Objectives: Organ trafficking has emerged worldwide as an important medical and ethical concern. In this study, we reviewed the literature presented on this matter to evaluate the global practices, ethical standards, and legal aspects of organ transplantation.

Materials and Methods: We adopted a qualitative study design to perform this study, which included conduct of a literature review. The main focus was organ transplantation.

Results: Our review suggested a dire need to adopt ethical principles and implement equitable distri­bution of organs around the globe as per the respective need.

Conclusions: Further studies are needed to evaluate the role and status of organ recipients to create a much more organized environment for safe and effective implantation of evidence-based principles of clinical transplantation globally.

Key words : Ethical concerns, Human trafficking Transplant commercialism, Transplant tourism

Introduction

Organ transplantation is considered to be one of the most important advancements in the medical field.¹ Over the span of about 100 years, solid-organ transplant has advanced from an experimental theory to a clinically effective procedure with ever-increasing efficacy and standards of care. With the success of the procedure of retrieving a functioning organ from one human body and transplanting it to the affected individual’s body, the chances of prolonging life and improving quality of life have significantly improved. Organ transplantation not only reflects advances in clinical technology and close cooperation between various specialities of medical sciences but also highlights the magnitude of human compassion spreading throughout the globe to help and save lives. Regardless of the achievements and positive outcomes of this life-saving therapy, there have also been gains in negative aspects in society in the process of organ transplantation. These factors include aspects in culture, legality, and political affluence along with factors concerning procurement, organ preservation, donor allocation, immunological implications, and efficient management of infections.^1-4

Although standard and cost-effective transplant procedures are available to save patients with organ failure, successes in their implementation have been victim to ever-increasing gaps between the number of potential recipients waiting for organs and the number of available donors.¹ Presently, the number of patients waiting to receive an organ transplant has reached up to 100 000 globally.¹ Unfortunately, these numbers are higher than the number of available donors and organs. These gaps between recipients on wait lists and the number of donors have subse­quently influenced states to adopt different strategies to encourage organ donation from potential sources. The most encouraging tactics have involved inspiring healthy people to donate organs after death. Despite various efforts, the increasing demand for organs has resulted in serious problems worldwide, including nonconsensual retrieval and organ trafficking.^1,2 The issue of organ trafficking has increased globally, resulting in the World Health Organization identifying the need to protect vulnerable people from transplant tourism and selling of tissues and organs. In 2004, the World Health Organization highlighted the significance of tackling the issue of international trafficking in organs and human tissues.^2,5

Over the years, trafficking of human organs around the globe has commercialized into an underground business running on large sums of finances moving worldwide.⁶ The concept mainly involves recipients who have an adequate amount of money to spend and express a strong demand for an organ, leading to the exploitation of vulnerable groups. A vulnerable person may either sell an organ in exchange for money consensually or may get trapped into the trafficking network and lose an organ without any active consent to operate. The flow of commercial networking is mainly concentrated in underdeveloped countries that encourage patient tourism to procure the organs.⁷ Although cases of illicit and unethical removal and trafficking of tissues and organs from human bodies have been reported, the matter was still disregarded in the 2006 annual meeting of active-member states of the United Nations. The matter was not given priority due to limited data and lack of a possibility to estimate the magnitude of human organ trafficking.^6,7 However, in 2007, the World Health Organization addressed commercial trafficking in the Second Global Consultation on Human Transplantation,² presenting that commercial sales of organs retrieved from living donors had been increasing worldwide. This global conduct mainly includes kidney transplants, which account for 5% to 10% of operations per year.⁸ The subject has been addressed extensively at the International Summit on Transplant Tourism and Organ Trafficking Convened by The Transplantation Society and International Society of Nephrology in Istanbul, Turkey, April 30 through May 2, 2008. The related definitions as quoted by the Summit are shown in Table 1.^2,9

Over the years, commercial transplantation has evolved into a clinical crime network. The modality includes diverse issues, from trafficking of vulnerable humans to medical complications that may arise with lack of postoperative care in such cases. Lack of consent and lack of knowledge with the added probability of higher morbidity and mortality rates are important concerns. In every aspect, the practice of commercial organ transplantation is deemed unacceptable in terms of medical ethics.¹⁰

Problem Statement
Despite the familiarity with its serious violations of human rights and laws, the business of human trafficking for organ removal is common in countries with vulnerable populations.⁶ To highlight the violation of human rights and to protect the people at risk of human or organ trafficking, the United Nations has developed protocols directed toward human trading. It has been realized that most targets of these underground and illegal industries are women and children, who are often engaged in organ trafficking through deception. In fraud cases, many people realize too late that they have lost an organ during a course of time; others are kidnapped and then deserted after the organ retraction. Along with these practices, many are left to suffer or even die because of lack of postoperative care.^10-12

