South Africa: Land of the Big Five

1. South Africa: Land of the Big Five Murder Rape Robbery Hijacking Theft

2. A South African Story: A Tissue of Lies

3. People involved • Durban, South Africa 2003 • An International ring trafficking human kidneys was broken up by the South African and Brazilian police. • Involved • South Africans, some of whom were doctors • Israelis and Iraqis who were the organ recipients • Brazilians who were the organ donors • a Netcarehospital in Durban, St Augustine's • the Israeli mafia.

4. Impoverished Brazilians flown to South Africa as organ donors • Recipients paid ~ U.S. $100,000 (R748 000) • Donors received ~ $13 000 (R82 000) • Some donors only received R6 000! • 80 organs were transplanted over a 2 year period in St Augustine’s.

5. 5 South African doctors • Arrested and charged under South African law for: • fraud, • assault • separate charges under the Human Tissue Act. • Separate investigation instituted - KwaZulu-Natal department of health. • The Human Tissue Act - department is required to use an independent investigator • Seized as part of the investigation: • transplant register of the Organ Donor Foundation • ministerial records were also seized as part of this investigation.

6. Dr H, the surgeon who carried out the procedures. Photographs by the Independent Newspapers Kwa-Zulu Natal JR, the head of surgery at St Augustine’s, who was also arrested for his involvement. Photographs by the Independent Newspapers Kwa-Zulu Natal

7. How it all happened in just 1 week…. Brazil I 11 recruiters I suitable donors, I IP, a member of, the Israeli mafia. I RFK in South Africa I donors and the recipients to South Africa I RFK would collect them from the airport I St Augustine’s transplant clinic I Donors and recipients screened by Dr JK, a nephrologist (a kidney specialist) I Dr H, the surgeon assessment suitability and readiness to undergo a surgical procedure I Patients spent 1 day receiving dialysis I surgery on the Friday I the donor’s operation taking 1 hour I the recipient’s 2 hours I Monday sent home I Donor receives payment.

8. The problem you ask? • Donors falsely represented that no money changed hands • In fact the donor was paid an amount of money for his/her kidney • Also lied about being related. • For transplantations between a living donor and recipient to take place legally in South Africa the donor and recipient should be related and money should not change hands.

9. Netcare - exonerated of any involvement • CEO of Netcare - “victim of wrongdoing” • RFK - 6 years imprisonment, suspended for 5 years and paid a fine of R250 000 • 11 Brazilian recruiters - arrested and prosecuted by the Brazilian police. • ??? The South African doctors involved??? • KwaZulu-Natal Department of Health - unable to provide any information

10. Points to Ponder • R59 840 000 made in total • R6 560 000 went to the donors • St Augustine’s Transplant Unit • sudden rise of transplants? • cross check? • Ministries permission for family members to donate an organ? • Only non – medical professionals publically prosecuted • Dr H • still registered as a practitioner • still head of the department and professor of general surgery at the University of Natal Medical School • still published in peer review papers and journals. • Dr H published a paper in the South African Journal of Medicine in Nov 2003, just before his arrest. • ‘Commerce in Organs – An Ethical Dilemma.’ (November 2003, Vol. 93, No. 11 SAMJ).

11. Contextual Features • Economic Factors • Recipients: Kidney transplant makes financial sense • Donors: Financially desperate • One Brazilian was paid $6000/R38 000 for his kidney

12. SA is appealing as a body-broker destination because: • The country is perceived as corrupt and foreigners believe a blind eye is turned to illegal activities • The rand/dollar exchange rate gives brokers and kidney recipients real value for money • There is an availability for top notch doctors and surgeons. (‘Body parts dealer hunted by SA police’: Stormfront.org)

13. Director of Organs Watch, a US-based organ trafficking watchdog: “Developing countries are considered ideal by brokers because they have First World medicine at Third World prices. And a nice don’t ask, don’t tell policy”. (‘Body parts dealer hunted by SA police’: Stormfront.org)

14. Religious Factors • Israel: Jews, Muslims, Christians. • Brazil: Roman Catholic Christians. • Jews: May donate when the intention is to preserve life (“pikuah nefesh”), but not to organ banks. • Muslims: May donate organs, but gaining financially from the donation is haram. • Christians: No prohibitions; personal choice.

15. Cultural factors • Israel: Hebrew, Arabic, Russian, English • Brazil: Portuguese • Communication of medical terms may have proved a challenge. • Doctors enjoyed huge financial gain.

