amahazion, 2016). Compensating donors
for the costs of their donation (including medical expenses and lost earnings) is
permitted lest they operate as a disincentive to donation (WHO, 2010). Besides
receiving payment for organs, it is also forbidden for patients to pay donors or
‘third parties’ in return for an organ, to advertise the sale of an organ and/or to
advertise the need for an organ in return for payment (Council of Europe, 2015,
2019b). Third parties can be recruiters, brokers, medical professionals and pub-
lic officials (Council of Europe, 2019b). As mentioned, payments for organs can
lead to THBOR if the trafficking elements are fulfilled (United Nations, 2000).
THBOR can be established irrespective of whether a donor has been paid (United
Nations, 2000).
Despite these regulations, the illegality of paying for a transplantation is not
always clear (Ambagtsheer etal., 2012). In countries without established health
insurance systems, it is common practice for patients to pay hospitals and clinics
directly in return for an organ transplantation. Such payments are not necessar-
ily illegal, in particular if it is not evident that a donor, recruiter and/or broker
has been paid or exploited (Ambagtsheer etal., 2012). Transporting an organ or
carrying an implanted/transplanted organ is also not illegitimate per se. Organs
are -by nature- legal goods. Identifying a patient who is carrying a transplanted
organ, even if the origins of the organ are unknown, will likely be insufficient
to establish a criminal case. In order to prove a criminal act, it must be estab-
lished that the organ has been obtained through illegal payments and/or exploi-
tation. Proving payments and/or exploitation is especially difficult if a patient
crosses borders with a transplanted organ (Ambagtsheer & Van Balen, 2020;
Ambagtsheer etal., 2012). As will be illustrated, the criminal networks involved
in Netcare and Medicus took advantage of jurisdictional loopholes by operating
transnationally.
Despite internationally agreed standards, legal regulations that govern living kid-
ney transplantations differ significantly between countries (Lopp, 2013). For exam-
ple, some countries such as Germany and Israel only allow living kidney donors who
can demonstrate a close emotional relationship to their intended recipient (Lopp,
2013). South Africa’s regulations require genetically non-related kidney donations
to be approved by a ministerial committee (Ambagtsheer, 2019, 2021). The USA,
The Netherlands and the United Kingdom by contrast do not require a relation-
ship between prospective living donors and recipients (Lopp, 2013). These coun-
tries accept different types of living donations, including anonymous kidney dona-
tion and paired kidney exchanges (Klerk, 2010; Rees etal., 2009; Roth etal., 2004;
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11
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The organization ofthehuman organ trade: acomparative crime…
Slaats etal., 2018).2 In recent years, some countries have started exploring global
kidney exchanges (Ambagtsheer etal., 2020; ENCKEP, 2017; Rees, Dunn, et al.,
2017). In global living donor kidney exchanges, incompatible donors and recipi-
ent pairs travel from low income countries to high income countries where they are
matched to other incompatible pairs (Rees, Dunn, etal., 2017). In many countries it
is accepted practice to accept living donors from abroad. In the USA for instance,
100–150 living donor kidney transplants are performed every year, utilizing donors
who do not reside in the USA (Al Ammary etal., 2019). Most of these donors are
friends or relatives of the recipient who live abroad (Shukhman etal., 2020). The
transplant community accepts this practice as a legitimate activity as long as there is
evidence of a personal relationship (Shukhman etal., 2020; Steering Committee of
the Istanbul Summit, 2008).
The varieties between domestic transplant regulations illustrate that the bounda-
ries between ‘legal’ and ‘illegal’ living donor kidney transplants are far from clear
and that they are contingent on the national and legislative context within which
they take place. Notably, not all countries conduct organ transplantations. Some
governments, including Kosovo, prohibit transplantation altogether (Ambagtsheer,
2019). These disparities preclude the development of a uniform, universal script of
a living kidney donation and transplantation procedure. Despite these differences,
there are agreed upon standards and procedures that a living donor kidney transplant
procedure should follow. Figure1 presents the stages of a legitimate living donor
kidney transplant procedure.
Cast andlocations
The cast of a legal transplant procedure generally involves a large multidiscipli-
nary team consisting of nephrologists, immunologists, transplant surgeons, anes-
thesiologists, nurses, research nurses, nurse practitioners, transplant coordinators,
social workers, dieticians, physiotherapists, pathologists, infectiologists, virologists,
Medical
screening
Psycholo gical
screeningDocumentsTransportRegistration and
scheduling
Preparing for
surgeryDonation
Post-operative care Discharge and
follow-upReimbursement
Recipient
and donor
In cross-
border
transplant
Only in countries
with health
insurance scheme s
Transplantation
Informed
consent
If donor is
anonymous / if
legally manda tory
Fig. 1 Script of a legitimate living donor kidney transplant
2 A paired exchange takes place if a willing prospective donor cannot donate his/her organ to his/her
intended recipient due to blood type incompatibility or other medical barriers. This pair is then linked to
another pair with the same problem (Rees etal. 2009; Roth etal. 2004; de Klerk 2010).
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12
F.Ambagtsheer, R.Bugter
1 3
bacteriologists, radiologists, researchers and lab workers. locations of living donor
kidney transplants include hospitals, (outpatient) medical clinics and transplant cent-
ers. The detailed script of a living donor kidney transplant is presented in Appendix 3.
