Journal of Trafficking and Human Exploitation

2017 / 2 (December)

State-organized Criminal Forced Organ Harvesting

Torsten Trey, David Matas*

1.Ethical Guidelines in Transplant Medicine

Transplant medicine is a relatively new medical discipline. Dr. Joseph Murray and Dr. David Hume led the first kidney transplant in 1954. Dr. James Hardy performed the first successful lung transplant in 1963, and the first successful liver transplant and heart transplant followed in 1967.N.S. Hakim & G.M. Danovitch (eds), Transplantation Surgery (London: Springer, 2001), 7, 14, 15, 182.

The majority of transplants depend on donated organs. Most of them stem from deceased organ donors; some organs, if not essential to the survival of the organ donor, like a kidney, can also be sourced from living donors.

With the emerging transplant medicine new ethical guidelines were needed. Different international health organizations responded by adopting ethical standards for transplant discipline. The World Health Organization (WHO) Guiding Principles on Human Cell, Tissue and Organ Transplantation are the leading ethical guidelines on organ transplantation and organ; accessed on 4 January 2017. The guiding principles are centered on altruistic organ donation and describe ethical organ procurement and donation procedures. The World Medical Association (WMA) highlights that the organ donor has to give free, voluntary and informed consent prior to the organ; accessed on 4 January 2017. In most countries, the required consent is obtained by following one of two alternatives: presumptive (opt-out) or explicit (opt-in) consent.

International bodies describe these ethical standards, which contribute to a code of ethics in transplant medicine. This allows monitoring of the practice to detect ethical breaches. However, ethical standards are only guidelines, not laws, and their implementation depends on the voluntary commitment of everyone involved in transplantation or any other medical discipline. There is only limited leverage to enforce them, unless governments set a legal framework based on such standards. The interaction between international ethical guidelines and national governments reveals that the implementation and impact of ethical guidelines depend on national governments’ decision whether to write ethical standards into law, or not.

2.Organ Trafficking – An Overview

The Global Observatory on Donation and Transplantation (GODT) collects transplant data from the WHO and other transplant organizations. For the year 2014, GODT reported 119,678 transplants performed; accessed on 4 January 2017.

WHO officials estimated that about ten percent of transplants are based on illegally procured organs on the black; accessed on 4 January 2017. With a price tag of up to $ 200,000 for a kidney transplantation, a commercial approach to the transplant market – facilitated through organ trafficking – equates to a billion dollar business. However, the lack of official statistics about illegal organ trade makes it difficult to estimate the actual scope of global organ trafficking. Transparency is needed to address this issue.

The WHO Guiding Principles on Organ Transplantation require health professionals to provide transparent reporting on organ transplantation. Lack of transparency is a critical factor in any type of transplant abuse. Transparency gaps can result in unreported transplant cases and open the field for organ trafficking. If organs are illegally obtained and traded in organ trafficking, lack of transparency facilitates organ ‘laundering’.A. Manzano et al., ‘The Invisible Issue of Organ Laundering’, Transplantation 98, no. 6 (2014): 1-4.

Transparent reporting of transplants depends on the voluntary commitment of involved professionals to abide by ethical principles. Transparent access to donor consent is also a critical factor to ensure compliance with such principles. Free, voluntary and informed consent sets the dividing line between legal and illegal forms of organ procurement and distinguishes altruistic organ donation from criminal organ harvesting.

Typically, the law has more leverage for enforcement when organs have been procured without consent than in the case of missing transparency. Yet a better enforcement of transparency would contribute to control organ trafficking more effectively.

If the international transplant community were determined to ensure ethical transplant practices, it should ask its members to report transplant figures, not only as aggregates but also broken down by transplant hospitals. The latter improves transparency and would set the conditions for independent scrutiny.

Transparency plays a particularly prominent role in the transplant discipline. Transplant medicine is based on altruistic organ donations and arguably the most important, essential ethical key value in organ donation is trust.A. Caplan, ‘Bioethics of Organ Transplantation’, Cold Spring Harbor Perspectives in Medicine 4, no. 3 (2014): a015685. Without trust, transplant medicine and organ donation cannot thrive, and without transparency trust becomes fragile.

