Declaration of Istanbul (organ trafficking and transplant tourism)

The Declaration of Istanbul on Organ Trafficking and Transplant Tourism is an international ethical framework, first adopted in 2008 and updated in 2018, that defines and condemns organ trafficking, transplant commercialism, and transplant tourism and sets out principles to guide policymakers and health professionals toward ethical organ donation and transplantation.[1][2] It is a professional consensus document rather than a binding treaty, but it has been endorsed by more than 135 national and international medical societies and governmental bodies and is widely cited as the field's authoritative ethical statement against the exploitation of vulnerable people for their organs.[2]

Background

By the mid-2000s, the success of transplantation had been "tarnished by numerous instances of organ trafficking, of trafficking in persons for the purpose of organ removal, and of patients who travel abroad to purchase organs from poor and vulnerable people."[2] A 2007 World Health Organization-associated estimate held that up to 10% of transplants worldwide involved such practices.[2][3]

To respond, The Transplantation Society (TTS) and the International Society of Nephrology (ISN) convened a Summit Meeting in Istanbul in April 2008. The 151 participants, representatives of scientific and medical bodies, government officials, social scientists, and ethicists, reached consensus on the Declaration of Istanbul, which was subsequently endorsed by more than 135 organizations and governmental bodies involved in transplantation.[2] The Declaration was published in summary form in The Lancet in 2008.[1]

The Declaration "expresses the determination of donation and transplant professionals … that the benefits of transplantation be maximized and shared equitably with those in need, without reliance on unethical and exploitative practices that have harmed poor and powerless persons around the world." It is explicitly framed as complementary to the work of the World Health Organization, the United Nations, and the Council of Europe.[2]

Core definitions

A central contribution of the Declaration is a set of precise definitions that have been widely adopted in law and policy. The 2018 edition defines:[2]

• Organ trafficking, any of the following: (a) removing organs from living or deceased donors without valid consent or authorisation, or in exchange for financial gain or comparable advantage to the donor and/or a third person; (b) any transportation, manipulation, transplantation, or other use of such organs; (c) offering or requesting any undue advantage by a healthcare professional, public official, or private-sector employee to facilitate or perform such removal or use; (d) soliciting or recruiting donors or recipients for financial gain or comparable advantage; or (e) attempting to commit, or aiding or abetting, any of these acts. This definition is derived from the Council of Europe's 2015 Convention against Trafficking in Human Organs.[2]
• Trafficking in persons for the purpose of organ removal, the recruitment, transport, harbouring, or receipt of persons by means of coercion, abduction, fraud, deception, abuse of power or of a position of vulnerability, or the giving or receiving of payments to achieve consent of a person having control over another, for the purpose of removing organs. This definition is derived from the United Nations' 2000 Palermo Protocol.[2]
• Travel for transplantation, the movement of persons across jurisdictional borders for transplantation purposes.[2]
• Transplant tourism, travel for transplantation that "becomes … unethical" when it involves trafficking in persons for organ removal or trafficking in human organs, or when the resources (organs, professionals, and transplant centres) devoted to providing transplants to non-resident patients undermine the country's ability to provide transplant services for its own population.[2]
• Self-sufficiency, meeting a country's transplant needs using donation and transplant services and organs provided within the country by its residents, or by equitably sharing resources with other jurisdictions.[2]
• Financial neutrality, donors and their families "neither lose nor gain financially as a result of donation" (see Financial neutrality and the prohibition on valuable consideration).[2]

Principles

The 2018 edition sets out eleven Principles, intended to be read as a whole. In summary, they hold that:[2]

• Governments should develop ethically and clinically sound programs for preventing and treating organ failure.
• The optimal care of organ donors and recipients should be a primary goal of transplant policy.
• Trafficking in human organs and trafficking in persons for organ removal should be prohibited and criminalized.
• Organ donation should be a financially neutral act.
• Each jurisdiction should enact legislation governing the recovery of organs from deceased and living donors and the practice of transplantation, consistent with international standards.
• Designated authorities in each jurisdiction should oversee and be accountable for organ donation, allocation, and transplantation to ensure standardization, traceability, transparency, quality, safety, fairness, and public trust.
• All residents of a country should have equitable access to donation and transplant services and to organs from deceased donors.
• Organs should be allocated within jurisdictions according to objective, non-discriminatory, transparent rules guided by clinical criteria and ethical norms.
• Health professionals and institutions should help prevent and address organ trafficking, trafficking in persons for organ removal, and transplant tourism.
• Governments and health professionals should implement strategies to discourage and prevent their residents from engaging in transplant tourism.
• Countries should strive to achieve self-sufficiency in organ donation and transplantation.