Deconstructing thetrade inhuman organs: thecrime scripts
oftheNetcare‑ andMedicus cases
Our analysis of the Netcare case yielded 7 sequential preparatory scripts (conception;
planning; recruitment; payments; medical screening, falsifying documents; transport),
6 pre-activity scripts (escort and accommodation; medical screening; coordination
and scheduling; falsifying documents; translation; preparing for surgery), 2 activity
scripts (donation; transplantation) and 4 post-activity stages (post-operative care;
discharge; transport; payments/reimbursement). The analysis of the Medicus case
yielded 7 preparatory scripts (conception; planning; recruitment; payments; medical
screening; scheduling; transport), 5 pre-activity stages (escort and accommodation;
falsifying documents and instructions; introductions; payments; preparing for sur-
gery), 2 activity scripts (donation; transplantation) and 4 post-activity stages (post-
operative care; documents and discharge; payments/reimbursement; transport).
At first glance, findings reveal the similar script-level trajectories of both cases,
in particular the extensive preparations that were needed to execute the schemes.
Nonetheless, there are also notable differences. Below, we present the script of each
case and highlight differences and similarities.
The Netcare case
In 2001, an Israeli businessman (Ilan Perry), depicted as the ‘main broker’ by the case’s
investigators and prosecutors, proposed a kidney transplant scheme to a private hos-
pital group in South Africa (Netcare Ltd.). His proposal involved transplanting Israeli
citizens at Netcare’s hospitals in Cape Town, Johannesburg, and Durban. Between 2001
and 2003, 224 Israeli patients were found to have traveled to South Africa for illegal
kidney transplantations. The donors were predominantly young men in their 20s who
were recruited in Israel, Romania, and Brazil (Ambagtsheer, 2021; De Jong, 2017;
Scheper-Hughes, 2011). Later, a second broker (Sushan Meir) joined the scheme, who
also supplied recipients and donors. Thus, with the arrival of this broker, two networks
co-existed, forming the ‘Israeli transplant scheme’ (Allain, 2011; Scheper-Hughes,
2011; Sidley, 2005). The script of this scheme is presented in Fig.2.
Preparation
Conception andplanning
Perry and Meir colluded with transplant coordinators in at least 5 hospitals, as
well as with Netcare’s CEO (Friedland), with Netcare’s legal advisor and with
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The organization ofthehuman organ trade: acomparative crime…
other medical staff to make use of these hospitals’ transplant resources. Resources
included operating theatres, a blood bank, surgeons, medical assistants and other
personnel.
Concealment emerged as a prominent theme during the offenders’ planning and
deliberations, which involved various tactics to conceal the transplants’ illegitimacy.
Early deliberations took place between Netcare’s national transplant coordinator
(Belinda Rossi), Friedland, Netcare’s legal advisor and ‘parties in Israel’ to identify
legislative loopholes. Rossi traveled to Israel to present South Africa’s transplant
regulations, meetings were held with South Africa’s Department of Health officials
and Netcare’s legal advisor was consulted on how to circumvent South Africa’s
transplant laws:
As it was high risk due to the non-South African citizens, I discussed it with
Friedland. It was high risk in the sense that we would have to take the parties’
word and at face value. The volumes they promised made it worth the risk.
Friedland wanted to know if there was any way we could prove the donors/
recipients were related. I said no. I showed him the documents I had received
from Perry and he told me to go to [Netcare’s legal advisor] to get it properly
worded. (Testimony Belinda Rossi, Notice of Motion between Applicants and
Prosecutor, December 2011; para. 85, pp. 85-86)
After Netcare’s legal advisor was consulted, a protocol was drawn up for the
Israeli transplant scheme in which consent forms were forged to make it appear
that donors and recipients were related even though they were not. By doing so, the
offenders circumvented the requirement of the ministerial committee that required
recipients and donors to be related. This process not only served to conceal the
scheme’s illegality, but also helped to embed the scheme within South Africa’s med-
ical infrastructure.
ACTIVITY
POST-ACTIVITY
PREPARATION
PRE-ACTIVITY
Conception Planning RecruitmentPayments Medical
Screening
Falsifying
documentsTransport
Escort and
accommation Payments Medical
screening
Coordination
andscheduling
Falsifying
documents Translation
Post-operative
care
Documents
anddischarge Transport
Preparingfor
surgery
Payments and
reimbursement
Donation Transplantation
Fig. 2 Crime script of the Netcare case
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F.Ambagtsheer, R.Bugter
1 3
Recruitment
Recruitment of donors and recipients formed a significant part of the prepara-
tion stage and was conducted transnationally through close collaboration between
recruiters, brokers, transplant surgeons and other medical staff. Donors were either
recruited via advertisements in newspapers or they heard about the opportunity to
sell their kidney from former kidney sellers. Initially, the donors were recruited in
Israel and Romania, but later, Brazilian kidney suppliers were recruited because
their kidneys could be obtained at a much lower cost. While the Israeli and Roma-
nian donors were promised $20,000 for their kidneys, the Brazilian donors were
promised between $3,000 and $8,000. Most donors were recruited in Brazil by 2
retired military officers (Ambagtsheer, 2021; De Jong, 2017; Scheper-Hughes,
2011).
Payments andreimbursements
Payments took place throughout all stages of the crime commission process.
Patients paid Perry/his company up to $120,000 prior to their travel and trans-
plant. Perry, and later also Meir, subsequently paid Netcare. Netcare in turn
disbursed payments to various actors in the scheme, including the transplant
surgeons and the blood bank. Netcare had an account at Nedbank that was des-
ignated for the Israeli transplant scheme. One of Netcare’s transplant coordina-
tors/interpreters handled this account. Occasionally, additional payments were
made directly in cash to the surgeons by Perry, his company, or his agents.
Perry also paid an escort/fixer (Rod Kimberley) and a nephrologist. Kimber-
ley paid low-tier offenders in the scheme, including the interpreters. Kimberley
additionally covered the costs of recipients’ and donors’ accommodations and
he gave donors pocket money upon arrival in South Africa as an advance to
their kidney payment. All donors received the promised amount in cash after
their operations.
