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Ethical and legal aspects of organ transplantation in Iran

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  • Endocrinology and Metabolism Research institute-Tehran University of Medical Sciences

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The great advances in the technology of organ preservation, immunosuppression, and surgical procedures have resulted in success in saving lives. However, these advantages have raised major ethical, policy, and religious problems in organ transplantation. Extensive efforts have been made to address these problems in different communities. In this study the transplantation program and implementation of legislation in Iran is reviewed. The history of the organ transplantation "Act of Organ Transplantation and Brain Death," which allows controlled living unrelated donors access to renal transplantation, is discussed as the main subject.
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Ethical and Legal Aspects of Organ Transplantation in Iran
B. Larijani, F. Zahedi, and E. Taheri
ABSTRACT
The great advances in the technology of organ preservation, immunosuppression, and
surgical procedures have resulted in success in saving lives. However, these advantages
have raised major ethical, policy, and religious problems in organ transplantation.
Extensive efforts have been made to address these problems in different communities. In
this study the transplantation program and implementation of legislation in Iran is
reviewed. The history of the organ transplantation “Act of Organ Transplantation and
Brain Death,” which allows controlled living unrelated donors access to renal transplan-
tation, is discussed as the main subject.
ORGAN TRANSPLANTATION is presently the treat-
ment of choice for life-threatening failure of a num-
ber of organs. There has been a steady increase in the
number of organ transplantations performed worldwide in
the past decade. However, the shortage of available organs
and the growth in the number of patients in need have
resulted in long waiting lists. For solving this problem,
methods have been proposed to expand the organ donor
pool. These methods have posed questions about ethical
conflicts. With the ongoing scarcity of cadaveric organs for
transplantation, the use of living donor organs has been
suggested, and implementation of legislation has occured in
Iran.
ISLAMIC PHILOSOPHY AND ETHICS
Islam has paid special attention morality and ethics. The
core of Islamic teaching is the perfection of ethical conduct
of a human being. According to Islamic belief each individ-
ual has a soul and body. The human condition depends on
the eternal soul. All men are equally situated with respect to
their spiritual perfection. God gave man the basic knowl-
edge of “good” and “bad” at the time of his inception. On
the other hand, human acts are of value if done by informed
freedom. The solutions to ethical problems are derived
from Islamic principles and updated in the the Holy Quran,
which includes the traditions of the prophet of Islam and his
successors (Sunna and Hadith), the consensus of scholars
(Ijma), and wisdom (Aqul). Islam encourages helping oth-
ers and saving lives. The Holy Quran states “and who so
ever gives life to a soul, it shall be as if he has given life to
all mankind” (5:32). According to religious sanctions
(fatwa), vital organs (such as the heart) cannot be donated
before death. Donation of other organs is permitted but it
should not be harmful to the donor. Donor and recipient
consent are necessary.
CURRENT STATUS OF ORGAN TRANSPLANTATION IN
IRAN
Transplantation has a long history in Iran. Avicenna (981 to
1037), the great Iranian physician, performed the first nerve
repairs. Modern organ transplantation with newer methods
dates to 1935, as shown in Table 1. Presently, Iran currently
has one of the most successful transplantation programs in
the Middle-East region. The overall patient and graft
survival are comparable with other centers in the world.
1–9
Multiorgan transplantation was started in recent years and
performed on several occasions.
Given that Islam represents the largest segment of the
population in Iran, ethical issues are frequently discussed
among physicians, legal experts, and religious scholars.
Positive fatwa is essential for approval of any parliamentary
act. Consensus of physicians and religious leaders has paved
the way for advancement of transplantation programs in
Iran in recent years.
The “Organ Transplantation and Brain Death Act” was
approved by parliament in 2000.
10
According to the Act,
brain death must be diagnosed and certified by four physi-
cians, namely a neurologist, a neurosurgeon, a medical
specialist, and an anesthesiologist. Members of the team
that diagnoses and establishes brain death must not be part
From the Endocrinology and Metabolism Research Center,
Shariati Hospital, Tehran, Iran.
