Organ donors are scarce. Waiting lists are long. And life is short — especially if you really need a new heart or liver.


So it makes sense that there's a black market for organs out there. But how would you go about scoring an illicit pancreas if you desperately needed one? Follow the threads people take, when they need to buy kidneys.

Life on the organ transplant list is miserable. The wait can take years, while you work your way up a list of tens of thousands. Sixty thousand people are on the list for kidneys alone, and the average person will be there for about five years. Because the organs all work together, the failure of one of them can slowly destroy the rest, making the person sicker and sicker as the years stretch out. No one has a guarantee. In the US, about eighteen people die every day waiting for an organ. Eventually, many look for other options. But where do they start?


All Quests Begin Online

The World Health Organization has instituted guidelines that forbid the practice of buying or selling organs. They were meant to prevent exploitation or coercion of the donors, and were endorsed by nearly two hundred countries, including the United States. The guidelines, however, were nonbinding, and though countries have their own local laws, the international traffic in organs is slipping through the cracks anywhere it can. Donors in Brazil, India, and South Africa are recruited and flown to various locations — South Africa and Turkey being popular but some do make it to the United States. Once they arrive, they have their organs taken out in improvised operating rooms, and have organs shipped to clinics that have a "don't ask don't tell" policy. Alternately, they have a policy of taking anyone who walks through the door claiming to be a friend of the patient willing to donate their organs — no matter how unlikely that friendship seems.

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The simple first step for many people is to go online and look for clinics, both at home and abroad, that offer a higher rate of organ donation. As laws vary, so does the explicitness of the online talk. Israel in the mid-2000s, for example, had no law against the brokering of organs, and one high-profile broker was only put away for tax evasion. Some clinics will set up pages devoted to organ 'tourists' who could pay the prices necessary. Other clinics will only talk about fewer restrictions and a higher number of donor organs 'available.' The first step people take is just net surfing until they find the right place.


Family Connections

Some people don't trust their lives to what they read on the internet, for some reason. And if nothing online looks promising, a sprawling family or network of friends can do the job for you. The trade is so firmly international that anyone whose acquaintances touch enough countries can get a line on organs. Countries with a very rich class, a very poor class — and even better, both — tend to be the first places to look. South Africa endorsed the WHO guidelines but is one of the few countries that harvest organs locally, due to an extremely poor segment of the population. Yemen, one of the poorest countries in the Middle East, has a brisk trade. Indian women are sometimes forced to sell their kidneys by their husbands. One researcher found actual newspapers advertising for donors and for takers in Africa, Brazil, and Moldova.


Shoppers also get a lead on organs if they know anyone in countries with a poor donation system. Any country with a severe lack of publicly available organs turns toward an unofficial market system. A booming trade in Israel flew donors from Brazil to Turkey, where the operation was done. In Israel, there tends to be a slightly lower rate of donation, since some Jewish schools of thought hold that it is wrong to in any way 'mutilate' the body, and thus people don't want to donate. (Others, of course, refute that theory and encourage people to donate.)


The United Arab Emirates don't have a good system of harvesting from live donors, and only using dead ones limits the availability of many organs. This so severely decreases their organ pool that citizens have well-established services that fly them to poor Southeast Asian countries, where organs can be bought cheaply. And China's practice of harvesting organs from executed prisoners made them a massive destination for transplant tourists. (Doctors say that the transplants trickled off around the time of the Olympics but have rebounded since then.) A network of people in any of these countries often points sick people in the right direction.

The American Organ Trade

Which isn't to say that America is a slouch in the organ trade. Since it was discovered that a kidney from a living donor will keep people alive two times as long as a kidney taken from a cadaver, the trade started up. Nick Rosen, an Israeli man and amateur filmmaker, sold his kidney for $15,000, making a documentary about it. He was given the money outside the Mount Sinai hospital in New York, which went ahead and did the surgery after Rosen told doctors that he was a friend of the patient who was paying him. A Maryland hospital, sensing something was amiss, declined to do the transplant. Nancy Scheper-Hughes, a researcher putting out fake feelers in America, was contacted by people from Brooklyn and Kentucky, looking to sell parts of their liver or their kidney to get money for their own, unrelated, hospital bills.