In the critical moment when the potential organ donor is, for instance, involved in an accident, when he/she is at the point of death, the individual needs to trust the medical doctor and system that his/her survival, and not his/her organs are the center of attention. While ethical guidelines help to build trust, it is the legal framework which consolidates trust by regulating consent and the organ procurement process.

In commercial organ trafficking, altruism and trust are bypassed and replaced with financial incentives. However, this bypassing of ethically based values often results in disappointed donors: eighty-one percent of commercial living kidney donors spent their money within five months after donations and ninety-four percent of them regretted the donation.D.A. Budiani-Saberi & F.L. Delmonico, ‘Organ Trafficking and Transplant Tourism: A Commentary on the Global Realities’, American Journal of Transplantation 8 (2008): 925-29.

Furthermore, commercial transplants from living unrelated donors take place under suboptimal conditions and inadequate pre-operative workup, with higher risks for the survival of the transplant recipients.K.S. Chugh & V. Jha, ‘Problems and Outcomes of Living Unrelated Donor Transplants in the Developing Countries’, KidneyInternational 57, no. 74 (2000): 131-135. Almost all countries where commercial transplants take place score poorly on the Corruption Perception Index compiled by Transparency International.V. Jha, ‘Paid Transplants in India: The Grim Reality’, Nephrol Dial Transplant 19 (2004): 541-543.

Commercial organ trafficking which uses organs from living unrelated organ donors reveals several issues which are suboptimal for organ donors and organ recipients alike. Key ethical standards are frequently bypassed and there is a lack of transparency with a reduced access to solid data.

Organ trafficking can take on unethical and criminal‑trafficking-a-deadly-trade.html; accessed on 4 January 2017. There should be a national or international legal framework to prosecute any wrongdoing. The prerequisites for keeping illegal organ trafficking in check are the isolation of organ trafficking and a legal framework which makes organ trafficking punishable.

If the legislative body of a State does not recognize illegal patterns in organ trafficking, correction of these patterns is weak. But if the State itself is involved in forms of organ trafficking, it is impossible to correct the practice from inside the State, and international attention and sanctions become a crucial resort to correct the practice.

State-organized organ trafficking takes the practice to a very different stage from private organ trafficking and can deviate to even severe forms of forced organ harvesting where the rights of the victims are ignored. State direction in organ trafficking can result in killing for organs, expanding the commercial availability of organs from one kidney to pairs of kidneys, liver, heart, pancreas, lungs and tissues like corneas.

3.China: State-organized or Black Market Organ Trafficking?

Starting from March 2006, testimony of unprecedented transplant abuse in China hit the news. Two Chinese individuals stated independently that the Chinese government was harvesting organs from living Falun Gong; accessed on 4 January 2017.

An investigative report by David Kilgour and David Matas in the summer 2006 published findings of organ harvesting from detained Falun Gong; accessed on 4 January 2017. The evidence, including oral admissions during phone calls with doctors of hospitals in China, indicated that it was a nationwide practice to use organs from persecuted, non-convicted Falun Gong practitioners for transplantations, allowing for pre-scheduled transplants with a waiting time of one to two weeks. A 2016 updated report by David Kilgour, David Matas and Ethan Gutmann compiled data from professional and state sources in Chinese and concluded that the actual number of transplants was more than ten times the officially reported transplant numbers in; accessed on 4 January 2017.

The official Chinese position had been that organs for transplants had been sourced from prisoners sentenced to death and then; accessed on 4 January 2017. However, executions in China appeared to be in constant decline after 2000,L. Burkitt, ‘China Accelerates Plan to Phase Out Prisoner Organ Harvesting’, Wall Street Journal, 2 November 2012;; accessed on 14 August 2017. and the country kept producing  – except for a brief period of time – a seemingly unaffected volume of transplants.J. Huang, Y. Mao & J.M. Millis, ‘Government Policy and Organ Transplantation in China’, The Lancet 372, Issue 9654, no. 6 (2008): 1937-1938, accessed 14 August 2017.