Address reprint requests to Dr Bagher Larijani, Endocrinology
and Metabolism Research Center, Shariati Hospital, North Kar-
gar Avenue, Tehran 14114, Iran. E-mail: emrc@sina.tums.ac.ir
© 2004 by Elsevier Inc. All rights reserved. 0041-1345/04/$–see front matter
360 Park Avenue South, New York, NY 10010-1710 doi:10.1016/j.transproceed.2004.05.065
Transplantation Proceedings, 36, 1241–1244 (2004) 1241
of of the transplantation team. After conrmation of brain
death, cadaveric organs and tissues are used for transplan-
tation with the consent of the deceased (ie, written will or
signed donor card) or next of kin. Despite sanctions by
religious leaders, some people do not offer permission for
cadaver organ donation. As of the end of 2000, only 84
cadaveric renal transplants have been performed in Iran,
2
a
number 0.8% of the total. Although cadaveric organ
donation has increased in recent years due to people having
signed organ donation cards, effective cadaveric organ
donation requires increased public awareness and better
medical equipment and laboratory facilities. As shown in
Table 1 in 2002, only about 6% of all renal transplants were
from cadaveric sources. Likewise, the shortage of cadaveric
donors is the greatest barrier to liver transplantation in
Iran.
1
Until 1988, all living donors were related to the recipient
in Iran. But, due to national demand and the increasing
number of patients, a controlled living unrelated donor
(LURD) program for renal transplantation was adopted in
1988. As a result, the renal transplant waiting list was
eliminated in 1999. In Iran, organ transplantation is assisted
by a governmental award. The law related to the gift of
organ donation was approved by the government of Iran in
1997. Rewarded giftingis reimbursed via the Charity
Foundation of Special Diseases (CFSD), which is a non-
governmental organization.
Reports of world experiences with LURD renal trans-
plantation, especially from countries of the Middle-East,
South Asia, and South America, have raised concerns about
the LURD program in Iran. But, due to the Islamic culture,
there is no commercial transplantation in Iran. At present,
transplantation procedures are performed only in govern-
mental university hospitals. All hospital expenses are paid
by the government. The transplant physician emphasizes
the advantages of living related (LRD) vs LURD trans-
plants recommending the use of an LRD. Donors are
referred by the Dialysis and Transplant Patients Associa-
tion (DATPA) or another popular charity association.
Members of these associations are often patients or their
families who have no nancial incentives. The surgical team
is not involved in this interaction. There are no middle-
menfor the transplant team. All donors are carefully
examined with regard to the medical aspects. Foreigners
are not allowed to undergo organ transplantation from
Iranian LURDs; they must bring donors from their respec-
tive countries.
In the current decade, several studies have been pub-
lished on the renal transplant characteristics of donors and
recipients in Iran. In the various studies, the LURD/LRD
ratios have been 45.1%,
9
67.8%,
5
80.8%,
8
86.7%,
6
90%,
11
and 94%.
7
According to the available results, more males
than females are LURDs; the male-female ratio has varied
from 3:1 to 9:1 in studies from different cities,
2,5,6,9,12
with
a ratio of about 1.7:1 among recipients.
5,7,12
Most LURDs
have been in their 30s or 40s, with a mean ages (SD) of
29.5 7.5,
6
28.8 6.5,
8
and 32 9.7
9
years. These
documents negate the possible violation and coercion of
women or children in Iran.
The literacy status of LURDs has shown their levels of
education to not be signicantly different from the recipi-
ents. In one study of LURDs, 6.2% had university, 63.4%
high school, and 24.4% elementary school training, and 6%
illiterate.
12
All LURDs have been from the low or middle socioeco-
nomic classes. In one study, 84% of LURDs were poor and
16% middle class.
12
However, 50.4% of recipients were also
poor, and 36.2% and 13.4% were middle class and wealthy,
respectively.
12
It is to be assumed that organ donation in all
cases is voluntary, although poverty may be the principle
incentive in some cases. However, responsible individuals
attempt to dissuade poverty-based donation, and help those
less fortunate in other ways. It is certain that donor and
recipients accounts in Iran are not havesand have-nots
ctions. It is notable that 80% of LURD renal transplant
recipients in Iran have a potential LRD,
2,13
but due to
cultural reasons it is not used. Most recipients are reluctant
to impose any emotional or physical pressure on their
families, particularly their children or wives. Although there
is rewarded gifting among LRD renal transplants as well
most recipients, even those who are are poor, prefer to
obtain an organ from unrelated donors.