In addition to payments, gifts were given to medical staff to mitigate their doubts
and concerns about the legality of the Israeli transplant program. As one respondent
stated:
The Israeli guys came and they would always kind of entertain us. [T]hey
would come, you know, the businessman […] and professor Shapira the doc-
tor, and the translators. And they always kind of took us out for meals, to nice
places or, you know, do nice things with us. [W]e went out for dinner one
evening and they just gave me a lot of money in my hand, saying ’we want you
to have this money to go to a conference. We want to sponsor you to go for a
conference, because you are helping us now. This is our way.’ (Social Worker,
former Netcare employee)
In addition to payments for their kidney, donors received additional payments
from their recruiters if they solicited new prospective kidney sellers, thereby becom-
ing recruiters themselves.
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The organization ofthehuman organ trade: acomparative crime…
Medical screening andscheduling
Recipients and donors underwent preliminary blood group and tissue-typing tests in
their home countries. Perry hired recruiters in Brazil who arranged for the donors’
medical screening, their blood tests and their travel to South Africa.
Transportation
Transportation of donors and recipients took place before and after the transplanta-
tions. Donors and recipients were frequently chaperoned by recruiters/brokers and
transplant surgeons. The offenders traveled to and from Israel in the preparatory stages.
Airports, planes, and cars served as vital travel hubs and modes of transportation.
Pre‑activity
Escort, accommodation, medical screening andscheduling
Upon arrival in South Africa, donors and recipients were accompanied by interpret-
ers/escorts who took care of their visas and travel bookings, accommodated them in
apartments and hotels, took them on safari and other sight-seeing tours, escorted them
to and from the hospital and assisted them with other daily logistics. Cross-matching
procedures were performed by staff of South Africa’s National Blood Bank to ensure
compatibility between donor and recipient pools. Subsequently, the transplant opera-
tions were scheduled.
Falsifying documents andtranslation
Israeli recipients and donors were instructed to sign documents in Israel before trav-
elling to South Africa that falsely stated that they were related. Other recipients and
donors signed false consent forms upon arrival in South Africa.
Activity
This stage involved the kidney removal (donation/nephrectomy) and the transplanta-
tion. It contained the least number of tracks. It also occurred within a short timeframe,
usually within the span of one day. The activity stage is thus the least elaborate script
of the cases’ crime trajectory.
Post activity
Post‑operative care, documents, discharge, reimbursement ofcosts
Organ trading schemes are characterized by their rapid discharge times, inadequate
medical screening and lack of post-operative care and follow-up of donors and
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16
F.Ambagtsheer, R.Bugter
1 3
recipients (De Jong, 2017; Ambagtsheer. 2017; Tong et al., 2012). Donors in the
Netcare case were discharged from the hospitals already after 2days. Whilst some
were reported to stay in South Africa up to 3weeks after discharge during which
they received post-operative care, others were ‘sent back on the next available flight’
immediately after their release from the hospital. While most donors did not receive
follow-up treatment in their home countries, some Brazilian donors were brought to
local clinics by police officers for follow-up care during the investigation.
Before returning to Israel, recipients received discharge letters and documenta-
tion that provided information for their doctors in Israel about their medication regi-
men. Medical professionals in South Africa collaborated with the patients’ doctors
in Israel to ensure follow-up treatment. The recipients’ transplants were reimbursed
post-operatively by their health insurance companies in Israel. Until 2008 it was
common practice for Israeli health insurance companies to compensate transplants
performed abroad, regardless of their illegitimacy (Ambagtsheer, 2017). In 2008,
Israeli authorities banned the practice of insurance companies covering the costs of
overseas living kidney donor transplants (De Jong, 2017; Ambagtsheer, 2017; Orr
etal., 2014; Scheper-Hughes, 2011).
The Medicus case
The Medicus Clinic was established in 2004 in Pristina, Kosovo, as a private urol-
ogy clinic and was owned by a Kosovar urologist, Lutfi Dervishi and his son,
Arban Dervishi. Lutfi Dervishi wanted to perform kidney transplants in his clinic
and came into contact with Yusuf Sonmez, a Turkish transplant surgeon, at a urol-
ogy conference in Istanbul. By contacting Sonmez, Dervishi tapped into a network
of Israeli and Turkish recruiters, brokers and surgeons that had been facilitating
illegal kidney transplants in hospitals and clinics across Eastern and Central Europe
for many years (OSCE, 2013; Sanal, 2004; Scheper-Hughes, 2004). From March
through November 2008, the network recruited 24 donors in Israel, Turkey, Mol-
dova, Russia, Ukraine, Kazakhstan, and Belarus and flew them to Kosovo for the
removal of their kidneys at the Medicus clinic. The donors were matched to 24
recipients, leading to 48 illegal transplant operations. Most patients were recruited
in Israel with the help of an Israeli transplant surgeon, Zaki Shapira. Other recipi-
ents came from Ukraine, Turkey, Poland, Canada, and Germany. The script of this
scheme is presented in Fig.3.
Preparation
Conception andplanning
While the Israeli transplant scheme in the Netcare case was embedded within South
Africa’s transplant infrastructure, Kosovo lacks a national transplant programme.
Thus, the offenders in the Medicus case had to conduct more extensive preparations
than offenders in the Netcare case. An international urology conference in Istanbul
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The organization ofthehuman organ trade: acomparative crime…
functioned as a vital location for Lutfi Dervishi and Sonmez to connect and col-
lude. Their preparations involved e-mail and phone communications, the purchase
of equipment, medications, and other resources, transporting these to Kosovo and
recruiting medical staff (e.g., anesthesiologists, nurses, technicians). The recruit-
ment of staff also included the application for a working license for Sonmez to con-
duct transplants in Kosovo:
Dear Lutfi, […] I understood you want from the Turkish Medical Association
my “doctor card”. This proves that I do my job as a doctor in Turkey. And
meanwhile I will try to send you a paper which I will ask to the notary to
translate into English a paper that I am working as a doctor. […]. I do all this
stuff next week and will send you by e-mail. The patients are already waiting.