Transparent access to organ sources and numbers is lacking. The installation of a computerized organ allocation system, the China Organ Transplant Response System (COTRS), was introduced to ensure a fair, transparent organ allocation. However, the mechanism eliminated all traces of the organ sources; it is a form of organ whitewashing.K.C. Allison et al., ‘China’s Semantic Trick with Prisoner Organs’, BMJ Blog, 8 October 2015; available at:; accessed on 4 January 2017. A detailed investigation and analysis of China’s transplant market with which the Government of China would cooperate is thus imperative.

China’s transplant market developed in a very short time. An array of transplant and organ donation related numbers and features show characteristics unseen in other countries, where the transplant discipline has developed over several decades with transparent access to data and respect for ethical practices. In stark contrast to transplant practices in other countries, where organ recipients have to wait for a matching organ, China’s transplant market has the characteristics of a domestic organ trafficking market where organs are made available on demand and on short notice for large sums of money.A. Sharif et al., ‘Organ Procurement From Executed Prisoners in China’, American Journal of Transplantation 14 (2014): 2246-2252.

With officially reported transplant numbers peaking at over 13,000 per year in 2004, and independent investigators suggesting transplant numbers up to 100,000 per year,See supra note 14. the evidence points to a systematic, highly organized transplant market in China with the characteristics of an organ trafficking market.N.W. Paul et al., ‘Human Rights Violations in Organ Procurement Practice in China’, BMC Medical Ethics 18, no. 11 (2017): 1-9. It is thus important to inquire whether the organized transplant market in China is a state tolerated or state-sponsored form of organ trafficking. Are there privately organized organ trafficking rings operating with the knowledge and tolerance of the State? Or is there a state operated transplant market where the State is not only aware of the practice, but sponsors the same through its administrative network.

A brief look into the type of organ sources shows that we are dealing with a state-sponsored scheme: Deputy Health Minister Huang Jiefu stated publicly in 2006 that most of the organs from cadavers were from executed; accessed on 4 January 2017. In 2005, the amount was estimated as ninety-five percent.The Congressional Executive Commission on China Annual Report 2006, p. 59, note 224, p. 201: ‘Organ Transplants: A Zone of Accelerated Regulation’, Caijing Magazine (Online), 28 November 2005.

China did not have a public organ donation system at that time and started its first pilot program of a public organ donation program only in 2010. Death row prisoners are held under surveillance of the State. Private, criminal organ trafficking rings would not have access to organs from these death row prisoners. Death row prisoners do not disappear from death row cells without the knowledge of the State.

The short survival time of organs, defined by their ischemic time limitations, demands immediate and organized organ procurement after execution. Otherwise organs become unusable. This, again, excludes the possibility that private, criminal organ trafficking rings could take advantage of the organ harvesting after execution, unless the State would be involved. This suggests that the State is not only tolerating the organ trafficking, but is knowingly involved in the organ harvesting and organ trafficking. It is thus reasonable to conclude that domestic organ trafficking system in China is state sponsored.

On the demand side – the organ recipients – Chinese hospitals have advertised to provide any matching organ within two to four weeks, in some cases even shorter.See supra note 13. In 2005, Deputy Health Minister Huang resorted to an unusual, unprecedented step when he performed an autologous liver transplant in the Northwest of China and ordered two backup donor livers, which were located, harvested and transported across the country within twenty-four; accessed on 4 January 2017. It is implausible that two voluntarily donated matching livers were available within a few hours upon request, but also ethically irresponsible to demand two livers, making it unavoidable that at least one liver would be wasted due to its short survival time, and thereby bypassing a patient on the waiting list for a liver transplant.

The example leads us to the supply side. Chinese criminal law says that convicted death row prisoners must be executed within seven days of sentence.Article 251 Criminal Procedure Code of China; available at; accessed on 4 January 2017. Therefore convicted death row prisoners cannot contribute to a standing pool of readily available organ donors as they are executed soon after their death sentence.