It should also be realized that legal and protective systems have also recognized vulnerable people as victims who may have sold their organ in exchange for money due to poverty or other situation. It is considered as exploitation of position or situation of a human that again comes under laws against human rights.^10-12 Although laws have been asserted to protect humans from victimization in organ trafficking, it is considered important to filter out the reasons behind these criminal activities. The most notable factor in this regard is that organ trafficking started as an underground industry that is being run with hefty financial backup. The main driving force of organ trade is recipient driven, where recipients may possess the capability of spending earnest amounts for an organ.¹⁰

Significance of the Study
Organ trading remains a major concern, and its roots have strengthened within an underground market. Although organ trafficking is considered a form of human trafficking, it has failed to be recognized and given importance in legal contexts due to a lack of perspective and evidence. Today, the number of chronic disorders is increasing worldwide, with an expanding life expectancy. The rising number of cardiovascular diseases has led to more with organ dysfunction, which may further progress to organ failure. As stated earlier, the rising figures and demands for organs is far higher than the available number of donors. The lack of donated organs, the rise of demand for organ transplants, and the increase in available resources and finances of recipients are potential influencers of organ trafficking. The underground market has been fuelling and running on these factors since the beginning.⁶ The underlying core reason and the common theme are a criminal empire and selfish demand for organs, hinged on an unavailability of donated organs. Nonetheless, our primary focus is not the unavailability of donors. Rather, our focus is to understand the factors that have led to organ trade and how to address this serious issue of global concern.

Materials and Methods

Study objectives
Our objective was to evaluate the practices, ethical standards, and legal aspects of organ transplantation globally, and our literature search reviewed and analyzed published studies on global organ transplantation. We adopted a qualitative study design to perform this study, which included conducting a literature review.

Search strategy
For the literature search, we conducted an online search for appropriate materials. During the search, the primary key terms included the following: commercial transplant, organ transplant, organ trafficking, organ tourism, organ trade, and patient tourism. We conducted and collected literature search findings in our institute’s database. Accordingly, we filtered data to optimize findings using the following characteristics: article types included scientific research papers and reports, text availability included full text of the article, publication dates included 10 years from 2008 to 2018, study subjects included humans, and publication language was English.

Organ Trafficking as a Global Problem
Despite its illegal and unethical practices, the underground market of organ trafficking has flourished globally. Exploitations have not only occurred within small-scale groups but have also included high-profile organizations and names in the trade. The market for illegal organs runs on large sums of money that have big profits for traders. This market has flourished more so in underdeveloped countries, where the population is poor and more vulnerable. There are rare instances where victims are put under anesthesia and wake to find their organs missing or are murdered for their organs. However, despite increased awareness throughout the globe regarding organ trafficking and organ donation, illegal practices alarmingly remain. The practice of organ trafficking is mainly attributed to the demand for healthy organs in the international market and the lack of affordable dialysis programs in resource-limited health care systems. Despite advancements and continuous research in immunology, grafting, and infection management that have improved allograft survival, these have diluted hindrances of precise biological matching.^13-16

An ever-increasing gap in demand versus supply of donor organs in wealthy countries with poor regulatory systems has fuelled the unethical practice of money changing hands in exchange for donor organs.¹¹ Organ trafficking is driven by 3 factors: first, the values of those in society who consider that the selling of the transferable organs should be legalized with the consent and authoritative power of the seller or donor; second, the prevailing environment of neoclassical economics that refer to consider transferable organs as a commodity. According to their approach, consideration of an organ treated as a commodity can increase its availability in the market, with the willingness to share the organ in exchange for payment. This has led to “organ for sale” becoming a new normal. Third, many unscrupulous surgeons and specialists in the field have colluded with young men under the burden of responsibility. These professionals have encouraged the market forces to retrieve organs from any possible means irrespective of its fairness in ethical or legal terms.^10-12,17

Regardless of the position in the society and level of education attained by each group, the desperation to obtain a healthy organ is reflected in a compromise in ethics and substandard practices in the medical field.¹⁸ It is known that the victims are mostly individuals from underdeveloped states, and such groups of people are often exploited. Exploitation not only involves deception but also involves the concept of economic desperation among the groups. Moreover, ignorance has also led to the contemptuous apathetic attitude of those at the helm of affairs toward a vulnerable and poor segment of society who are exploited because of obliviousness to their rights. That is why the trade of organs is seen as an abuse to the justice and rights of humans in a vulnerable situation.¹⁸ Therefore, it is also considered important to reflect on the role of organ retractors and traders to get more familiar with the characteristics of organ trafficking. Thus, below we review sellers in the organ trade market.