16. Personal Bias • Doctors enjoyed huge financial gain.

17. The process involved in kidney transplants: • Physician’s decision • medical history & physical examination • chest x-ray • ECG • abdominal ultrasound • Bladder tests • Psychiatric evaluation • The patient’s family • living donor kidney transplant • cadaver kidney transplant

18. Transplant process continued • tissue typing & blood tests • Tissue typing, also called HLA typing, is a process of identifying genetic markers (antigens) on white blood cells • 6 antigen match is the best possible match for kidney transplants • Blood Type Compatibility

19. The Donor • evaluated by a nephrologists • Opt in system (vs “opt out” system)

20. Ethical Theory • Law in South Africa • Financial gain • Libertarian theory • individual rights

21. Ethical Dilemma • Should individuals have the right to sell their organs? • personal autonomy • Cherry-prohibiting individuals from selling their own body parts constricts the individual’s right to freedom • Jacqueline Laing-does not follow Cherry’s opinion

23. It is alleged that the doctors and surgeons evaded the Human Tissue Act, which prohibits trading in human organs, the Department of Health regulations by instructing donors and recipients to make false declarations that they were blood relatives and that no money had changed hands. Mercury: Kidney trade charges set out: www.themercury.co.za

24. In this regard they had been charged with 109 counts of defrauding Netcare and the Department of Health and a further 109 counts of contravening the Human Tissue Act. Mercury: Kidney trade charges set out: www.themercury.co.za

25. The Human Tissue ActHuman Tissue Act 65 of 1983: www.kznhealth.gov.za • The Human Tissue Act, (Act 65 of 1983) provides for the donation or making available of human bodies or tissue for the purposes of medical and dental training, research or therapy or the advancement of medicine and dentistry in general.

26. Chapter 3: Authorised institutions, import and export of tissue, and of blood, blood products and gametes, and related matters • 26: Payment in connection with import, acquisition or supply of tissue, blood, blood products or gametes

27. The National Health Act(The National Health Act 61 of 2003, www.alp.org.za) • The National Health Act incorporates many of the provisions of the Human Tissue Act

28. Chapter 8: Control of use of blood, blood products, tissue and gametes in humans • Section 60. Payment in connection with the importation, acquisition or supply of tissue, blood, blood products or gametes • Section 61: Allocation and use of human organs • As of 9 September 2008, section 60 and 61 had not yet been proclaimed  by the president

30. Israeli legislation regarding organ procurement • Due to religious beliefs of the large population of orthodox Jews, organ transplantation is a controversial issue in Israel. • Outcome - severe lack in organ donation and supply compared to organ demand. • Transplant tourism • Until 2008 there was no law prohibiting organ trafficking in Israel which made Israel to focal point for international organ trade. Israeli’s payed up to $80 000 per organ.

31. In 2008 two laws were approved in regulation of organ donation. • Brain respiratory death is defined as a situation in which a person who has no blood pressure, fails to breathe without external life support systems and has no response from the pupils or any other reflexes is declared dead by two certified doctors. • Various benefits should be provided to living organ donors such as: • Monetary reward from the state $ 5 000 • Priority on the transplant list in case they need an organ transplant in the future • Waived self-participation fee for any medical service resulting from the organ donation • Chronic patient status which entitles the donor to additional medical benefits. • This law criminalizes organ trafficking, receiving compensation for organs or acting as an organ broker.

32. Brazilian legislation • Firstly Brazilians are reluctant to consent to organ donation • Secondly successful transportation of the organs between remote rural towns and rugged terrain are impeded

33. In 1998 Brazil responded by legislative action to increase organ supply for transplants. • All adults are potential donors unless they filed for exemption • Organ removal is allowed from the deceased without any notification or family consent unless the person had filed for non-donor status. • Family members interfering with organ removal could be sued. • Doctors were allowed to remove organs against the donor’s family’s consent, but they were not legally obligated to do so. • However, the legal coordinator of the health ministry warned that doctors who refused to extract organs, regardless of the family’s wishes, could be prosecuted for failing to assist a person in need.

34. However due to: • critics fearing unfair conduct and conspiracy • Brazil’s weak infrastructure incapable of administering such a complex plan • violation of the law of independence and freedom of belief • violation of autonomy

35. Recommendations‘Ethical issues concerning the implementation of an opt out approach for human organ donation in South Africa: http://witsed/.../pdf • Effective public education campaigns • Religious leaders • Community leaders • Further research • Changes in legislation • Consultation with the Physician Associations