The short time would make it difficult for organ trafficking rings to plan transplants without the knowledge and active involvement of the State. A period of seven days for execution also makes it impossible to plan and schedule transplants with more than seven days advanced notice, a situation described by foreign patients who travelled to China with two to four weeks notice.

Accordingly, China presents a domestic, commercial organ trafficking system that is state sponsored. Yet, a system sourcing organs from prisoners sentenced to death and executed within one week cannot explain the transplant phenomena observed over the years.

Dr. Jacob Lavee reported that one of patients who was waiting for a heart transplant was told one day to come to China for a scheduled heart transplant with a two-week advance notice.J. Lavee, ‘The Impact of the Use of Organs From Executed Prisoners’, in State Organs: Transplant Abuse in China, ed. D. Matas & T. Trey (Woodstock, Canada: Seraphim Editions, 2012), 108. A potential deathbed patient in intensive care unit (ICU) would have triggered an immediate invitation without a delay of two weeks; the regulations for execution would suggest scheduled heart transplantations within seven days. Dr. Lavee’s patient’s two-week advance notice and Deputy Health Minister Huang’s two backup livers provided within twenty-four hours require an explanation of the on-demand availability of matching transplant organs.

Given the prevalence of infectious diseases and drug abuse in the prison population and the absence of a nationwide operating organ allocation system before 2010, China presents us with a combination of factors that demand explanation.

China had a national organ donation rate of virtually less than one donor per million people.N. An et al., ‘Organ Donation in China: The Major Progress and the Continuing Problem’, Journal of Biomedical Research 30, no. 2 (2016): 81-82. If we apply the national organ donation behavior on death row prisoners, we could not possibly get to the amount of organs sourced from executed prisoners and used for transplants. If all death row prisoners were used as organ sources, then the prison environment would have altered the national consent rate from virtually nil to virtually 100%, suggesting a form of force that would have influenced the consent behavior, and thus confirming that the ethical guideline as set forth by the WMA that prisoners deprived of their freedom cannot provide free, voluntary consent, is justified.

From different angles, the officially claimed source of organs – executed prisoners – cannot explain the scope and characteristics of the transplant market as practiced in China. Another source of organs must be identified. Which group, other than convicted and executed prisoners, could provide organs in the numbers that were available on demand, without leaving a trace upon disappearance?

The situation of non-convicted prisoners of conscience makes this group particularly vulnerable for exploitation due to the lack of publicly available records. In contrast to death sentences by the court, which create an official record of the convicted death row prisoners, there are either no or only scarce official records of detained prisoners of conscience, making it difficult or impossible to find out what happened to them.

Detained Falun Gong practitioners report that some of their peers disappear from detention camps without a trace of their stay. An analysis of eyewitness reports of Falun Gong practitioners who were in Chinese detention reveals unusual phenomena. Detained Falun Gong prisoners of conscience were forced to undergo medical exams, blood tests and other medical diagnostic procedures. They were not informed about any results. If they refused, guards forced them. In some cases, tests were so comprehensive that costs would range in the hundreds of dollars per person. Research found that the medical examinations were not isolated incidents but systematically and periodically applied to thousands of Falun Gong; accessed on 4 January 2017.

Yet, such a large-scale, systematic medical exploration of prisoners of conscience is unprecedented and it raises a question: who pays for the expenses of these medical exams? Since Falun Gong practitioners are subject to torture, brainwashing, forced labor and suboptimal living conditions, medical exams cannot be motivated by a wish to provide health care. It is also unlikely that detention camps would have a budget for large-scale medical exams, unless repayment of the expenses is in sight. The systematic medical checks and blood tests of detained Falun Gong prisoners of conscience set the stage for a grim reality: forced organ harvesting from living, detained Falun Gong prisoners of conscience to provide healthy, matching organs on-demand in a short time.See supra note 13.