Organ Trafficking: Hidden Form of Human Trafficking
Among different forms of human trafficking, organ trafficking is the most concealed form, which uses devious methods by exploiting loopholes. Unlike forced labor or prostitution, organ trafficking is difficult to trace and lacks robust laws and regulations to control or even identify culprits and traffickers. Usually, the victim is recognized after the loss of an essential organ, which cannot be retrieved back. The criminal footprints in this regard are destroyed easily, and the traffickers remain to earn high profits. The value of each organ that can be transplanted varies with the desperation of demand of the organ and the difficulty of supply in the market.¹⁶ Organs that are transplanted include cornea, lungs, heart, liver, and kidney. Figure 1 shows differences in value of transplantable organs in 2007 and 2017.^13,19

According to a report presented by Global Financial Integrity, about 10% of the transplanted liver, lungs, and heart are obtained through organ trafficking globally. Apart from these, the most highly demanded and also the most illegally trafficked organ are kidneys, which comprise about 75% of the illegal organ market.²⁰ The World Health Organization estimated that 10 000 kidneys are trafficked illegally around the world for transplantations. This equals more than 1 kidney retrieved unethically from a human body every 1 hour. Furthermore, the report stated that organs are often retrieved from vulnerable populations. These populations are mainly from China, India, and Pakistan.²¹ Although these 3 countries are infamous for organ procurement for “organ sale,” other countries have been also involved, including Mexico, Costa Rica, Peru, Turkey, Egypt, Sri Lanka, Cambodia, Vietnam, Philippines, Singapore, and Indonesia.¹⁶

The involvement and integration of an international market led to the phrase “patient tourism,” which involves the seeker or receiver of treatment to travel to obtain the best possible treatment, management, and care. For patients with organ failure and the need for transplant, organs are the main driving factor for travelling. In these aspects, the seeker sometimes travels to another country to obtain the organ or the trader takes the responsibility of delivering a healthy organ to the buyer. This is referred to as the “transplant tourism,” where an individual may travel to retract an organ from the market.²

Transplant Tourism
According to the records, the first case of selling a human organ was reported in the 1980s.²² Today, the business of trading human organs for transplant has evolved into an established market. Initially, the practice involved street dealing with only a few people involved in obtaining organs through coercion. However, this dealing has evolved into a major trade and expanded its roots through both developed and underdeveloped countries. Most organ trades involve long-distance travel, as organs are resourced through vulnerable populations who are either deceived into the practice or paid poorly in exchange for the organ. Due to high awareness, practices of management and care, and the power over finances, it is not convenient to perform these activities in economically wealthy states. Therefore, these activities are conducted in underresourced areas. These underresourced targets mainly include Asia and Africa, including India, Pakistan, Egypt, and the Philippines, as well as some parts of Eastern Europe. Prisoners in China have been victims of the inhumane practice of using them as organ donors, raising suspicion of whether orders of execution involved the demand for their allografts.^23-25 Nonetheless, in searches for healthy organ, buyers frequently travel to these locations that somewhat encourage tourism, which equates to a major medical crime.²⁵

Transplant tourism has gained interest as more and more people have been travelling for organ procurement. Individuals with strong financial capabilities tend to be more inclined toward transplant tourism. However, there have been instances of misuse of the system, in which a select few have had backup from their government or health insurance to fulfil the expenses of procuring an organ. Travelling for transplant tourism has been observed in wealthy states of the Gulf region, Europe, and Israel. Major transactions and procurement activities have been mainly performed in regions of Asia, Eastern Europe, Latin America, and South Africa, where buyers arrive for trading. The kidneys remain the most obtained and demanded organ; kidneys have been advertised on online platforms or through brokers in the market.^23,24

It is important to locate areas of demand and control the eagerness and desperation to seek monetary profits and health benefits that involve selfishness and violation of human rights. Organ trafficking involves varying factors and many targeted organs. However, it has been realized through estimations and reports that the most demanded and valuable organ on the international market is the kidney.²⁶ Furthermore, recent research has shown that chronic renal diseases are significantly increasing among the people of the United Arab Emirates.^27,28 The region is well-known for economic strength and improvements in living standards over the past few decades. However, the evolution of urban culture has led to an increase in people with chronic disorders.^27,28

Chronic renal disorders are also increasing globally. About 13.4% of the global population has chronic renal disorders, with the greatest number of patients at stages 3, 4, and 5 of chronic kidney disease. About 4.6% of men and 2.8% of women in the United Arab Emirates are affected with different stages of chronic kidney disease.²⁷ In line with these observations, a possible emerging need for kidney transplants has been identified due to the rising prevalence of chronic kidney disorders. Of note, the United Arab Emirates is known for financial strength; therefore, the combination of demand and availability of adequate finances can attract organ traffickers in the region to market illegal organ procurement.