DISCUSSION
There are noteworthy arguments for and against paid
LURD transplantation worldwide. We should note that the
risks of living donation are relatively low, when medically
Table 1. Historic and Current Data Regarding Organ Transplantation in Iran
Organ or tissue First transplant Total number
2002
Total Living donor Cadaver donor
Cornea 1935 18,000 2581 2581
Kidney 1967 14,000 1681 1585 96
Bone marrow 1990 800 170 170
Liver 1993 55 23 1 22
Heart 1993 45 11 11
Lung 2001 4 1 1
Heartlung 2002 1 1 1
Pancreas and islet cell Initial experiences ——— —
1242 LARIJANI, ZAHEDI, AND TAHERI ET AL
suitable donors are selected. Donation can be performed
with acceptable perioperative morbidity, no renal compro-
mise and negligible perioperative mortality.
1417
The short-
term risks are morbidity of about 20%
18
and mortality of
0.03%. The long term risks of developing renal failure
appear to be no greater than those for the normal popula-
tion.
1820
The graft and patient survival results of LURD
transplants continue to be superior to those of transplants
from cadaveric donors, and are equivalent to those of LRD
transplants.
15,21
Fear of involvement in organ commercial-
ism is the main barrier for acceptance of LURD transplan-
tation by Islamic and non-Islamic authorities. Unfortu-
nately, discussion about the sale of organs is overshadowed
by cases of exploitation, murder, and corruption.
22
Some
studies have shown that physicians in underdeveloped
countries have used kidneys from total strangers who were
paid for their donation. The survival rates of patients and
grafts have been poor among these illegal transplants.
15
In
addition, there have been some reported cases of HIV
transmission to recipients.
15
Those against paid donation
say that selling a kidney begins a slippery slopetoward
selling vital organs such as hearts. Vendors are often not
given proper care. They may also be underpaid or cheated,
or may waste their money due to inexperience.
23
Also they
are likely to be too uneducated to understand the risk,
which precludes informed consent. Furthermore, because
these people coerced by their economic circumstances,
their consent has sometimes been considered nongenu-
ine.
23
In parts of the world where women and children are
essentially chattel, there can be a danger of them being
coerced into becoming vendors.
23
We are certain that there
are none of the aforementioned problems in Iran. As noted
earlier, the Iranian transplantation program is one of the
most successful programs from the medical aspect.
It should be considered that, for some people, living
organ donation (or selling) is more agreeable than cadav-
eric donation. However, do we have the right to harvest
organs of the dead without permission, only presumed
consent? The general public in some countries is against
presumed consent, but cadaveric donation can be encour-
aged by means of increased education with regard to this
issue.
Special attention should be paid to the psychosocial state
of related donors. Are genetically unrelated donors much
more vulnerable to coercion than related donors? Which of
the two is better when there is no other alternative
inevitable consent obtained from a related donor under
emotional pressure, or paid donation from someone in the
grip of poverty? On the other hand, which of these would be
superioran unlawful donation without any protection and
support of donors, or a controlled program with ethical
standards.
In India, several thousand uncontrolled commercial renal
transplants have been performed in private back-street
clinics.
24
Incomplete donor and recipient evaluations re-
sulted in a high incidence of complications. The kidneys
were sold by middlemen to wealthy patients.
24
In 1994, the
Indian government legislated against organ sales, a policy
that was adopted by most states. As a result, the price of
illegally transplanted kidneys in India has increased sharp-
ly.
25
The best way to address such problems would be by
regulation or establishment of a central procurement sys-
tem to provide screening, counseling, reliable payment,
insurance, and nancial advice.
23
In 1998, the International
Forum for Transplant Ethics concluded that organ trade
should be regulated rather than banned.
18,23
Thus, some
investigators proposed a strictly regulated and strongly
ethics-based market in live donor organs and tissues to
prevent illegal LURD transplantation.
18,26
Although no
system of control is complete, there is much greater oppor-
tunity for exploitation and abuse when desperately needed
goods are made illegal. If we hope to protect the exploited,
we can do so only by decreasing the level of poverty that
makes people vulnerableor by controlling the trade.