All the best, Yusuf. (Basic Court Judgment, 29th April 2013, p. 99).
Regular meetings took place between Lutfi Dervishi, Sonmez, Moshe Harel (a
broker), Sokol Hajdini (the lead-anesthesiologist), Arban Dervishi and government
officials to apply for a license to conduct transplants in the Medicus Clinic. Simi-
lar to the Netcare case, offenders in the Medicus case employed various tactics to
give the scheme an appearance of legality. The processes through which illicitly
obtained organs take on the veneer of a licit transaction are also known as ‘organ
laundering’ (Manzano etal., 2014). The issuing of a transplant license for a clinic
that is not legally mandated to perform transplants is an example thereof. Whilst
it has not been established that Dervishi’s application for a transplant license was
successful, the Ministry of Health provided him with a ‘confirmation of license
approval’. The offenders also used this document to convince and recruit hesitant
recipients and donors whom they falsely informed that the transplant procedures
were legal.
ACTIVITY
POST-ACTIVITY
PREPARATION
PRE-ACTIVITY
Escort and
accommation
Falsifying
documents,
instructions
Payments
Conception Planning RecruitmentPayments Medical
ScreeningSchedulingTransport
Preparingfor
surgery
Donation Transplantation
Post-operative
care
Documents
anddischarge
Payments and
reimbursementTransport
Fig. 3 Crime script of the Medicus case
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18
F.Ambagtsheer, R.Bugter
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Recruitment
Donors and recipients in the Medicus case were also recruited transnation-
ally through close collaboration between the various offenders. Patients were
recruited transnationally via online advertisements or through word of mouth
from other patients in dialysis clinics. The phone numbers of recruiters/brokers
were known and shared amongst patients in these clinics. Patients met their
recruiters in their homes, in café’s and in shopping malls where they received
information about the transplant costs and procedure. In both cases patients
signed contracts with ‘medical service companies’ that were owned by the bro-
kers/recruiters. Some patients were recruited by transplant surgeons in Turkey
and Israel. These surgeons were their first point of contact. They recommended
the patients to travel to Kosovo, South Africa, and other countries for transplan-
tation, as illustrated by an Israeli indictment that charged Shapira, an Israeli
transplant surgeon who was also involved in the Netcare case, for brokering
illegal kidney transplants in Kosovo:
[Shapira] was responsible for examining the “Medicus” Medical Clinic
and examining its suitability for the execution of the transplants. On that
basis, he used to meet with potential [r]ecipients; he would explain to
them the transplant process, referred them to carry out medical examina-
tions, examined the medical documents of the [p]atients and [d]onors and
authorized the execution of the illegal transplant with respect to the medi-
cal condition of the [p]atients and the suitability of the [d]onor. In some
of the cases, [he] would accompany the [p]atients during their hospital
stay in Kosovo. (Tel Aviv-Jaffa Magistrate Court Indictment, para. 17).
Donors were recruited via newspapers –and online advertisements in Israel,
Turkey, Moldova, Russia, Ukraine, Kazakhstan, and Belarus and were promised
between $10.000-$30,000 for their kidney. This type of ‘passive’ recruitment
is a common tactic in organ trading schemes. Posting advertisements and using
subtle ploys instead of actively or forcibly recruiting patients and donors into
transplant schemes renders exploitation less evident and therefore more dif-
ficult to prove by law enforcers (De Jong, 2017). Donors met their recruiters
in parks and at bus stations in their home countries. Some were introduced to
former kidney sellers to mitigate their doubts and concerns about their kidney
sale.
Payments andreimbursements
Payments in the Medicus also case took place throughout all stages of the crime
commission process. Patients in the Medicus case paid up to $108,000 for their
transplants in installments. Their first payments were made prior to their travel
to Kosovo to recruiters/brokers, transplant surgeons and to their escorts. They
carried their second installments with them on the plane and paid these at the
Medicus Clinic, either before or after their transplant to Harel, Arban Dervishi
and to other offenders.
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The organization ofthehuman organ trade: acomparative crime…
Recipients’ payments were used to (partially) pay the donors after their
operations. The remaining profits were distributed between the recruiters/bro-
kers, transplant doctors and other offenders. Contrary to donors in the Netcare
case, none of the Medicus’ donors received the promised amount. Some did not
receive payment at all but were promised payment only if they recruited new
prospective kidney sellers. Withholding payments to kidney sellers in order for
them to recruit new prospective kidney sellers is a tactic in organ trafficking
schemes to sustain the transplant program (De Jong, 2017). Contrary to other
types of (trafficking) crimes where victimization can reoccur over a longer
period of time, donors in living donor kidney trading schemes become ‘dispos-
able’ after their kidney sale, which increases the need for frequent recruitment
cycles to guarantee a continuous flow of donors.
Medical screening andscheduling
Recipients and donors underwent preliminary blood group and tissue-typing
tests in their home countries and underwent additional ‘confirmatory’ blood
tests during their transits in Istanbul. These tests took place in cars, in hotel
rooms, in hotel lobbies and in medical clinics under the supervision of escorts.
These tests served to cross-match the patients and donors in order to find a
transplant match. Subsequently, the surgeries were scheduled and further travel
arrangements were made. While the data in the Netcare case contains gaps per-
taining to screening and pre-operative work-up of Israeli recipients, the Medi-
cus case revealed extensive communications by phone and email between recip-
ients/donors and their transplant surgeons and recruiters. This communication
involved exchange of medical information, confirmations that donors and recip-
ients had been found and scheduling their transplant operations. Recruiters fre-
quently referred patients to Shapira for recipients’ pre-operative work-up.