International Organ Shortages
Some organs can be transplanted from a living person, whereas others can only be explanted after the death of a potential donor. Transplantable organs include the heart,²⁹ lungs,³⁰ the liver,³¹ kidneys,³² corneas,³³ and pancreas.³⁴ Contemporary research has even made advances in transplanting the uterus to treat and manage infertility.³⁵

According to a report from the World Health Organization, there are 91 countries that practice kidney transplant.36 In about 1 year, 100 000 operations are conducted globally that involve human solid-organ transplants. In 2007, the following transplants were recorded: 68 250 kidney, 19 850 liver, 5179 heart, 3245 lung, and 2797 pancreas transplants,³⁷ with a total of 139 024 organ transplants performed worldwide.38 In the United States, 39 718 organ transplant procedures were conducted in 2019. However, over 112 000 people are on organ wait lists in the United States, and a new person is added every 10 minutes. On average, 20 people die every day waiting for an available organ in the United States alone.39 Similarly, in 2009 in China, there were 86 500 renal transplant procedures, with 14 500 hepatic, 900 cardiac, and about 220 other types of transplant operations. Regardless of being under the category of a vulnerable population for organ trade, around 164 clinical institutes in China are legally licensed to conduct organ transplants.³⁷

Although the number of transplant procedures seems notable, it should be considered that these figures are not enough to fulfil the demand of the whole industry. Despite resources and organ donations, the number of available organs for transplant is not enough to achieve the level of global demand. In 2007, the Global Database on Donation and Transplantation reported about 21 489 people who had consented to donate organs after death and from whom the organs were procured after their death.⁴⁰ These numbers are not enough to cover the demands of millions of people who are waiting for a healthy organ. In 2010, the United States had 105 966 people waiting for an organ transplant.^39,41

Likewise, the United Kingdom, another econo­mically stable region, also has a lack of organ donations. In 2008, about 3500 organ transplant operations were conducted in the United Kingdom. However, there were about 9000 patients on wait lists. However, the United Kingdom medical legislation made changes to eliminate bias from the system. The change involved banning private treatment of patients for organ allocation. Private facilities had been raising concerns because wealthy patients could pay for services regardless of other patients waiting for the same organ transplant. This systematic ban to eliminate possible organ trading was implemented in 2009.⁴²

In 2007, the European Commission stated that there were 40 000 people waiting for organ transplants. Because the number of donated organs remains low, about 10 patients on wait lists die each day in the European Union.³⁶ In China, about 14 000 transplants are conducted annually, whereas wait lists in China exceed 300 000 individuals.⁴³

The gap between number of donors or donated organs and the number of people waiting for a transplant continues to increase. Moreover, the increasing number of ailments is adding to an ever-increasing gap. Although several institutions are working on ways to spread awareness and spread knowledge on organ donation, the number of donated organs remains low. It is important to understand why the number of donors continues to not increase and why the number of recipients continues to increase. Life expectancy has also increased over the years; therefore, donors are living a longer life, perhaps leading to declined numbers of available organs. To understand these aspects, it is important to review the international approach toward organ donation and its related aspects.

Organ Donation Policy in Different Parts of the World
Although donation and transplant rates for organs vary around the world, there seems to be a shortage of organs for transplant. To combat the immediate need of organ availability, various approaches have been attempted to increase the number of donors. Unfortunately, some approaches have been illegal and unethical. Recently, many international societies of political and social backgrounds have begun to express interest in organ donation. Almost all these organizations have preferred to exercise under practices directed by the World Health Organization. Among the leading bodies, The Transplantation Society has also been an active professional organization in the international pool. The main joint focus of this union is to develop and implement a legally and ethically acceptable plan to encourage states to exterminate the unethical activities and to control the illegal procurement of transplantable organs. Furthermore, their aim also includes encouraging people to participate in organ donation programs with active consent. Many other nations have also initiated ways to become self-sufficient in organ procurement as primary attainment.⁴⁴

Organ transplant has high clinical importance. It is well known that transplant procedures are cost-effective and sometimes the only mode of action to treat patients with end-stage organ failure. Over the past decade, both professional and governmental organizations around the world have started to put their words and actions into the matter of organ transplants, including programs focused on maxi­mizing organ procurement potential by encouraging deceased organ donation and decreasing the demand for transplant using ethical conduct, safe clinical methods, and equal opportunity to every seeker. To ensure the safety of human rights and lives at risk, both deceased and living organ donations have been considered. However, living donation has been the preferred mode globally. Deceased organ donation remains insufficient to fulfil organ demands. Living organ donation, although it does not exist in many parts of the world, is often seen as a healthy source for transplantable kidneys and livers. However, living donation has the possibility of overt or subtle exploitation of donors; therefore, transplant programs should include strong safety policies.^44-46

Some countries have adopted policies for organ donation and transplant per guidelines from the World Health Organization and strategies specified by The Transplantation Society and the International Society of Nephrology. Table 2 presents guidelines quoted from the World Health Organization on organ transplant.⁴⁴

With policies defined by the World Health Organization and in collaboration with professional and internationally recognized societies, many countries have set ethically sound approaches for organ procurement. Regions actively taking part include the United Kingdom, the United States, Australia, and Spain.44 The approaches of each region for procuring transplantable organs are further described below.