23
What is the Islamic perspective? Transplantation from
LURDs is not prohibited in Islam, yet organ selling is not
permitted by most religious scholars. Despite the prohibi-
tion of organ vending, the recipient can thank the donor by
offering a gift, such as money. Al-Mousavi et al sought the
views of senior Muslim scholars on organ donation in six
Islamic countries: Kuwait, Saudi Arabia, Iran, Egypt, Leb-
anon, and Oman.
27
All 32 scholars agreed that organ trade
is degrading and not permissible, but 22 (68.7%) permitted
purchase of an organ to save life when the donor insists on
selling and if the patient has no alternative. These scholars
also support the idea of a reward in return for his dona-
tion.
27
CONCLUSIONS
The prevention of commercial dealing in organs is a most
important aspect of the Iranian law. We must consider that
cadaveric organ donation has not been successful, despite
several decrees (fatawa) from religious leaders and ap-
proval by parliamentary act. In contrast, nonconsensual
harvesting of cadaveric organs is morally unlawful and
impractical in our country. Therefore, we have to nd
another pool for an organ supply.
Xenotransplantation is not performed in Iran due to
technical obstacles and cultural barriers; indeed, this type of
transplant has not been successful in other centers in the
world. However, religious scholars are not opposed to
transplantation from animals to humans. Reproductive
cloning is prohibited in Iran, but stem-cell research and
therapeutic cloning have recently begun after previous
religious sanction by an Islamic national leader. In the near
future we may be able to take advantage of these techniques
to increase availability of organs and tissues, but until then
we will have to adopt a morally preferable, controlled
model emphasizing donation in order to save lives.
Recently, initial efforts have been made for a national
transplant registry. At present, the Iranian Network for
Organ Procurement (related to the Ministry of Health and
ETHICAL AND LEGAL ASPECTS 1243
Medical Education) is responsible for supervision and
coordination of activities. This network will pave the way
for short- and long-term follow-up of results and for
investigation of its psychosociologic suitability. We must
consider the possible disadvantages of the current program.
Steps should be taken to alleviate poverty and move toward
social justice.Furthermore, living donors are often not
given proper care and some of them do not receive fol-
low-up visits after donation. A postoperative medical insur-
ance plan has been offered to donors, but it needs to be
long-term with sufcient information. Establishment of an
independent management team that takes the side of the
donor, with regard to medical and psychosocial aspects, is
clearly necessary.
There is a need to motivate the general public to donate
organs. Special emphasis must be given to cadaveric dona-
tion. The mass media may be a valuable means to motivate
the population about organ donation. Medical, legal, ethi-
cal, and religious aspects of transplantation in Iran have
been discussed in the book Comprehensive Outlook on
Organ Transplantation (in Farsi).
28
The second edition of
this book is now in press. We hope that these attempts will
increase general public awareness and encourage authori-
ties and decisionmakers to prevent unadvisable or immoral
practices in the eld of transplantation.
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1244 LARIJANI, ZAHEDI, AND TAHERI ET AL
... [4] OD in Iran has a history of over 40 years. [5] The OD rate relative to the number of brain dead people is very low in Iran. [6] There are approximately 5000-8000 potential brain deaths annually in Iran, the possible organ donor number is 2500-4000, while the actual donations happen <1000 times. ...
... They identify key and influential individuals in potential donor families and based on the assessment, the social workers could plan to meet the family's needs and time frames for information giving, counseling, advocacy, and referrals. [1][2][3][5][6][7][8] Social workers and the interventions they deliver apply a holistic perspective and put the family experience in the context of their emotional, social, familial, economic, and cultural context and highlight how OD affects these dimensions of their life. It is unreasonable to expect physicians and nurses to perform two conflicting roles: highly technical, scientific tasks with considerable expertise, for example, patient care in the ICU, testing for brain death, and at the same time, dealing with feelings of the family around the death of the patient and yet, seek ODs. ...
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Introduction: Lack of consent from brain dead individuals’ families is a major impediment for organ donation (OD) which is caused by several factors. Families need to receive information and support before, during, and after OD. Involving social workers in the transplantation team could be helpful. Methods: To develop a guideline for OD‑related social work interventions, we conducted an inductive content analysis on experiences of experts providing services for families of brain dead individuals and searched scientific documents to identify eligible social work guidelines and studies. The participants were invited through purposeful and convenience sampling. Sampling was terminated when no additional information was acquired, and data saturation occurred. Results: Eleven experts who had experience in interviewing families of brain dead individuals participated voluntarily. In‑depth and semi‑structured interviews were conducted individually for each participant. We shared the draft for the social work guidelines with experts and finalized the guidelines according to their comments. Recommendations for social work interventions for brain dead individuals’ families in three main phases were categorized; before donation (process initiation and family consent), during donation, and after donation (short‑term and long‑term interventions). Conclusion: Social workers can get involved in transplantation teams to improve family protection during the consent seeking process and after the family’s consent about donation.