Transportation
Transportation of donors and recipients took place both before and after the
transplantations and they were frequently chaperoned by recruiters/brokers and
transplant surgeons. Sonmez traveled regularly to and from Kosovo in order to
perform transplants. In this case, airports, planes, and cars also served as vital
travel hubs and modes of transportation. Istanbul functioned as an important
transit city.
Offenders devised various strategies to avoid detection during transit and
travel. They provided recipients and donors with false invitation letters and
instructed them to inform customs at the airport in Pristina, that the purpose of
their visit was to undergo heart treatments at the Medicus Clinic. A broker who
regularly escorted recipients and donors to Pristina falsely informed customs
that he was traveling to Kosovo for his elevator business. Sonmez claimed that
he traveled to Kosovo to correct previously conducted transplant operations for
recipients suffering from complications.
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20
F.Ambagtsheer, R.Bugter
1 3
Pre‑activity
Escort, accommodation, medical screening andscheduling
The script of the Medicus case diverges from Netcare’s script at this stage. In the
Medicus case, pre-transplant screening and cross-matching occurred before donors’
and recipients’ travel to Kosovo. The patients’ and donors’ duration of stay in Kos-
ovo was therefore much shorter than those involved in the Netcare case. Upon arrival
in Kosovo, patients were transferred directly to the Medicus Clinic. Donors were
either accommodated in hotels or brought directly to the clinic. Operations would
either occur on the same day of donors’ and recipients’ arrival in Pristina or the day
after. The differences in scripts between both cases are explained by the absence
of a transplant surgeon in Kosovo and the presence of a transplant infrastructure in
South Africa. The scheduling of Sonmez’s transport and transplant operation dates
in Kosovo therefore coincided with those of the recipients and donors.
Falsifying documents andtranslation
In the Medicus case, donors and recipients were instructed to sign so-called ‘Deeds
of Donation’ and ‘Kidney Donation Clearance Forms’ upon arrival in Kosovo that
declared that they were related, that the donation was altruistic and voluntary and
that they had appeared before an ethical committee. The purpose of this committee
was to show that the donors were donating their kidneys for altruistic reasons or to
relatives. No proof however was found that this committee existed.
A difference between the cases is that in the Netcare case Hebrew and Portuguese
interpreters were hired to provide translations between donors/recipients and medi-
cal staff. Recipients and donors were thus informed about what they were signing.
Due to the lack of translation in the Medicus case, most of the recipients and donors
reported that they did not understand the content of the forms that they signed.
Activity
The cases diverge with respect to the locations and legal embeddedness. Contrary
to the Medicus case where transplants were organized in one clinic that was not
licensed to conduct transplants, transplants in South Africa were facilitated in at
least 5 hospitals across the country that were legally mandated to perform trans-
plants. The short timeframe of the main activity (donation/transplantation) differ-
entiates living donor kidney trading schemes from e.g. sex -and labor trafficking
schemes, where victimization and profit-making can re-occur with regards to the
same victim over longer periods of time (Hiah & Staring, 2016; Leclerc etal., 2011;
Savona etal., 2013).
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21
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The organization ofthehuman organ trade: acomparative crime…
Post activity
Post‑operative care, documents, discharge, reimbursement ofcosts
Donors were discharged up to 5days after their nephrectomy and escorted back to
their home countries. They reported considerable physical and psychological trauma
as a result of their nephrectomies:
When B.B. awoke from the anesthesia, he suffered from acute pain due to an
infection from the surgery and from serious bleeding. After being hospitalized
for several days, on a date which was coordinated in advance as a result of
his medical condition, B.B. was released from the “Medicus” Medical Clinic
while he was suffering from an infection in his blood. B.B. did not receive any
explanation about the possible complications, the necessary treatment and
lifestyle after the removal of a kidney, and he was released on his way without
any care for any medical treatment whatsoever following the surgery. (Tes-
timony by an anonymous donor-victim, in: Tel Aviv-Jaffa Magistrate Court
Indictment, para. 17)
Other donors similarly reported a deteriorated medical state following the opera-
tion due to improper functioning of the remaining kidney and post operatory com-
plications. Many reported regret and did not receive information about the risks and
long-term follow-up that is required after a kidney donation. Recipients in both cases
generally received better care than their donors although they also reported com-
plaints. In the Medicus case, some patients reported suffering from graft rejection
and post-operative infections. Several patients had to be hospitalized upon return to
Israel. All recipients in the Medicus case received notarized receipts, which allowed
them to declare their transplant costs from their insurance companies in Israel.
A weak legal environment, geopolitical fragility andcorruption
create opportunities fororgan trade
The modus operandi of the studied networks cannot be adequately understood with-
out also taking into account the broader legal and geopolitical contexts within which
the networks operated (Borrion, 2013). We identified 3 overarching themes that
explain why the studied networks chose South Africa, Kosovo and Israel as the geo-
graphic locations for the organization of cross-border illegal transplants.
At the time when Netcare’s activities were exposed, South Africa’s legislation
governing organ trade was old and ill-equipped to address the relatively new trade in
living donor kidneys. The 1983 Human Tissue Act for instance does not prohibit the
purchase of organs. Although it prohibits the sale of organs, it is ambiguous about
whether institutions are prohibited from receiving payments that derive from illegal
transplants. This allowed financial proceeds derived from illicit transplants to flow
to Netcare. South Africa also lacked a prohibition of THBOR at the time when the
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22
F.Ambagtsheer, R.Bugter
1 3
case came to the attention of law enforcement as a result of which the case was nei-
ther regarded nor prosecuted as a trafficking case (Ambagtsheer, 2021).