Organ procurement in the United Kingdom
Clinicians in the United Kingdom follow a nationally recognized structure as recommended by the Organ Donation Taskforce. The Organ Donation Taskforce functions in 3 steps: (1) delivering the vision of the organization regarding donation in the region, (2) familiarizing local clinical practices with working elements of the donation program, and (3) developing a program friendly environment to present better outcomes. The program’s focus is to enhance the number of donors. The primary framework also refers to deceased donation, which considers action during end-of-life care.⁴⁶

Organ procurement in the United States
The Organ Procurement and Transplantation Network (OPTN) was established by the National Organ Transplant Act of 1984. As per the framework of the organization, Medicare and Medicaid Services require hospitals to recognize a potential donor and connect them to their local organ procurement organization. The identification process is mainly conducted in emergency departments, where a potential organ donor is identified.^44,47

Organ procurement in Australia
Despite the involvement of federal and state administration, Australia struggled to upgrade their organ procurement activities for about 2 decades. The major influence in the enhancement of organ procurement in Australia developed with the volunteering of surgeons, clinicians, and doctors involved in transplant surgeries and intensive care units. Because of the lack of a structure, the organ donation rate had seen a decline in Australia. However, with voluntary activities in the country, people soon realized the significance and need for organ donation and transplant. This awareness has been largely stimulated through government-financed activities and also the inclusion of known public figures in the campaigns. Over the past few decades, a framework for organ procurement has evolved in Australia that runs on the services of dedicated transplant departments and procurement system. Currently, the Australian Organ and Tissue Authority manages donations in the region, with individual bodies of the state government conducting cross-matching and allocation of tissue types for transplant. Furthermore, Australia has also developed an organization named “DonateLife,” which is solely dedicated to organ donation and related concerns. The organization has not only focused on spreading public awareness but has also managed to develop a systematic pool of medical professionals to provide seekers with the best services for transplant. Moreover, the program also has options for potential donors to obtain medical aid in the future. The allocation system in Australia has been established on a national level that includes donation after cardiac death and paired kidney exchange programs. Consequently, organ procure­ment has been greatly enhanced in Australia. The major contribution in this regard has been of the community, who actively participate in raising awareness, and the political backup to movements and organizations. Currently, the Australian government has taken over the system of organ donation and is now handling all matters at the state level. Therefore, previous voluntary programs also now fall under the category of governmental organizations and/or activities.^44,48

Organ procurement in Spain
Spain has a defined model for organ transplant that is known as the Spanish Model of Donation and Transplantation. The model includes the Transplant Donor Coordinators, a group introduced by the National Transplant Organisation of Spain. Most of these coordinators are either doctors or nurses. This organ donation model has been successful with regard to the contribution of these active coordinators. The reference points of this model include the activity on the national level along with the practice in regions and hospitals. Coordinators working in hospitals tend to work on enhancing the number of organ donors within their centers. Previously, coordinators were mainly physicians; however, nurses are also now involved in the group.^49,50

Another factor of success for the Spanish transplant model has been the active involvement of legal protocols. Furthermore, the organ donation program allows participants to opt-out at any moment, giving them space and comfort to look into the program and its benefits in the future. Similarly, despite a patient’s active consent during life, after death, relatives are asked about the organ donation and consent before any medical procedure. Nonetheless, approaches of coordinators to the family of the deceased patient and health counseling on the matter have greatly influenced the number of organ donations in Spain. Notably, the number of donations from the local population is equal to the number of donations from immigrants in Spain. Overall, the outcome of the program and the efforts of the coordinators for encouraging donation have been strongly positive.^44,49,50

Iranian model for organ donation
The Iranian model for kidney donation was established and implemented in 1988. The program works on a legal framework to encourage unrelated individuals to donate kidneys within the community. The program basically works under the Iran Kidney Foundation; the purpose of this foundation is to identify matches for organ recipients among the population pool of unrelated donors. The program is under the administration of local governments along with compensation for recipients as per the requirements.^30,51,52 With extensive legal and governmental assistance, it is expected that the list of patients waiting for organ transplant in Iran might decline in the initial 10 years of implementation of this model. The donation model gained popularity due to its attitude toward the restriction of organ trading in the region, prohibition of organ transplant surgeries within institutes, and limitation to generate profit out of the practice.40 Despite its commitment to welfare of the local community and great expectations, the Iranian model did not turn out to be a success in the region. Consequently, in 2011, the list of patients waiting for organ donation expanded to about 17 000 cases.⁵³

The Iranian model has some loopholes in terms of ethics and legal protocol. The varying concerns related to the donation model in Iran included the charitable approach of the model, autonomy of the donor, encouragement to living donation, possible coercion among the donors, the involvement of active consent, provision of complete information to the donor, and authoritative nature of the medical intervention.^50,51 Apart from all these issues, the most debatable issue in this regard has been the financial compensation. The model has mentioned defining ways to provide compensation to the donors, bringing concerns about the nature of the donation. The deficient follow-up program, with inadequate medical incentives for donors, has created a wave of uncertainty within the donor community.⁵⁴

Istanbul Declaration on Organ Trafficking and Transplant Tourism, 2008
By 2005, commercial organ trading was a prevalent crime. Only after a long period of commercialization did this subject become noted on international forums in 2005. As stated earlier, most victims of organ trading have been the vulnerable populations of economically weak states like Egypt, India, Pakistan, and the Philippines. Moreover, unethical organ sourcing has also been reported through prisoners executed in China and deceased people of Colombia. In May 2008, the Declaration of Istanbul on Organ Trafficking and Transplant Tourism was developed as a response to this crisis of commercial organ trading. The Declaration was formed by The Transplantation Society and the International Society of Nephrology. At the event, the Declaration of Istanbul Custodian Group was also developed to endorse and manage the principles of organ procurement and transplantation, as defined in the Declaration of Istanbul.

