Organ trade: The Iran model

Balasubramaniam Ramana

doi:10.1038/nindia.2008.229 Published online 20 June 2008

Donors are mostly poor and vulnerable.

Earlier this year, the unearthing of a highly successful kidney transplant racket in the National Capital Region of Gurgaon shook the conscience of the Indian people. The consensus in the media was that such a racket, where kidneys are bought or extorted from poor labourers and sold to the highest bidders, was immoral, exploitative, and needed radical punishment. The World Health Organisation secretariat acknowledges this in a 2003 report: "Donors always come from the poorest and most vulnerable parts of the population."

The Organ Transplantation Act of 1994 prohibits explicitly the sale or donation of organs by unrelated donors. In exceptional cases, a committee has to verify the claims of an altruistic donation and decide on the merits of the case. Many economists and social scientists feel this ban is self-defeating and ineffective. There is even a school of thought that questions the moral premise of such a ban as it infringes on the fundamental right of a person to the ownership of his own body and its parts.

The recent Gurgaon episode is only one in the history of transplant surgery in India. In the past, several rackets, for instance in Mumbai and Punjab, have been unearthed. The rackets seem to be having a life-source of their own.

The current system has visible weaknesses: too many recipients, few related or voluntary, altruistic donors, high cost, an unregulated, illegal nexus of brokers and doctors. They are obvious enough for us to ponder over alternatives. For example, one could even ask a politically unpopular question: Is organ trade good for the patients? For the sake of argument, if we permitted organ-donation-for-money among unrelated people, would it work? Or is this purely rhetorical, speculative and theoretical?

Many nephrologists would agree with Benjamin Hippen, who points to Iran for a solution. The Iranian system, nine years after organ vending was legalized, has successfully wiped out a recipient waiting list. In contrast, more than 30,000 Americans have died in that country since that time while on the waiting list for a transplant. Recently, a proposal was also made in Australia2 that young, healthy people be allowed to sell their kidneys for $50,000, and thereby help restore health to thousands of renal failure patients on whom billions of dollars are spent in futile terminal care.

In Iran, the vendor (donor) of the kidney gets a financial compensation from the Government, apart from health insurance for one year. The intermediary (or broker) between the vendor and the recipient (which in countries like India consists of criminal or unscrupulous elements) is a voluntary organization served by patients of kidney disease who contribute their time and efforts without commercial interests. Foreigners are not eligible to receive kidneys in Iran. In Phillipines, organ sale within the free market is permissible3.

Critics, including the Catholic Church, argue that organ sale cannot be permitted in any civilized society because the organs would be extorted from the poorest people for the benefit of the wealthy. Free market votaries say, however, that anything that a poor person does is for economic gain. Would the fact of being poor deprive him of any right to volitional action? Do all acts for material gain by such a poor person automatically become exploitative and unethical? If not, how can one make an exception to organ sale?

Ethicists argue that a person's body (and therefore, its organs) is his personal property, and the State is outside its scope in trying to control his decisions regarding his body4.

To come back to the Indian context, a huge marketplace exists for kidneys, with an annual sale of 2000 Indian kidneys. By making organ sale illegal, this market is pushed underground, and organized rackets thrive by working outside the society's laws and regulations. One of the spin-offs is the phenomenon of organ theft. Many of the victims of the Gurgaon transplant racket are said to be labourers who never knew about their operation. Such an organ harvest is obviously illegal. Organ theft and organ sale, however, are not the same thing. Every sane person will surely condemn the stealing of a poor man's kidney, but if such a person volunteers to sell it for money, would it be all bad5?

The Iranian system throws up several interesting possibilities for India (a country that has nearly 200,000 transplant candidates every year), as it does for the rest of the world. One of the desirable end-points of a new, rational and workable system should be the protection of the rights of the donor and the recipient. Our current system, clearly, is not being successful at this, with recipients deprived of options and donors deprived of freedom of choice, and even their own kidneys.


  1. Hippen, B. E. Organ Sales and Moral Travails - Lessons from the Living Kidney Vendor Program in Iran. Policy Analysis, CATO Institute 614, 1-20 (2008) Article
  2. Donating organs is 'noble', selling them 'unacceptable'. The Catholic Weekly. (2008) Article
  3. Shimazono, Y. The state of the international organ trade: a provisional picture based on integration of available information. B. World Health Organ. 85, 901-980 (2007)
  4. Holcberg, D. Human Organs for Sale? Capitalism Magazine (2005) Article
  5. Taylor, J. S. Black markets, transplant kidneys and interpersonal coercion. J. Med. Ethics 32, 698-701 (2006) | Article |