Israeli recipients were recruited because, at the time, Israeli health insurance
companies reimbursed the costs of transplants performed abroad regardless of the
transplants’ illegitimacy. It is far more cost-effective for insurance companies to
cover the costs of a kidney transplant than to cover dialysis costs (Mohnen etal.,
2019). This provided an opportunity for recruiters to solicit large groups of patients
who were able to pay high sums for their transplants (Orr et al., 2014). In addi-
tion, at the time, Israeli transplant laws did not include penalties for brokering over-
seas transplants (Ambagtsheer, 2021). The activities in the Netcare case are thus
explained by a weak legal and regulatory environment and jurisdictional loopholes
(Ambagtsheer, 2021). This weak environment created an opportunity for the offend-
ers to embed their scheme within South Africa’s and Israel’s medical institutions
and to obtain vast profits.
The weak legal environment also served as an opportunity for organ trade
because of the reduced risk of penalties. Due to the absence of adequate legisla-
tion, South African prosecutors had no choice but to draw up a mix of assault,
racketeering, money laundering- and human tissue act charges from various acts,
most of which contained mild penalties (mostly fines). The Netcare case resulted
in relatively low sentences for peripheral players and a permanent stay of prosecu-
tion of the main accused (Ambagtsheer, 2021). Perry was investigated for tax fraud
in Israel but released because of the jurisdictional loopholes in Israeli anti-organ
brokering laws. Despite these problems, the Netcare case constituted the first (and
so far, only) reported conviction of a hospital chain for wittingly facilitating illegal
transplants. In 2010, Netcare Ltd. Entered a plea sentence agreement and paid a fine
of 4 million Rand together with a confiscation order of 3.8 million Rand (approx.
€800.000)(Allain, 2011).
The activities at the Medicus Clinic must be understood within the context of
the postwar vacuum that arose in Kosovo after the 1999 Yugoslav War. After the
implosion of the Yugoslav regime, illicit economies proliferated to fill the gaps in
Kosovo’s economy (Proksik, 2013). The power vacuum that was left behind after
the retreat of the Yugoslav forces, was filled by structures of the Kosovo Libera-
tion Army (KLA). The KLA played a dominant role in the formation of organized
criminal networks. Many of these networks obtained political influence with many
of its former leaders acquiring governmental positions. Many continue to hold gov-
ernment positions in Kosovo today (Proksik, 2018). A number of these ‘political
elites’ have repeatedly been accused of either being directly involved in organized
crime (including trafficking crimes) or maintaining close relationships with criminal
networks (Proksik, 2013). Throughout our study, Lutfi Dervishi was said to form
part of this elite.
Kosovo’s corrupt, post-conflict environment arose as a prominent theme
during our research, which explains the establishment of the illegal transplant
scheme despite that transplants are prohibited in Kosovo. This fragile environ-
ment has hampered the prosecution of not only the Medicus case but also many
other serious crimes in Kosovo (Proksik, 2018). What’s more, prosecutors of the
Medicus case reported delays and others problems in cross-border collaboration
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23
1 3
The organization ofthehuman organ trade: acomparative crime…
during the case’s investigation because many countries don’t recognize Kosovo
as a sovereign state (Ambagtsheer, 2021; Ambagtsheer & Weimar, 2016b). In
2013, the Basic Court found proven that 48 illegal transplant operations took
place at the Medicus Clinic. It sentenced Lutfi Dervishi to eight years imprison-
ment and a €10,000 fine and Arban Dervishi to seven years and three months in
prison and a €10,000 fine, both on charges of THBOR and organized crime. It
additionally found Lutfi Dervishi and other medical doctors guilty of unlawful
exercise of medical activity. The lead-anesthesiologist and other accused medi-
cal doctors also received prison sentences. The court further ruled that the iden-
tified victim-donors were to be given compensation for psychological and physi-
cal damages for the amount of €15.000.
Since 2013, the Medicus case has been subjected to numerous appeals and
retrials. In 2015, the Court of Appeals modified the Basic Court decision, reduc-
ing the number of proven transplants to seven and acquitting some of the defend-
ants. In 2016, the Supreme Court ruling overturned the original verdict on the
basis of procedural irregularities and ordered a retrial. In May 2018 the Basic
Court confirmed its earlier convictions, sentencing Lutfi Dervishi to seven years
and six months in prison and a 8,000 euros fine, and sentencing the lead-anes-
thesiologist to a one year imprisonment (Balkaninsight., 2018). At the time of
writing, case proceedings are still ongoing. The defendants have been released
on bail, most of whom have fled the jurisdiction.
The foregoing demonstrates that organ trade offenders can take advantage of a
weak legal environment, geopolitical fragility and corruption to organize illegal
kidney transplants. These findings suggest that eliminating corruption, strength-
ening legislation and preventing regional conflict may act as deterrents for organ
trading schemes. However, these opportunities should also be assessed in light
of some limitations. First of all, the identified opportunities are unlikely to apply
to all organ trade cases. Empirical research has shown that not all forms of organ
trade are transnational or organized and do not always take place in fragile or
corrupt settings (Ambagtsheer & Van Balen, 2020; Van Buren et al., 2010;
Fry-Revere, 2014). Different opportunities and facilitators may exist for vari-
ous types of organ trade, which illustrates the need for more rigorous and com-
parative research on this topic. In addition, tightening legislation against organ
trade does not necessarily act as a deterrent against organ trade. Recent empiri-
cal research in Egypt has found that the criminal trajectories of organ trade net-
works became more sophisticated, hidden and violent as a result of stricter leg-
islative controls, in particular in the absence of enforcement (Columb, 2020).