In response to the Declaration, many countries developed and implemented strict policies concerning organ transplants.24 Developments achieved in each state are described below.

Development in Pakistan
In 2010, the commercial selling of organs was deemed illegal in Pakistan. This proclamation was made under the leadership of the Sind Institute of Urology and Transplantation, in the city of Karachi, with support from the Declaration of Istanbul Custodian Group. Since then, the rate of illegal organ procurement has declined greatly. In the meantime, members of the Declaration of Istanbul Custodian Group have recognized other various illegal and unethical programs running in the region and have subsequently banned them. The declaration has still asserted to keep a check on local activities to cut down on the probability of recurrence of any such practice.⁵⁵

Development in India
From 1980 to the 1990s, India was the most preferred region for commercial procurement of organs. However, in 1994, the Transplantation of Human Organs Act encouraged the Indian Parliament to ban commercial organ trading.⁵⁶ In response to the regulation of laws, the rate of organ trading has declined in India. Despite these control measures, the approach of the trading industry changed in the region. Vulnerable sections of society were then coerced into situations with emotional motivations, as the laws did not prohibit unrelated donors to donate in compassion.^24,57 However, these loopholes were amended with the introduction of the Declaration of Istanbul in the region.⁵⁶ The amendments then focused on defining relationships when donating organs, ensuring protection of vulnerable populations from exploitation, and having foreign recipients obtain acceptance to organ procurement from the Authorisation Committee of India. Furthermore, many attempts have been made to encourage and motivate the local population to consent to deceased organ donation.⁵⁸

Development in China
It has been reported that organs were obtained from executed prisoners in China for global trade. This concept of donation by execution is an unethical practice, affecting the human rights of prisoners and also rights of the local population in need of organ transplants.⁵⁹ The practice had been greatly discouraged by the Declaration of Istanbul Custodian Group and Amnesty International and Human Rights Watch.^59-61 The government of China realized the unacceptance of the international forum on the matter and the illegal nature of the commercial organ trading in the region.^43,59 The responsible officials in China banned several organ donation programs in the state as per the policies of the Declaration of Istanbul, including the donation by execution.⁶¹ Nonetheless, it has been realized that Chinese law is not yet open to ethical scrutiny as per the human rights and internationally accepted principles of medical ethics concerning organ transplantation in the region.²⁴

Development in the Philippines
Due to extreme poverty in some parts of the Philippines, the region evolved as a major source of organ procurement for organ sale. However, in 2008 and in response to the Declaration of Istanbul, a ban was imposed on providing organs to foreign recipients. Subsequently, the Anti-Human Trafficking Law was implemented to control organ trafficking in the region.24 Soon after the implementation of new laws in the Philippines, the rate of organ recipients from international grounds declined greatly within a year.⁶²

Development in Egypt
In the Middle East, Egypt has been considered the most sought state for organ procurement.²⁵ The Declaration of Istanbul Custodian Group and the World Health Organization intervened in this matter in 2010. In response, Egypt introduced the Law on Human Organ Transplantation, which banned organ trafficking or trading of any sort.²⁴ Regardless of these laws, Egypt has remained involved in commercial organ trading and trafficking of donors. The reason behind the negligence in the matter has been the political deviations in the country. The state requires a well-organized structure concerning organ transplant that can be effective in the long run.²⁴

Development in Colombia and Latin America
For a long time, Colombia and other regions in Latin America provided organs for transplantation to foreign recipients. The regional governments collaborated on this matter and developed laws that concentrated on providing organs to local recipients with priority.^6,24,28 The Latin American Society of Nephrology supported the Declaration of Istanbul and established regulations with the term Document of Aguascalientes in the region, as introduced by the committee.⁶³ Among all the nations, Brazil was the first state in the region to include the regulation of Declaration of Istanbul as national commandments for organ transplantation.²⁴

Organ trafficking in Syria
The ongoing Syrian Civil War has displaced 6.2 million individuals inside the country and forced 5.6 million to vacate Syria, creating an international refugee crisis. These refugees are left homeless and desperate, making them vulnerable to human trafficking, much of which happens during the transit out of Syria. In some host countries, like Egypt, Turkey, Lebanon, Jordan, and Iraq, 60% of Syrian refugees live below the poverty line, making them more desperate for work. Many choose to leave the Middle East entirely and turn to smugglers to get them illegally to Europe. This migration caused a boost in organ trafficking, as desperate Syrians have been willing to sell their kidneys and other organs to survive.^64,65 The illegal business is increasing, causing the Levantine region to become the new prime location for organ trafficking, surpassing China and the Philippines.

