Transplant tourism is one of the main unacceptable aspects of medical tourism, implicating travel to another country to receive an allograft. Organ shortages in wealthier countries have persuaded patients to preclude organ waiting lists and travel to other countries for getting organs especially kidneys. On the other hand, in many countries, there is no transplant program, and hemodialysis is expensive. Hence, patients with end-stage kidney disease may have to travel to get a kidney allograft for the sake of their lives. In Iran, a legal compensated and regulated living unrelated donor kidney transplant program has been adopted since 1988, in which recipients are matched with live-unrelated donors through the Iran Kidney Foundation and the recipients are compensated dually by the government and the recipient. In this model regulations were adopted to prevent transplant tourism: foreigners were not allowed to receive a kidney from Iranian donors or donate a kidney to Iranian patients; however, they could be transplanted from donors of their own nationality, after full medical workup, with the authorization of the Ministry of Health. This was first considered as a humanitarian assistance to patients of the countries with no transplant program and limited and low quality dialysis. However, the policy of “foreign nationality transplant” gradually established a spot where residents of many countries, where living-unrelated donor transplant was illegal, could bring their donors and be transplanted mainly in private hospitals, with high incentives for the transplant teams. By June 2014, six hundred eight foreign nationality kidney transplants were authorized by Ministry of Health for citizens for 17 countries.

In this review, we examine the negative aspects of transplant for foreign citizens in Iran and the reasons that changed “travel for transplant” to”transplant tourism” in our country and finally led us to stop the program after more than 10 years.

Key words : Travel for transplant, Transplant tourism, Iranian model of kidney transplant

Introduction

Transplant tourism is one of the main unacceptable aspects of medical tourism, implicating travel to another country for receiving an allograft. People used to travel from under-developed to developed countries to receive the types of medical treatment that were not available in their home countries.^1,2 However in case of organ transplant the route has mostly reversed from wealthier to underdeveloped countries for the sake of economic issues or by­passing the legal barriers.

Organ shortage in wealthier countries has persuaded a number of patients to preclude long-term organ waiting lists in the United States, Canada, Australia, Israel, Japan, Oman, Saudi Arabia, and European countries and travel to other countries for getting organs especially kidneys. On the other hand in some countries such as Tajikistan, Afghanistan, and Uganda, among many others, there is no available transplant program and hemodialysis is expensive and not covered by public health care systems. In these countries, patients with end-stage kidney disease may have to travel abroad to get a kidney allograft for the sake of their lives.

In most of the countries of the world buying and selling organs are illegal and allografts can be received from cadavers, live relatives, and sometimes emotionally related donors and paired kidney donation. However, in many countries, there are no strict rules for patients who have been transplanted through transplant tourism and the medical team has to take care of the recipients after returning back to home countries. The Istanbul Declaration distinguishes transplant tourism from travel for transplant.³ Travel for transplant is the movement of organs, donors, recipients or transplant professionals across borders for the purpose of transplant. Travel for transplant becomes transplant tourism if it involves organ trafficking and/or transplant commercialism or if the resources devoted to providing transplants to foreigners undermine the country’s ability to provide transplant services for its own population.

Kidney transplant model in Iran
In Iran, a legal compensated and regulated living-unrelated donor kidney transplant program has been adopted since 1988, in which recipients are matched with live-unrelated donors (LURD) through Iran Kidney Foundation and the recipients are compensated dually by government and the recipient.⁴ This model could eliminate the transplant waiting list of the country within a decade, and due to restricted kidney donation/sale by Iranians to Iranians, restriction of transplant operation to the university hospitals and nonprofit nature of the whole procedure for the transplant teams, gained some popularity.⁵ However, during the next decades, the model was not successful in this regard, and the waiting list has grown to more than 17 000 by 2011, although the latter figure includes the hemodialysis patients who have not been registered for transplant.⁶

On the other hand, apart from the main issues that should be thoroughly examined in every organ donation program, which are beneficence, nonmaleficence, donor autonomy, altruistic donor motivation, coercion free donation, fully informed consent, and avoidance of medical paternalism,⁷ the model is not free of ethical debates, within its defined and accepted legal frameworks. The main debates are the increasing financial relation between the donor and recipient, which could have ideally been eliminated by total governmental compensation instead of a dual recipient-government payment, and the lack of a proper donor follow-up program, with little information about the future of donors.^8-10

Foreign nationality transplant in Iran
In the Iranian model of kidney transplant, several regulations were adopted to prevent transplant tourism: foreigners were not allowed to receive a kidney from Iranian unrelated or a deceased-donor or donate a kidney to an Iranian patient; however, they could be transplanted from volunteer living related or unrelated donors from their own nationality, after full medical workup, with the authorization of from Ministry of Health.^11,12 This policy helped keep the model within its legally defined framework for many years. By June 2004, among 241 Afghan refugees with end-stage kidney disease in Iran, 62 had undergone kidney transplant, all receiving kidneys from donors of their own nationality which were living-unrelated donors in 50 cases, living-related donors in 9 cases, and a spouse or deceased-donor each in 1 case.¹³ Ghods also reported 7 ESRD patients from Azerbaijan transplanted in Hasheminejad Kidney center from Azari donors (5 LURD and 2 related donors) and considered it as a humanitarian assistance to the patients of a country with no transplant program and limited and low-quality dialysis. He also reported 4 patients from Turkey, 2 patients from India and Japan living in Iran, and 1 who came from Yemen, all transplanted from same nationality donors, except for the Japanese woman who had married an Iranian man and was an Iranian citizen.¹¹ As the recipients brought their matched donors to Iran, full medical work-up was implied and Iranian donors were not used for foreign citizens, this was accepted by the Ministry of health and more private and governmental hospitals were allowed to practice “travel for transplant” in Iran. By June 2014, six hundred eight foreign nationality kidney transplants were authorized by Iranian Ministry of Health for citizens from 17 countries (Table 1 and Figure 1) (Dr. Katayoun Najafizadeh, personal communication).