The strengthening of legislation should thus always be assessed in light of the
possible risks that may arise for victims and should be accompanied by dedi-
cated enforcement (Ambagtsheer & Weimar, 2016a). By contrast, the tightening
of legislation by Israeli authorities against health insurance companies covering
the costs of illegal transplants abroad, resulted in a significant drop in “trans-
plant tourism” (Greenberg, 2013), which indicates the possible strong deterrent
effect of this policy. Since the Netcare and Medicus cases have been exposed,
other countries have strengthened their legislation against organ trade (Council
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24
F.Ambagtsheer, R.Bugter
1 3
of Europe Treaty Office,2022; Columb, 2020). These changes are likely to have
refined the crime trajectories of organ trading schemes.
Recognizing anddisrupting illicit transplant activity
The above findings indicate that preventing organ trade may be rather difficult if
this activity occurs within weak and fragile contexts (VonLampe, 2011). Given
the value of disruption in CSA (LeClerc & Savona, 2016), it may be more use-
ful to explore opportunities for disruption rather than prevention of organ trade.
In order to aid recognition of illicit transplant activity, it may be worthwhile to
explore differences between legal and illegal transplant schemes. Our comparison
of the crime scripts with a legitimate kidney transplant scheme resulted in a num-
ber of insights that are helpful for state -and non-state actors to recognize illicit
transplant activity.
First of all, legitimate transplant schemes contain a lower number of scripts, in
particular during the preparation stages, but contain more elaborate tracks than
illegal transplant schemes, particularly pertaining to medical screening and pre-
and post-transplant care. Legitimate transplant scripts further diverge from illegal
scripts regarding their rigorous informed consent – and psychological screening
procedures. Legitimate transplants also involve a lower diversity in the locations
where transplants are prepared and carried out (most are clinics and transplant
centers) and they contain larger, multidisciplinary transplant teams (see Appen-
dix 3). Offender-networks in criminal scripts by contrast involve a lower vari-
ety of medical personnel. Complicit medical staff collude with escorts, mind-
ers, recruiters and brokers. A key feature of the studied crime scripts is their
transnational nature and their focus on profit-making and concealment. Brokers
in particular function as vital connectors across different jurisdictions. Further-
more, offenders demonstrate a high variation in their roles and activities. Crime
scripts thus contain higher levels of permutations and flexibility than legitimate
transplant schemes: they present more tracks that consecutively lead to profitable
transplants. Illicit transplant scripts further reveal a larger diversity in recruitment
-and concealment strategies and a larger diversity in locations for the pre-opera-
tive work-up of donors and recipients than licit transplant schemes.
The need for concealment and profit-making in illicit transplant schemes
enhances the risk of deception, fraud, and lack of appropriate medical care of
patients and donors. To avoid detection, donors and recipients particularly run
the risk of a rapid discharge time which increases the likelihood of medical
complaints. The need for frequent recruitment cycles further enhances the risk
of coercion, in particular when payments to donors are withheld and enhances
the risk of deception during the recruitment stages if donors and recipients are
(falsely) informed that the transplants are legal and without medical risk. While
in both cases trafficking elements were reported (De Jong, 2017), exploitation
in the Medicus case was particularly excessive: all of the identified donors were
found to be victims of coercion, deception and fraud (Ambagtsheer, 2021).
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25
1 3
The organization ofthehuman organ trade: acomparative crime…
Comparison of the scripts further revealed that offenders in the illegal trans-
plant schemes utilized the same opportunity structures that facilitate legal trans-
plants, in particular transplant units, hospitals, dialysis clinics, blood banks, hotels
and airports. These locations may thus function as potentially vital points to
train staff into recognizing and disrupting dubious transplant activity. The Medi-
cus case for example came to the attention of law enforcement due to suspicions
raised amongst airport customs, which demonstrates the importance of alerting
airport personnel into recognizing suspicious transplant activity (Ambagtsheer,
2021). Our results further show that hotels serve as potentially vital locations for
the recognition of the pre-operative transplant works-ups (i.e. blood tests).
The Netcare case came to the attention of law enforcement because a whistle-
blower working for a medical facility contacted the police (Ambagtsheer, 2021;
Ambagtsheer & Weimar, 2016b). This illustrates the potential for implementing
anonymous reporting mechanisms for transplant staff. While barrier models, indi-
cators and recommendations for the identification and reporting of illegal trans-
plant activity by state and non-state actors have been developed over the last few
years (Ambagtsheer &  Van Balen, 2020; Capron et al., 2016; Caulfield et al.,
2016; De Jong & Ambagtsheer, 2016; Martin et al., 2016), organ trade-reporting
mechanisms within hospitals and other locations are still largely absent (Ambagt-
sheer & Weimar, 2016a). Furthermore, it remains unclear in many jurisdictions
whether medical professionals can legally report illicit transplant activity without
facing repercussions for violating their secrecy oath and privilege of non-disclo-
sure (Ambagtsheer &Van Balen, 2020).In the absence of clear guidelines on this
issue, transplant professionals –when confronted with suspicious transplant activity-
remain reluctant to report potential organ trade and trafficking cases (40, 94).
Conclusion: implications forsituational crime prevention oforgan
trade networks
In sum, the studied crime scripts elucidate complex and sophisticated criminal deci-
sion-making processes in the organization of cross-border illegal kidney transplants.
We found little evidence of opportunistic decision-making in our data. The organi-
zation of transnational kidney transplants requires strategic and long-term planning
and medical know-how, particularly for the testing and cross-matching of pools of
donors and recipients. The medical industry in the studied cases was found to be
crucial in providing the infrastructure and expertise needed for organ trade networks
to facilitate and sustain illegal organ transplants. Brokers played a key role in the
studied networks by adopting multiple tasks and by filling up structural holes across
jurisdictional borders).