Organ trafficking in Iraq
A review of the underlying causes of the increase in human organs trafficked in Iraq showed political and socioeconomic factors as contributors. Following the US invasion in 2003, up to 5 million Iraqis have been displaced inside Iraq, which is the largest number of displacements in the region since 1948. They face strong social stigmas, are highly discriminated, and are forced to live in inhumane, poor conditions. The externally displaced are often living in extreme poverty and subjected to multiple displacements. Many families have no shelter, no finances, and no access to health care, education, or security of any kind, making them vulnerable to human trafficking. Hence, organ trafficking became a lucrative business in Iraq due to the high levels of poverty and little to no intervention from the Iraqi government. The presence of ISIS (Islamic State of Iraq and Syria) in the area had exacerbated the crisis further. Hundreds of cadavers discovered in ISIS-controlled territories in Iraq have revealed that organs appeared to have been purposefully removed, most likely to obtain money from organ retrieval and trading of human organs to the international trafficking mafia, including from its own injured members, prisoners, and deceased individuals. Moreover, the growing number of Syrian refugees in Iraq has put additional strains on local infrastructure and essential services, which were already significantly weakened by the years of war and instability and made these refugees vulnerable to organ trafficking. As per the Director General of the Syria Coroner’s Office, from 2011 to November 2015, more than 25 000 surgical operations were performed in refugee camps of neighboring countries and ISIS-controlled areas of Syria and Iraq, with an estimated 15 000 Syrian organs removed and sold on the black market.^66,67

Current Approach of the Declaration of Istanbul
The Declaration of Istanbul has been recognized and endorsed by about 115 global bodies dedicated to the matter of organ transplant. The union on such a vast scale has been escalated by conference participation, organized by the members of the Declaration of Istanbul. The condition to participate, to present their work, or even to join as a guest speaker in the conference has been to endorse the policies of the Declaration. Furthermore, it was also necessitated for most internationally recognized journals to identify the author’s association with the Declaration of Istanbul before publishing the paper. Once endorsed, members must ensure that any conflicts in exercising the policy shall be communicated to the Patient Affairs Committee. This committee has been dedicated to evaluating practices in certain locations and only communicates with the high authorities of the country rather than with the groups within. As a result, authorities in many countries seem to be more responsible for their local activities to avoid any possible chance of unethical conduct regarding organ procurement and transplant.⁶¹

Another significant impact was the media unit of the Declaration of Istanbul Custodian Group. The members of the media unit have been working extensively to encourage change in national policies of several countries, which has turned out to be a successful approach. The main focus of the media unit has been to discourage commercial trading of organs among people and to bring changes in the policies of states. Regardless of the extensive networking and massive upgrade of the system, the shortage of transplantable organs remains a global concern.^61,68 In the following section, we discuss the varying factors of this subject as per the global approach.

Organ transplants and the global approach
The World Health Organization has developed an association between the rates of transplants around the world and the Human Development Index (HDI). Countries with a low to average HDI have shown a decline in the rate of transplants. However, countries with comparatively higher HDI have exhibited increases in rates of transplant. The rates of transplant are recorded in units of pmp (per million population).⁶⁹ In 2010, economically stable regions like Australia, Western Europe, and the United States showed transplant rates of about 30 pmp (range of 20-30 pmp across countries).^61,70

Among the more wealthy regions, the United States has had the highest number of total organ transplant surgeries as well as the highest rates of transplant per million population. Nonetheless, a variation in transplant rate has been observed within some US populations, particularly among minority groups and underprivileged communities, including African American and White populations. Moreover, it was also noted that, comparatively, women are more deprived of required transplant procedures in the United States.⁷⁰ Likewise, it has been recorded that Aboriginal populations have a 46% lower rate of transplant in Canada followed by 34% of African and 31% of Asian populations.⁷¹ In Australia, the Aboriginal population has about 45% less probability of receiving transplants, whereas in New Zealand, the Maori population and people from the Pacific Islands have 53% less chance of organ transplant.⁶⁸ The rate of transplants also varies with the capability of the population. For instance, people with health insurance in Mexico tend to have a higher rate of transplant (ie, 72 pmp) compared with those who may not have insurance (ranging up to only 7 pmp).⁷¹

The reason behind the low rate of transplant in economically weak countries is the factor of instability among the local population. These reasons can vary according to regional differences, including social factors, cultural outlook, and economic stability along with the clinical concerns for immunology, biological matching, genetic cross-matching, metabo­lic factors, pharmacological concerns, and incidence of comorbidity in the community. Similarly, transplant rates may also vary with the availability of skilled professionals and postoperative care and manage­ment in the region for both the donor and the recipient.69, To attain more success in organ transplant, authorities must develop a friendly framework for organ procurement and management of patients. Moreover, it is also necessary to cultivate a globally integrated transplant program to enhance the rate of procurement and transplant of organs for all kinds in populations around the world.