An exploration of the national transplant numbers with other events provides further insight. In 2010, Deputy Health Minister Huang presented transplant numbers at a transplant conference in Madrid. The annual transplant numbers between 1999 and 2004 increased exponentially by about 300; accessed on 4 January 2017. In absence of a public organ donation program, where did the extra organs for such an increase come from?

To put this into perspective, we note that the GODT generates charts on transplant numbers; accessed on 4 January 2017. and the annual increase of transplants worldwide is between two to three percent per year. This equates to an increase of ten to fifteen percent during a similar five-year window and is nowhere near the increase reported from China. The steep increase of transplant surgeries in China after 1999 is unseen anywhere else in the world.

A comprehensive analysis of transplant data from China reveals other concerns. Looking into professional medical journals and official Chinese sources, investigators found an expansion of the transplantation infrastructure in China, with increasing bed counts, transplant surgeons, investments in the transplant field and revenue.

For instance, the Organ Transplant Center of the Armed Police General Hospital in Beijing stated that their Organ Transplant Center is the ‘main department for making money. Its gross income in 2003 was 16,070,000 Yuan. Between January and June of 2004 the income was 13,570,000 Yuan. This year [2004] there is a chance to break through 30,000,000 Yuan’; accessed on 4 January 2017.

Despite these factors showing a growth of the transplantation industry in China, the annual transplant numbers of China for the past ten years were officially reported as stagnating at about 10,000 per year. It is implausible that the reported growth and expansion of the transplantation infrastructure in China would not be reflected in annual transplant numbers for over ten years, which challenges the veracity of the officially reported numbers, and subsequently raises the question whether the officially reported transplant numbers were artificially reported low in order to hide an undisclosed organ source.See supra note 14. This situation demands to look into such organ sources.

Falun Gong is a peaceful, spiritual discipline, in the Buddhist tradition, teaching the principles of truthfulness, compassion and tolerance. The principles are practiced with a clear mind in daily life including abstinence from drugs, smoking and alcohol. Their Qigong-like exercises help practitioners to maintain health. Communist repression of the practice since 1999 made adherents a vulnerable target. Since 1999, Falun Gong has been ostracized, dehumanized and persecuted. Deprived of their basic rights, Falun Gong practitioners became the primary target for forced organ harvesting.K.C. Allison et al., ‘Historical Development and Current Status of Organ Procurement from Death Row Prisoners in China’, BMC Medical Ethics 16, no. 85 (2015): 1-7. This occurred not because a law authorizing torture and forced organ harvesting had been adopted, but because statements of the Communist Party had been turned into a state policy.E. Bryan & J. Richardson, ‘Falun Gong and the Law: Development of Legal Social Control in China’, The Journal of Alternative and Emergent Religions 6, no. 2 (2003): 312-331.

Most leading voices in the transplantation field have ignored the issue and failed to investigate the claims. WHO Director-General Chan has stated that China is ‘in line with WHO Guiding Principles’; video message, October 2016; at minute 6:20-6:40; accessed on 4 January 2017. And the WHO official responsible for organ transplantation, José Nunez, is quoted by Xinhua, the official Communist Party of China news service, as saying that the Chinese transplant practice is ‘transparent, and ethical’.‘Int’l Professionals Recognize Chinese Organ Donation Achievements’, 18 October 2016; available at; accessed on 4 January 2017. Yet, the Government of China does not respect several of the WHO standards. The WHO Guiding Principles ban financial incentives for organs, and demand traceability and transparency.See supra note 2. China plainly fails to comply.

Chinese law both prohibitsState Council of the People’s Republic of China March 31, 2007 regulation on human organ transplant effective as of May 1, 2007; Art. 8; available at 06/05/c_46236_2.htm; accessed on 4 January 2017. and allowsChinese Government Regulation with regard to use of Dead Bodies and Organs of Condemned Prisoners Article III(1) October 9, 1984 reproduced in Human Rights Watch report ‘Organ procurement and judicial execution in China’, August 1994; available at; accessed on 4 January 2017. the sourcing of organs from prisoners without consent. The prohibition has no practical effect, since it cannot be applied against the Communist Party and its state organs.

