The Philippines’ ethical time bomb

Filipinos have narrowly escaped the establishment of a legal market for organs. But will the new system work?

Healthy kidneys are a hot product in the black market. Growing demand and a lack of donors in developed countries have turned developing countries like India, China and Pakistan into quarries for unscrupulous businessmen and doctors. And until recently, it looked as though the government of the Philippines was going to deal with its own black market problem by effectively legalising it.

After intense international pressure was applied, the government has endorsed a more ethical stand. But there is great scepticism from observers about whether it can keep its high-minded promises.

Here is what happened. On March 3 the Philippine Department of Health issued an administrative order, "Revised National Policy on Kidney Transplantation from Living Non-related Organ Donor and its Implementation Structures". The proposed regulations sounded ethical, but the devil was in the detail. Donors would be allowed to specify a person to receive their organ or they could make a "non-directed" donation.

This was a loophole wide enough to drive a Mack truck through, permitting poor donors to sell their kidneys to unrelated foreigners.

What type of person has a kidney to spare for a bit of cash? Poor people. And the Philippines has lots of them. In Basesco, on Manila Bay, about 3,000 of the slum’s 50,000 inhabitants are reported to have sold a kidney.

Former health secretary Alberto Romualdez called this an "ethical time bomb." Harvard’s Francis L. Delmonico, of The Transplantation Society, the leading professional body for transplant surgeons, told MercatorNet that it "would have enabled rich foreign patients to use the Filipino as a targeted source of organs". The country’s Catholic bishops denounced it: "Human organ sale or trade, by its very nature is morally unacceptable. It is contrary to the dignity of the human person, his or her authentic autonomy and the essential equality of all persons... [The] body ought not to be treated as a commodity or object of commerce."

Under this barrage, health officials revised the plan. Late last month they closed the loophole and banned all kidney donations to non-related foreigners. Recent reports indicate that legislators are even contemplating on extending the ban to non-related locals.

Will a ban succeed?

But how likely is that awful business of selling kidneys will evaporate overnight? Organ trafficking has sunk deep roots in the Philippines. Between 1996 and 2006, according to the Philippine Society of Nephrology (PNS), the number of kidney transplants locally sextupled. Transplants from the living and related (ie, a family relative) donors flatlined while the number of non-related transplant donors ballooned out from 52 in 1999 to 473 in 2006. The number of foreign recipients in 2004 and 2005 increased by a whopping 62 percent.

What type of person has a kidney to spare for a bit of cash? Poor people. And the Philippines has lots of them. In Basesco, on Manila Bay, about 3,000 of the slum’s 50,000 inhabitants are reported to have sold a kidney.

According to the PNS, these donors are all male, with an average age of 29. A third of them have not even reached high school. Most are farmers or tricycle drivers with a US$90 average household monthly income. They received just US$2,800 for a kidney, which they used to pay debts, support their family or set up a business. In most cases, it turned out to be a bad deal. About three-quarters told researchers they did not improve their lives economically. Four-fifths felt their capacity to work was reduced. Almost none would recommend that others sell their kidney.

Despite a government-imposed cap which had restricted the number of transplants to foreigners to 10 percent of the total, wealthy foreigners, many from the Middle East, were the chief beneficiaries under the old system. At the moment, selling or exporting human organs carries a 20-year jail term and stiff fines – but prosecutions are rare. It is a lucrative business for enterprising surgeons.

Critics are sceptical

That’s why Amihan Abueva of the lobby group Asia Against Child Trafficking fears that the new guidelines will just be ignored, or that brokers will find loopholes. Dr Gene Nisperos, of the Health Alliance for Democracy (HEAD), notes that several administrative orders have been issued without ever being fully implemented. Nisperos told MercatorNet that the government’s privatisation of health care makes him question the seriousness of the virtuous new policy.

The government itself is sceptical. A report for the Philippine Organ Donation Program said last year that the health department was "unable to enforce rules due to the lack of capacity and ability to monitor accredited facilities… The organ donation program of the country has also no mechanism to adequately enforce ethical guidelines on accredited facilities… Compliance to regulations is poorly documented and enforced due to inadequately designed incentive structures, capacity limitations and non-coordination of efforts".

Liberal ideologues

One reason why government officials may not be taking the kidney market seriously is that it actually seems like a good idea to starry-eyed economists. The Economist, for instance, is a consistent supporter of legalising an organ market: "Many people will find the very idea of individuals selling their organs repugnant. Yet an organ market, in body parts of deceased people, already exists. Companies make millions out of it. It seems perverse, then, to exclude individuals. What's more, having a kidney removed is as safe as common elective surgeries and even beauty treatments (it is no more dangerous than liposuction, for example), which sets it apart from other types of living-organ donation."

In an ideal setting, there would be proper medical examinations to determine a donor’s suitability. But in the slums of Manila, the broker is not interested in ensuring the donor’s health, and the donor is not interested in telling the truth. It is easy to fake urine samples or to normalise blood pressure with drugs. Newsbreak, a local news and affairs magazine, recently featured the case 50-year-old Doming Umandap, a resident of Quezon province, who died of a heart attack a few months after donating a kidney.

In the Philippines and in other poor countries there is no level playing field. Family men without a dime are selling their organs because they have nothing else to sell. The Philippines needs another John Steinbeck to update The Grapes of Wrath for contemporary organ trafficking.

Only if there is a resolute political will to enforce the law, will there be no more Domings. Unfortunately few Filipinos believe that a new set of government regulations is going to change anything.

Dean Menchavez is a freelance journalist from the Philippines.