But there's more than one kind of organ trade in the US. There are plenty of places that need tissue instead of full organs, and there are places to go to get that. The most popular place to look for donors was that last stop of the dead, the funeral home. Yes, it's illegal, but funeral home directors, especially those who do on-site cremation, can be certain that their handiwork isn't going to be checked. They can harvest tissue from the mouth and gums, and sometimes remove entire dead organs for lab technicians to practice on. (While writing Bonk, her book about the study of sexuality, Mary Roach came across a catalog of organs, including an entire vagina, with clitoris.)


Oral surgeons are another place to go for living black-market tissue. They can remove a little extra tissue (or use the tissue they legitimately remove) and sell it to black market organ brokers. Any place that collects healthy living tissue can be hit up for involuntary donations.

Lastly, and legally, there's the morgues of the hospitals themselves. Although no good for many organs, long-dead tissue can be harvested by doctors in the morgue. It can even be harvested legally. Many states, and foreign countries, have 'routine removal' statutes, which allow doctors to remove corneas from corpses without the knowledge or consent of the person's family, or a signed consent form from the patient. Corneas are rarely checked for by anyone, and the statutes aren't publicized, so this quiet practice continues.


The Solution?

The thing is, routine removal works - in the sense that people aren't waiting for the better part of a decade for donated corneas. When waits for vital organs are five years on average, and thousands of people die every year waiting for a transplant, and many more would die if it weren't for the estimated fifteen percent of transplants that are bought and sold, perhaps other solutions are needed. Roughly one to two percent of deaths in the US result in eligible organs. But of those eligible people, only about half actually donate organs. Is it time to move towards presumed consent? Proponents argue that presumed consent - a system which assumes organ donation will occur unless the person in question puts themselves on a registry of abstainers - more precisely serves the will of the people. Ninety percent of people are in favor of organ donation, but not all make it official, or communicate their wishes to their family. Even if the person does say they want to donate, often the living family over-rides their wishes. Even though it negates the original person's will, the family is alive to sue, and the hospital doesn't want trouble. If allowing people to donate their organs is taken as seriously as refraining from doing so if they don't wish to donate, then presumed consent may be the best way to honor the wishes of most people, while saving a lot of lives and cutting down on organ brokering.


Israel has another system that might up the number of donors. Those who aren't on the organ donation list, who then find that they need organs, will be placed on the bottom of the recipient list. This kind of low-level incentive might make people think twice about not signing up to be a donor.


On the other end of the scale, there is the approach Iran took. Iran, uniquely, has set up a formal system of trade when it comes to organs. The nation itself pays for kidneys, and recipients can add to the pay, to entice donors. Although that opens up an imbalance in the care wealthy and poor people receive, it at least avoids the dangers of the illegal organ trade. Bringing in someone to have their organs harvested in a hospital is better than unofficial clinics. If organ donation were legal in all first world countries, it might still be third world donors - who have to go back to dangerous living conditions - who end up donating. An American will expect more money for a kidney than, say, a Brazilian to whom eight thousand dollars is nearly a decade's pay. A kidney, or slice of liver, will usually net something like six thousand dollars, though in some countries it goes up to fifteen thousand and in Kenya it's rumored to be as low as six hundred and fifty dollars. The only thing that would even out the price is the ability to dispense with the middle men. A six thousand dollar kidney can be sold between sixty and a hundred and twenty thousand dollars to the person who actually needs the organ. It's this discrepancy that is the loudest argument for paid donation - or at least it's the loudest argument against a black market. The current market hurts the poor both ways. Those forced by circumstance into selling their organs get a fraction of the price they would get if they could contact buyers directly. Meanwhile, only the wealthiest buyers can afford the prices demanded by the brokers. Is there another way?



Top Image: US Navy

Laptop Image: Matthew Bowden

Second Surgery Image: Matthew Jackson

Scalpel Image: Opto Scalpel

US Currency: Pen Waggener

Via NPR, Women's Health, NY Times, LA Times, WSJ, Havocscape, The Daily Beast, Arabian Business.