Prosecutors cannot enforce the law against the Party and state institutions, since the Party controls the police, the prosecution, the courts and even the defence bar, by constitutional right. The constitution of China refers to ‘the Chinese people of all nationalities led by the Chinese Communist Party’ or ‘under the leadership of the Chinese Communist Party’ six different; accessed on 4 January 2017.

In stark contrast to other countries, where organ trafficking practices are contained or regulated through national or international laws, the judicial corrective is missing in this domestic practice, presenting a unique form of organ trafficking market, one that is state sponsored. Under these conditions, health professionals in China are torn between international ethical standards and their local work environment. A discrepancy has emerged between China’s wish to join the international community and its failure to abide by that international community’s common ethical standards.

The unique domestic transplant model in China exploits gaps in international law that the WHO and international transplant societies have not encountered elsewhere and international judiciary bodies have failed to control. It presents a challenge to those outside China in a globalized, connected world. How should the international community react when a country’s government participates in an unlawful, criminal organ trafficking practice?

4.Working on Solutions

Transplantation, more than other medical disciplines, is built on trust. The altruistic organ donor is the foundation of ethical transplant medicine. Forced organ harvesting with – in the extreme case – donors being killed during the organ harvesting process, undermines this key ethical value.

It is the trust that convinces people to register as organ donors, trust in the medical doctors and the transplant system, trust that, if one is at the point of death, the survival of the registered donor, not his or her organs are at the center of attention. Trust is the area where the death of the donor and the survival of the recipient overlap.

To establish trust, transparency is an indispensable factor. Transparency creates the conditions to build trust; lack of transparency in transplant medicine is unjustifiable. While transparency is desired and mandatory in an ethical transplant system, transparency is an unwelcome partner to state-sponsored organ trafficking. The State would naturally have an interest in hiding the practice. Lack of transparency in a state-sponsored organ trafficking environment throws into doubt the data which the State has produced.

The Red Cross Society of China publishes numbers of registered organ donors on the website of the Organ Donation Administrative Center. They showed an increase of exactly 25,000 registered donors within one day between 30 Dec. and 31 Dec. 2015. The sudden large increase in a country that traditionally is reluctant to donate organs is; accessed on 4 January 2017.

In the early 2000s, as noted, the transplant numbers increased by 300 percent within five years while the global increase was only about ten to fifteen percent. Ten years later, starting with the newly founded organ donation pilot program in 2010, the organ donation numbers increased by a staggering 100-200 percent per year.See supra note 22. To put this into perspective, the donation numbers in the US in the past twenty-nine years increased by only two to ten percent per‑data‑reports/national‑data/; accessed on 4 January 2017. While the lack of transparent access to real data obstructs any verification, the official numbers published in China raise many questions.

The transplantation field in China is claiming to meet the criterion of transparency, but so far has not. There is still a lack of transparency in China’s transplant system. And the lack of traceability has been institutionalized through the implementation of the COTRS.T. Trey et al., ‘Transplant Medicine in China: Need for Transparency and International Scrutiny Remains’, American Journal of Transplantation 16 (2016): 3115-3120; available at; accessed on 4 January 2017. The combined failure to implement these WHO Guiding Principles of transparency and traceability conceals an acute problem; the crimes of forced organ harvesting can thrive behind the disguise. Without a national legal framework in China to punish forced organ harvesting from prisoners of conscience and without sufficient scrutiny so far by leading medical organizations, it is imperative that other institutions and organizations take the lead to push for an independent, institution based investigation, with which China would cooperate, to end the forced organ harvesting from any type of prisoner in China.

Potential transplant reforms in China have to fulfil critical requirements. They would need to address concerns of all stakeholders. They would need to address concerns of the vulnerable victims. Reforms that would distract from or cover up past and ongoing crimes, would – if accepted by the international community – create a disastrous human rights crisis. International attention must not be diverted by such alleged reforms; instead, the international community has to seek answers to the question whether prisoners of conscience, primarily Falun Gong practitioners, were and continue to be killed for their organs.