... Despite the program of unrelated renal donor organ transplantation starting in 1988 [4,8], the initiative to provide financial compensation to living unrelated donors (LUDs) began in 1997 [1,4]. A non-related kidney donation program was considered a safe and costeffective procedure with acceptable risk to donors and a ready solution to a scarcity of organs and long waiting times for transplant patients [16]. The reason for introducing compensation for LUDs was the recognition by Iranian society that receiving kidneys from LUDs would increase the donation rate [1]. ...
... Iranian scholars who support an unrelated kidney donor organ transplantation program often argue that monetary compensation or reward for kidney donation to LUDs is permissible as it saves the lives of many vulnerable patients [4,8]. Further, it is associated with acceptable donor risks, reduces the scarcity of transplantable organs through a 'safe' and 'cost-effective' procedure, and decreases the death rate for patients with end-stage organ failure while on the waiting list [16]. The Iranian government's financial compensation scheme for LUDs is an effort to address many issues plaguing Iranian society, including increasing unemployment and poverty, poor dialysis patient outcomes, and the black market in organs [3]. ...
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Background Advocates for a regulated system to facilitate kidney donation between unrelated donor-recipient pairs argue that monetary compensation encourages people to donate vital organs that save the lives of patients with end-stage organ failure. Scholars support compensating donors as a form of reciprocity. This study aims to assess the compensation system for the unrelated kidney donation program in the Islamic Republic of Iran, with a particular focus on the implications of Islam on organ donation and organ sales. Methods This study reviews secondary documents for philosophical argumentation and ethical analysis of human organ donation and sale for transplantation. Results and discussion According to Islamic law, organ donation is an act of sadaqatul jariyah, and individuals are permitted to donate organs with the intention of saving lives. The commercialization of humans as organ sellers and buyers is contrary to the Islamic legal maxim eethaar , undermining donors of ‘selfless’ or ‘altruistic’ motivations. Such an act should be considered immoral, and the practice should not be introduced into other countries for the sake of protecting human dignity, integrity, solidarity, and respect. I, therefore, argue that Iran’s unrelated kidney donation program not only disregards the position of the Islamic religion with respect to the provision or receipt of monetary benefits for human kidneys for transplantation but that it also misinterprets the Islamic legal proscription of the sale of human organs. I also argue that the implementation of Iran’s unrelated kidney donor transplantation program is unethical and immoral in that potential donors and recipients engage in a bargaining process akin to that which sellers and buyers regularly face in regulated commodity exchange markets. Conversely, I suggest that a modest fixed monetary remuneration as a gift be provided to a donor as a reward for their altruistic organ donation, which is permissible by Islamic scholars. This may remove the need to bargain for increased or decreased values of payment in exchange for the organ, as well as the transactional nature of ‘buyer and seller’, ensuring the philosophy of ‘donor and recipient’ is maintained. Conclusions Offering a fixed modest monetary incentive to organ donors would serve to increase organ supply while protecting donors’ health and reducing human suffering without legalizing the human organ trade.
... Shī`ah Islamic scholars, however, support the sale of organs by a living donor or by the deceased donor's relatives through the concept of "divine consent". 111 Divine consent requires that an act be done with a sincere intention, confirmed by reason and divine revelations that bring about peace, while preserving dignity and autonomy. In Iran, the only Shī`ah Muslim country, a fatwā by the Ayatollah sanctioning the sale of organs paved the way for legislation of a state-run compensated organ procurement system. ...
