Orient XXI. — In Muslim countries, is it legal to remove organs from a person, living or deceased? How do doctors specializing in transplants get around the prohibitions?
Aziz El-Matri. — Islam holds the human body to be sacred: it is an inalienable property and a Muslim is duty-bound to preserve its integrity. But there is also an obligation to preserve life, even if this means infringing certain restrictions. Thus the principle of necessity takes precedence over the prohibitions. It became a matter of consensus among Muslim jurisconsults, of whatever persuasion, that organ transplants were licit. Kuwait was the first country to authorize the practice, with a fatwa promulgated in 1979. It was permissive enough to serve as a model for scholars in other countries of the region. It was followed by a consensual decision taken at a meeting of the Scientific Council of the Islamic Fiqh Academy (Casfi) in Jeddah in August 1988. Since then, several jurisconsults have issued fatwas authorizing organ transplants, insisting on the notion of voluntary donation and excluding commercialization. However, there is a disagreement over the removal of organs from a cadaveric donor despite decision No. 5 by the Casfi at its October 1978 session in Amman, recognizing the reality of brain death. Consequently, whatever the letter of the law, very few Muslim countries tolerate kidney transplants from deceased donors, with the exceptions of Saudi Arabia, Jordan and Tunisia.
O. X. — But what about the organ trade and trafficking? How is it possible to find donors outside the family circle?
A. M. — Chronic kidney disease, which often leads to end-stage renal failure, is increasingly frequent in our part of the world — as everywhere else — so that there is a need for more and more kidney transplants while there are not enough organs available. International bodies consider that the number of organs (kidneys) on offer in the world represents only 10% of actual needs. It is this imbalance between supply and demand that has brought about the development of organ trade. In countries where no laws exist or are not enforced, poor populations have become a potential reservoir of organs. In order to counteract this tendency and fight against commercialization, the World Health Organization (WHO) laid down guiding principles, which have been revised several times. An international committee drew up a charter of good conduct that gave rise to more than one declaration, including the Amsterdam Declaration in February 2004. Subsequently, in May 2008, the WHO joined with two international scientific bodies, The Transplantation Society (TTS) and the International Society of Nephrology (ISN) to organize a meeting of representatives of 78 countries in Istanbul. Out of this summit came the Declaration of Istanbul on Organ Trafficking and Transplant Tourism which states that these practices violate the principles of equity, justice and respect for human dignity and should be prohibited.
In our region, the organ trade is religiously illicit and is officially outlawed in all Arab-Muslim countries. However, the reality is a different matter. Some countries tolerate a blatantly illegal trade; others have introduced measures which allow for a degree of flexibility. In Iran and Saudi Arabia, the law allows a “rewarded legal gift for living renal donors,” which jeopardizes the principle of non-paid donation. In Saudi Arabia one is allowed to give advantages in kind or in cash to living donors or the family of a deceased donor – who are often foreigners residing in the country. This might take the form of direct or indirect payment for the transportation and burial of the donor’s mortal remains and remuneration of accompanying persons to the country of origin, plus a certain cash compensation.
In Iran, an unrelated living donor is considered a benefactor of the community at large and is officially “compensated” by the State (the amount is fixed and public). Besides which, the recipient’s family or an association supporting him/her are allowed to contribute a “reward” negotiated between the parties. This system allows for every kind of abuse, although we cannot deny that since it was established the number of voluntary living donors has risen considerably, making it possible to treat pathologies much sooner. And contrary to all other countries where there are long waiting lists for recipient patients, in Iran the waiting lists are for donors. This pragmatic measure has the advantage of solving to a large extent the problem of treating chronic kidney deficiency in a country with limited means. But it has raised an ethical problem which constitutes a real dilemma for healthcare professionals.
Israel is another country in the region which has long tolerated the transplant trade. Following Egyptian President Anwar El-Sadat’s visit in November 1977, Israeli officials took advantage of the opening of diplomatic ties with Egypt and the absence of any clear legislation to enable their nationals to receive kidney transplants purchased from unrelated foreign donors, such as poverty-stricken inhabitants of neighboring countries. It appears that these operations were reimbursed by private health insurance companies and sometimes by public systems. Officials in charge of the Istanbul Declaration sent a warning note to Israeli authorities. At the same time, especially in Egypt, the civil society organized street demonstrations protesting against the “donation” of organs to foreigners.
O. X. — Is organ donation at all organized in the Arab world today?
A. M. — Most Arab countries now have kidney transplant programs functioning within the public hospital system, sometimes in the private sector. Such is the case in Egypt, Jordan and Lebanon. To my knowledge, there is no more organ trading in those countries than in the rest of the region. But the rate of transplantation, in the best case scenario, is around ten transplants for a million inhabitants per year, far below the number of patients on the waiting lists. The actual yearly number of new cases is around one thousand per million inhabitants. Iran is the only country with a program adapted to its situation and the means at its disposal, which allows treatment of patients as soon as end-stage failure is reached.
No Arab country has adopted a long-term organ transplant strategy.
O. X. — What about Tunisia?
A. M. — Nephrology, the treatment of kidney disease, is a relatively recent creation, it did not become independent of internal medicine until the nineteen sixties, when the first European specialists were trained. Personally, I was in the third class to graduate from the center for nephrological studies in France. I returned to Tunis in 1975 where I joined an internal medicine clinic, developing with other colleagues new techniques in nephrology.
While the first kidney transplant was performed in the United States, and soon afterwards in France (1954), Tunisia —like Morocco and Algeria— was able to begin in 1986. Urological and nephrological teams performed a first transplant from a related donor, then another from a cadaveric donor. At the time there was no explicit law. We took as our reference a schematic legislative decree dating from 1952 which authorized organ removal for diagnostic or therapeutic purposes in view of a corneal transplant. It was vague enough to be freely interpreted. It was not until much later, in 1991, that a specific law was passed for organ removal and transplantation from a voluntary living donor, related or unrelated, or a deceased donor.
At first our medico-surgical team confined itself to removals from living donors biologically related to the recipient, but after February 2000 removals were extended to persons “emotionally related”, in other words, to the husbands and wives of patients.