Ethics and Equality in Organ Transplant
The allocation of a donated organ is a complicated process that requires coordination of various factors, including among donors and recipients. During organ procurement and allocation, it is crucial to ensure that human rights codes are applied.

Organ recipients
As a result of the increasing number of cardio-metabolic disorders and increasing life expectancy, the incidence of end-stage organ failure has risen globally. Although organ transplant is required as a response to organ failure, it often becomes complicated for authorities to identify and prioritize recipients for an available organ. Nonetheless, the number of donated organs keeps declining, while the number of recipients keeps on increasing. To deal with this situation, organ transplant protocols have been restructured in some countries such as Singapore, Israel, and Chile with innovative donor-recipient clauses. It is stated that people who are registered as organ donors in the national registry will be prioritized for organ transplant if they would be in a situation to require transplant procedures in the future. The clause has been estimated to encourage more donors in the pool with a notable benefit for the future.⁷²

Living donors
Research has shown that kidney retrieval from a living donor is clinically safe. However, a slight chance of death has also been reported in such cases.²⁰ It is often expressed that procuring kidneys from living donors could greatly influence the global sufficiency of renal transplants. Concerning the significance of living organ donation, the Declaration of Istanbul has asserted in their policies to ensure the protection of rights of living donors. Living donation, however, has been a part of commercial organ trading and trafficking for quite a long time.⁷³ Therefore, it is necessary to provide safety in this regard to donors and avoid the element of exploitation in such cases. Subsequently, living donors must be recorded and followed in case of clinical complications or need for medical aid in the future related to the organ donation.⁷³

Deceased donors
Deceased organ donation is the most frequent form of organ procurement in the United States. It has been stated that a deceased individual can save multiple lives by donation of essential organs to clinical authorities. Although the individual must sign up in life to be a donor, the immediate family of the deceased individual can also consent for organ donation. Contemporary protocols have focused on enhancing the number of registered deceased organ donors globally, as 1 deceased donor has the potential of saving many lives and declining the gap between organ availability and the number of patients waiting for transplant.⁷³

Medical ethics and other issues
For organ allocation, it is important to justify the need of the recipient. With regard to life expectancy of the recipient, it has been expressed that patients less than age 50 years should be prioritized for transplant. However, the clause has been deemed unethical to some extent; in response, it has been asserted that the biological fitness of a patient for transplant should be considered rather than age.⁷³

Another concern that has often been observed in international fields is the lack of biological compatibility due to much higher mismatching among unrelated donors and recipients. Human leukocyte antigen matching among donors and recipients may show differences of races or ethnicities between donors and recipients, which may lead to longer waiting time for transplants and lesser chances for minorities to receive an organ.⁷⁴ Furthermore, with regard to physical fitness, people with obesity are often underprioritized for transplant and have to wait longer. The factors ultimately increase their risk of death during support procedures like dialysis.⁷⁴

Reports and observations for organ recipients tend to express a bias in terms of economic stability, age, race, sex, and even geographical location.⁷⁴ Along with legal organ procurement protocols, there is also a need to develop globally organized well-regulated bodies for ethical organ allocation.

Conclusions

The review of global practices and policies of organ transplant has suggested a dire need for more ethical principles and a way to equitably distribute organs around the globe as per the respective need. Authorities play a crucial role in controlling the illegal and unethical forms of organ procurement. The main concern in this matter is that each affected region, in terms of organ trafficking, has its own legal system and varying ethical values. These variations within societies and communities play a part in the ethical and legal procurement and distribution of organs. Therefore, it is proposed that individual evaluations be conducted on the ground level in each region. Moreover, increased attention is needed in the legal procurement of organs. There should be a focus on the ethical allocation of organs to recipients and consensual organ procurement from potential organ donors.

Limitation of the Study
A review of the global literature involves vast searches of materials and reviews of the literature. However, evidence on the matter of organ trafficking or trading is rather limited. The main reason behind this limitation is the lack of global legal regulations. Likewise, due to certain laws and the influence of large finances, such medical crimes are often cleared easily or not easily traced, especially without the subtle (or implied) support of the highest in the land. Therefore, information provided from certain regions may have been restricted. Similarly, data may have also changed over time.

Recommendations for Further Approach
In support of the discussion of Clawson and associates,⁷⁵ it is recommended that studies should evaluate the role and status of organ recipients to create a much more organized environment for safe and effective implementation of evidence-based principles of clinical transplantation. Furthermore, future approaches should emphasize the challenges of unethical practices in organ donation.13 A com­prehensive study should be conducted on the challenges of organ donation so that professionals could recognize prevailing issues within each region and then counteract each problem accordingly. Previously evaluated records have already high­lighted the health care systems that are most affected by the unethical practices of organ trade. The next step with respect to both research and practical approaches is with regard to organ facilitation.

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