Our research makes a number of theoretical and practical contributions to sit-
uational crime prevention in the context of organ trade. Our findings show, for
example, that (organized forms of) organ trade, like other forms of smuggling and
trafficking, can be characterized as a transit-crime that relies on the same social
and physical opportunity structures that are utilized for the organization of legal
activity (Kleemans etal., 2013, 2018). We identified a range of legal facilitators
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26
F.Ambagtsheer, R.Bugter
1 3
including hospital lawyers, notaries and accountants who colluded with medical
staff and brokers to ‘launder’ and conceal illegitimate transplant activity. A medi-
cal conference served as a crucial social setting for offender-networking (Felson,
2006). As such, similar to other grey markets (Huisman, 2019), and in corre-
spondence with prior organ trade research (Columb, 2020), we found no clear
legal/illegal divide in the studied organ trade schemes. In addition, like other
smuggling and trafficking crimes, organ trade cannot be reduced to one particular
point in time and space. The crime’s physical and social dimensions as well as its
targets change over time depending on the specific objectives within each stage of
the crime-commission process. For example, in the preparation phase, the donors
and recipients are the main ‘target’ whilst in the activity stage this shifts to the
organ that is transplanted. This finding has significant practical implications for
identification and disruption of illicit transplant activity.
Finally, opportunities for organ trade cannot be understood without taking into
account the broader societal and geopolitical context within which illicit transplant
activity takes place (Edwards & Levi, 2008). While more research is needed on why
organ trade offenders choose specific geographic locations for their crimes, this
study suggests the importance of an environment of (medical) impunity for offenders
to embed and sustain organ trade activity. From a practical perspective, applications
of the situational crime prevention model, in particular its notion of guardianship
(Edwards & Levi, 2008), will have little effect if organ trade networks consistently
choose fragile or corrupt states for the organization of illegal transplants. As the
Medicus case illustrated, preventative or disruptive measures will particularly have
little effect in places where the political and medical elite are closely intertwined.
A previous study on the investigations of these cases, revealed that whereas law
enforcement efforts led to some degree of disruption, the organ trade networks dis-
placed their activities to other regions (Ambagtsheer, 2021).
To conclude, our results challenge public perceptions of organ trade operating
as an underground organized crime that is run by mafia-like criminals and ‘rogue’
doctors. While more research is needed to obtain a fuller depiction on how organ
trade is organized, our results indicate the need for a broader conceptualization of
organ trade that incorporates -but does not necessarily distinguish between- organ-
ized crime and white collar crime perspectives (Friedrichs, 2009; Huisman, 2019).
Currently, no such approach to organ trade exists. Combining these perspectives
can help guide future research into corporate complicity, organizational crime and
occupational offending in organ trading schemes. The role of the medical sector in
providing opportunities for organ trade particularly warrants more research attention
(Huisman & van Erp, 2013; Von Lampe, 2011).
Despite our grounded approach, knowledge gaps remain in the crime scripts that
require more in-depth research. Furthermore, a limitation of CSA is that it places
more emphasis on physical opportunity structures than on the social embeddedness
of crime (Van deBunt et al., 2014). Our data indicated the existence and signifi-
cance of social and professional ties between the offenders. This warrants a network
approach to acquire a better understanding of the structure of organ trade networks
(De Vries, 2018), in particular its embeddedness within the transplant industry.
Finally, a limitation of our study is that only 2 cases were studied that took place
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27
1 3
The organization ofthehuman organ trade: acomparative crime…
some time ago. Subsequent strengthening of laws against the organ trade will likely
have altered the organization of organ trade networks. It must be borne in mind that
our results are not generalizable to other organ trade cases.
Supplementary information The online version contains supplementary material available at https:// doi.
org/ 10. 1007/ s10611- 022- 10068-5.
Acknowledgements The authors wish to thank the respondents for their contributions to this study, in
particular the police investigators and prosecutors for hosting and supporting the research team during the
study visits. For confidentiality reasons, their names are not disclosed. The authors further wish to thank
the HOTT project research team, in particular Susanne Lundin, Jessica Steenbergen, Linde van Balen and
Martin Gunnarson for contributing to the data collection processes during the on-site visits. Furthermore,
the authors are grateful to Erasmus MC’s transplant team, in particular Marry de Klerk, for her input and
feedback to the transplant script. Finally, the authors wish to thank Robby Roks and Sean Columb for
their valuable comments to an earlier draft of the manuscript.
Funding This study was funded by the Prevention of and Fight against Crime Programme of the Euro-
pean Commission Directorate General Home Affairs, under the project, ‘Combating trafficking in persons
for the purpose of organ removal’ (the HOTT project) Grant no. 4000002186, 2012–2016.
Data availability The datasets generated and analysed during this study are not publicly available due to
the sensitive and personalized information contained therein. All data was analyzed on the premise of
anonymity. Anonymized data can be made available by the corresponding author on reasonable request
and only if those (respondents, law enforcement authorities, etc.) who provided the data consent to this
data being shared with third parties.
Declarations
Conflict of interest The authors have no conflicts of interest to disclose.
Open Access This article is licensed under a Creative Commons Attribution 4.0 International License,
which permits use, sharing, adaptation, distribution and reproduction in any medium or format, as long as
you give appropriate credit to the original author(s) and the source, provide a link to the Creative Com-
mons licence, and indicate if changes were made. The images or other third party material in this article
are included in the article’s Creative Commons licence, unless indicated otherwise in a credit line to the
material. If material is not included in the article’s Creative Commons licence and your intended use is
not permitted by statutory regulation or exceeds the permitted use, you will need to obtain permission
directly from the copyright holder. To view a copy of this licence, visit http:// creat iveco mmons. org/ licen
ses/ by/4. 0/.
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