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Journal Club – Ethical Issues in Renal
Medicine: ‘Transplant Tourism’
Transplant Tourism in the United States: A
single-centre experience. Gill J, Bhaskara R
et al cJASN 3: 1820-1828. 2008
Matthew Graham-Brown
LGH August 2013
Introduction - Ethics
• ‘Ethos’ – meaning character
• Ethics is the philosophy of morality that involves
systematizing, defending and recommending
concepts of right and wrong
• The study of moral behaviour in humans and how
one should act
• Ethics seeks to resolve questions dealing with
human morality—concepts such as good and evil,
right and wrong, virtue and vice, justice and
crime
Introduction – Morals (Morality)
• Moralitas, meaning manner, character, proper
behaviour
• Morality is what ‘you’ believe to be right or
wrong – informed by ethics, (religious) beliefs,
experiences and observations.
• ‘What is believed to be right or good’
• Immorality: active opposition to morality
• Amorality is an unawareness of, indifference
towards, or disbelief in any set of moral
standards or principles
Ethical Theories
• Utilitarianism – greatest good for the greatest
number
VS
• Immanuel Kant – ‘categorical imperative’ reason is the source of morality, ‘universal right
and wrong’, ‘cannot use a person as a means to
an end – they must be an end in themselves’
VS
• Situation ethics – what is the most loving thing to
do in any given situation
Medical Ethics - Historical
• Formula Comitis Archiatrorum – (Early 5th century) It demands
from physicians that they widen and deepen their knowledge
and enacts the consultation with other physicians
• Hypocratic Oath – Honesty (Physicians only!) 
• Declaration of Geneva (1948, 1968, 1983, 1994, 2005 and
2006) – Post Nazi Germany. Modernised Hypocrates
Medical Ethics
Key Tennants
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Autonomy
Beneficence
Non-maleficence
Justice
Relevance Today
So… This Study (!)
• Transplant tourism – ‘The practice of travelling
outside the country of residence to obtain organ
transplantation’
• Implications of this are largely unknown
• This study described the characteristics and posttransplantation outcomes of patients who sought
transplant abroad and returned to be followed up
at UCLA
Study Design & Methods 1
• Single Centre (UCLA)
• Retrospective, observational, comparison study,
including a comparison against a ‘matched’
cohort
• Included - All living and deceased-donor kidney
transplant recipients followed up at UCLA who
underwent transplantation outside the US as of
April 2007 – Total number 33 patients
• Excluded – patients who had moved to US after
transplant and all non-kidney patients (1 kidney
pancreas transplant was included)
Study Design & Methods 2
• Looked at:
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Demographic recipient data
Donor data (where available)
Transplant data (where available)
Clinical events
Graft survival
Patient death
Acute rejection
Serum creatinine after transplant
Infectious events
• Data verified with transplant staff + physicians,
NOT patients (attempting to negate recall bias)
Study Design & Methods 3
• Compared ‘tourist’ demographics, transplant
characteristics and outcomes with:
1. ALL adult patients who had transplant at UCLA
during the study period (graft survival, patient
survival, incidence rejection at 1 year, serum Cr at 1
yr)
2. A matched (Age, race (Asian vs non-Asian),
transplant year, previous transplantation, dialysis
time, donor type) cohort of 66 adult patients who
had transplant at UCLA (graft survival, patient
survival, incidence rejection at 1 year, renal function
and infectious events)
Results – Tourism over time
Results – Demographic Details
Results – Country of Transplantation
Results – Countries of origin
(data incomplete)
Worrying
group…
Hospital stay and D/C Meds
• Average length of stay was 15 days (info
unavailable for 47%)
• All D/C’d on CNI
• 90% D/C’d on Pred + Mycophenolate
• Only 24% received induction immunosup (info
unavailable in 39%) vs 60% of UCLA patients
• Only 12 patients received co-trimoxazole and
no patients received CMV prophylaxis
Results – Arrival post transplant
• Median time to initial visit to UCLA post Tx
was 35 days (13  2796 days)
• 4 patients needed immediate admission, 2
lost grafts, 1 recovered function after
prolonged period of Gram –ve sepsis and 1
died of fulminant hepatic failure on ITU
(presumed Hep B contracted from unscreened
donor)
Results – Graft &Patient Outcomes
Results - Infections
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Overall no difference in infection rates 52% vs 48%
But….
Marked difference in severity
27% tourist group required hospital admission, vs 9%
of matched cohort
• More than twice as many CMV positive patients (30%
vs 12.1%) with one CMV pneumonia in tourist group
• ??Increased incidence of bacterial infections in
matched cohort group ??Incomplete records of
infections from transplant centres
Results - Infections
Discussion – General Points
• Supply and demand an underlying problem
• More and more common
• Predominantly American-Asian patients
sought transplants abroad – Cultural aspects
poorly understood…..
• Reasons for travelling abroad not sought, not
clear and certainly multifactorial
• Why go abroad for live related… ?cost in US
Discussion – A fair bit lacking
• Live donors most common – lack of
documentation on where kidney comes from –
vendor-driven, executed prisoners, open
market….
• Lack of information from transplant centers
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Health, age, viral status of donor
Cold/warm ischaemic time
HLA matching
Post-op issues
Drug levels
Discussion - Reasonable outcomes,
Not without risk
• No statistical significance between one year graft and
patient survival, even in matched group, but low
patient and event numbers limit power (NB only
patients that return included…)
• Discursive results section wanting to demonstrate
experience that when things went wrong they went
very wrong!
• Inferior graft function and patient survival described
elsewhere in literature (refs 5,7,9,14,15)
• Higher episodes of acute rejection
• Generally higher rates of (severe) infections and less
prophylaxis. CMV a particular problem
Discussion - A public Health Issue?
• Potential infectious diseases
• Unclear donor selection
• Further work required
Dicsussion - Trust
• Of the 29 ‘transplant tourists’ evaluated at
UCLA prior to Tx ‘few’ discussed plans to go
abroad
• Can you council patients on transplant
tourism? Can you give information on risks?
Should you mention it’s an option? Should you
ask if they’re thinking about it?
• Does it damage the Dr/patient relationship
when patients return with grafts
More ethical stuff to think about
• Right or wrong?
• Incredibly complex mixture of social, political,
economic, cultural factors underpinning decisions of
people willing to sell organs and those willing to buy
them. Desperation on both sides
• Are we supporting this practice by looking after
patients when they return? We can’t not look after
them!
• Can we affect practices happening in a far away land??
• Way forward? – continue striving to improve transplant
services here (including numbers of organs) so people
don’t ‘need’ to go abroad…
Limitations
• Small study, low power
• Retrospective and observational (selection bias)
• Only returning tourist included – no evidence
about peri-operative deaths/deaths from
complications in those not returning
• ‘Matched’ group contained no matching for
nature of underlying renal disease or co-morbid
illness
• Lots of incomplete data from transplant centres
Thankyou!