Taken together, the Principles favor national self-sufficiency, the development of deceased-donation programs, the protection of vulnerable populations (especially poor living "donors" who are in fact sellers), financial neutrality, and the criminalization of organ sales and trafficking.[2]

The 2018 edition

In 2010 TTS and ISN created the Declaration of Istanbul Custodian Group (DICG) to disseminate the Declaration and respond to new challenges in organ trafficking and transplant tourism.[2][4] Between February and May 2018 the DICG conducted a wide-ranging, open public consultation to update the Declaration in light of clinical, legal, and social developments since 2008. The revised text was adopted in Madrid in July 2018 during the International Congress of TTS, on the Declaration's tenth anniversary.[2][4] The 2018 edition aligned the Declaration's definitions with the intervening Council of Europe Convention (2015) and updated UN instruments, and is accompanied by a Commentary Paper that elaborates the text and suggests implementation strategies.[2]

The Declaration of Istanbul Custodian Group (DICG)

The DICG is a group of transplant and nephrology experts whose mission is to "promote, implement and uphold the Declaration of Istanbul so as to combat organ trafficking, transplant tourism and transplant commercialism and to encourage adoption of effective and ethical transplantation practices around the world."[4] It monitors implementation, issues guidance, and maintains the Declaration's text and supporting materials.[4]

Relationship to other instruments

The Declaration is explicitly complementary to, and draws on, the binding and quasi-binding instruments in the field:[2]

• The WHO Guiding Principles on Human Cell, Tissue and Organ Transplantation (endorsed in World Health Assembly Resolution WHA63.22, 2010), which prohibit payment for organs and promote ethical, equitable transplantation.[3]
• The United Nations Palermo Protocol (2000) on trafficking in persons, and UN General Assembly Resolution 71/322 (2017) on organ donation and trafficking.[2]
• The Council of Europe Convention against Trafficking in Human Organs (CETS No. 216, opened for signature in Santiago de Compostela, 25 March 2015), the first international criminal-law treaty in the field, from which the Declaration's definition of organ trafficking is drawn.[2][5]

Status

The Declaration of Istanbul is not a treaty and creates no legal obligations of its own. Its force comes from professional endorsement and uptake: it has been endorsed by more than 135 medical and governmental bodies, is referenced in national legislation and professional guidelines, and functions as the field's principal statement of consensus ethics against the exploitation of vulnerable people in transplantation.[2] Binding legal force in this area is supplied instead by national criminal law and by the Council of Europe Convention for its signatory states.[5]

See also

• Organ trafficking and transplant tourism
• Financial neutrality and the prohibition on valuable consideration
• National Organ Transplant Act (NOTA)

References

• Steering Committee of the Istanbul Summit. Organ trafficking and transplant commercialism: the Declaration of Istanbul. The Lancet. 2008 Jul 5;372(9632):5-6. https://pubmed.ncbi.nlm.nih.gov/23644753/
• The Declaration of Istanbul on Organ Trafficking and Transplant Tourism (2018 Edition). Preamble, Definitions, and Principles 1-11. https://www.declarationofistanbul.org/images/Policy_Documents/2018_Ed_Do/2018_Edition_of_the_Declaration_of_Istanbul_Final.pdf
• World Health Organization. WHO Guiding Principles on Human Cell, Tissue and Organ Transplantation (WHA63.22, 21 May 2010). https://apps.who.int/gb/ebwha/pdf_files/wha63/a63_r22-en.pdf
• Declaration of Istanbul Custodian Group (DICG). About / mission. https://www.declarationofistanbul.org/
• Council of Europe. Convention against Trafficking in Human Organs (CETS No. 216), Santiago de Compostela, 25 March 2015. https://www.coe.int/en/web/conventions/full-list/-/conventions/treaty/216