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Religion plays a pivotal role in people’s attitude to organ donation. Generally, practising Muslims (adherents of the Islamic faith) are unlikely to consent to organ donation because they believe it is not in keeping with the tenets of Islamic law (Sharī`ah). Although there is a wealth of information on organ donation with reference to both South African and Islamic law, there has not been a study comparing the two sets of laws. The purpose of this article is to develop the literature on living and cadaveric organ donation by drawing a comparison between Islamic law and South African law on this issue. Apart from a few minor differences inherent in each set of laws, there is a startling consensus in South African law and Sunnī (mainstream) Islamic law on the issue of organ donation. This research is also significant in that it provides legal and medical professionals, academics and practitioners with an informed position from which to advise clients and/or patients. This may in turn raise awareness among clients and/or patients, which could result in a desirable increase in organ donation rates among Muslims in South Africa. This article makes a number of recommendations in this regard.
... 183-213 reducirse, según sus defensores, el riesgo de explotación para el donante y los peligros para su salud. Un mercado regulado de órganos (de vivo) ya se ha implementado en Irán, India y Filipinas (Ghods, 2002;Hippen, 2008;Larijani et al., 2004), con resultados que algunos autores estiman como positivos, al haber reducido e incluso eliminado la lista de espera, y que otros ven con escepticismo por incrementar las desigualdades locales y plantear problemas asociados al turismo de trasplante. ...
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... Iran is leading example among Muslim societies, where transplantation using organs from deceased donors has been introduced successfully (Einollahi 2008). But this supply is very scarce (Larijani et al. 2004). People know that there is no religious conflict of interests for posthumous donation in Islamic jurisprudence. ...
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Organ transplantation from living related donors in Bangladesh first began in October 1982, and became commonplace in 1988. Cornea transplantation from posthumous donors began in 1984 and living related liver and bone marrow donor transplantation began in 2010 and 2014 respectively. The Human Organ Transplantation Act officially came into effect in Bangladesh on 13th April 1999, allowing organ donation from both brain-dead and related living donors for transplantation. Before the legislation, religious leaders issued fatwa, or religious rulings, in favor of organ transplantation. The Act was amended by the Parliament on 8th January, 2018 with the changes coming into effect shortly afterwards on 28th January. However, aside from a few posthumous corneal donations, transplantation of vital organs, such as the kidney, liver, heart, pancreas, and other body parts or organs from deceased donors, has remained absent in Bangladesh. The major question addressed in this article is why the transplantation of vital organs from deceased donors is absent in Bangladesh. In addition to the collection of secondary documents, interviews were conducted with senior transplant physicians, patients and their relatives, and the public, to learn about posthumous organ donation for transplantation. Interviews were also conducted with a medical student and two grief counselors to understand the process of counseling the families and obtaining consent to obtain posthumous cornea donations from brain-dead patients. An interview was conducted with a professional anatomist to understand the processes behind body donation for the purposes of medical study and research. Their narrative reveals that transplant physicians may be reticent to declare brain death as the stipulations of the 1999 act were unclear and vague. This study finds that Bangladeshis have strong family ties and experience anxiety around permitting separating body parts of dead relatives for organ donation for transplantation, or donating the dead body for medical study and research purposes. Posthumous organ donation for transplantation is commonly viewed as a wrong deed from a religious point of view. Religious scholars who have been consulted by the government have approved posthumous organ donation for transplantation on the grounds of necessity to save lives even though violating the human body is generally forbidden in Islam. An assessment of the dynamics of biomedicine, religion and culture leads to the conclusion that barriers to posthumous organ donation for transplantation that are perceived to be religious may actually stem from cultural attitudes. The interplay of faith, belief, religion, social norms, rituals and wider cultural attitudes with biomedicine and posthumous organ donation and transplantation is very complex. Although overcoming the barriers to organ donation for transplantation is challenging, initiation of transplantation of vital organs from deceased donors is necessary within Bangladesh. This will ensure improved healthcare outcomes, prevent poor people from being coerced into selling their organs to rich recipients, and protect the solidarity and progeny of Bangladeshi families.
... The Iranian experience and the lesson to draw from it is contested (for influential articles, see(Zargooshi 2001;Ahad J. Ghods 2004;Larijani, Zahedi, and Taheri 2004;A. J. Ghods and Savaj 2006;Rizvi et al. 2009;Aramesh 2014;Pajouhi et al. 2014). ...
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Kidney International aims to inform the renal researcher and practicing nephrologists on all aspects of renal research. Clinical and basic renal research, commentaries, The Renal Consult, Nephrology sans Frontieres, minireviews, reviews, Nephrology Images, Journal Club. Published weekly online and twice a month in print.
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