However, Ghods later mentioned the brokers who arranged paid donation in Azerbaijan and admitted that “these kidney transplants are in the category of unethical commercial transplant tourism and should be avoided.” He denied to continue LURD transplant for foreigners and considered it as a type of medical tourism and suggested to exert pressure on Azerbaijan health authorities to establish their own kidney transplant program.⁸

Iran was essentially trying to provide kidney transplant to her citizens through a controlled LURD program, while expanding deceased-kidney transplant, together with helping the foreign refugees and a few neighboring countries, which had no transplant program and limited dialysis facilities.^10,11,14 However, the policy of “foreign nationality transplant” gradually established a spot where residents of Oman, India, Saudi Arabia, and many other countries, where LURD transplant was illegal, could bring their LURD donors, and be transplanted mainly in private hospitals, to where foreign nationality transplant operations were gradu-ally transferred, with high incentives for the transplant teams. Reports of cases of Omani and Saudi citizens receiving kidneys from Iranian “paid” donors had been previously published and 3 more such cases were recently discovered by Ministry of Health in 2 private hospitals, who had submitted fake Iranian ID cards to receive kidneys form Iranian donors.^8,15 Doctors from India unofficially complained about the transplant of Indian citizens from LURD Indian donors in Iran and mentioned the brokers and Indian organ trade Mafia on personal emails to one of us (Dr. Behrooz Broumand). In the past few months, the concerns of neighboring countries for formation of a transplant tourism spot in Iran intensified and detection of cases of illegal Iranian to foreign citizen kidney transplant together with identification of 12 illegal organ trade bands, led the Iranian Ministry of health to forbid any kidney transplant for foreign citizens and again limit transplant operation to university hospitals with no incentives for the transplant team.15,16

The negative aspects of foreign nationality transplant
What were the negative aspects of transplant for foreign citizens in Iran and what changed “travel for transplant” to “transplant tourism”? The declaration of Istanbul says that “Travel for transplant becomes transplant tourism if it involves organ trafficking and/or transplant commercialism or if the resources devoted to providing transplants to foreigners undermine the country’s ability to provide transplant services for its own population.¹

In Iran, Iranian kidneys were not officially sold to foreign citizens, although organ sale and hence “organ trafficking” was happening in the home country. However, with higher fees offered by foreign citizens to Iranian donors, compared to the relatively fixed “rewarding gift” that is paid by Iranian recipients and controlled by Iran Kidney Foundation, there was a risk of increasing illegal kidney sale from Iranians to foreigners. Also the transplant teams which used to receive a fixed and limited fee for service incentive from the governmental hospital, were set at the risk of being seduced by the high fees offered by foreigners, especially those form rich countries. On the other hand, although some neighboring countries were actually happy with the transplant of their citizens in Iran (like Azerbaijan, which did not set up a transplant program), others including India seemed to be concerned about the new activity that was taking place over their borders and with the organ trade mafia that was conducting this activity. So it is obvious that organ trafficking, at least form outside to inside of Iran was happening.

Second, the Iranian resources, especially kidneys were not generally provided to foreigners. However, in addition to the increased risk of illegal kidney sale to the foreign citizens due to financial appeal, the transplant teams were spending their time on foreign citizen transplant and this can be assumed as an important country’s resource. With the increasing number of foreign transplants and more financial attractiveness of the transplant fees in private hospital, this would undermine the country’s ability to provide sufficient transplant services to its own population.

Third, the main strong points of Iranian model of LURD transplant have been the full informing of transplant complications to the donors, clear agreements between the donor and the recipients about the “rewarding gift,” and consent of the donor first-degree relatives (father in case of single donors and spouse in case of married ones), together with full payment according to agreements (no cheating), although the mere obligation to donate under economic “coercion,” dual donor-governmental compensation (instead of full governmental) and lack of a regulated donor follow-up registry, are the main concerns with this model. With donors found and negotiated outside our country’s regulations, none of the mentioned conditions could be expected to be met, and although full medical workup was routinely done and the transplant procedure was a “clean” one regarding donor infections and operation conditions, the model was not working for the foreigners within its legal frame works.

Conclusion

We are delighted to inform that this activity, as a form of transplant tourism, was stopped on August 14, 2014, after 608 transplants for foreign citizens had been performed, with a number of cases of illegal Iranian to foreign citizen kidney sales.17 According to our experience, it seems that it is very hard or impossible to legalize any form of live-unrelated kidney transplant program for foreigners even in the context of a legal live-unrelated kidney transplant program, as in our country. Due to monetary nature of such programs and organ shortage in general, deviations from any defined regulations will finally happen and the unethical issues especially organ trafficking mafias, will establish. We insist on maintaining on banning any kind of organ trafficking and transplant tourism and not to try to establish or legalize such programs in response to worldwide organ shortage.

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