Medical doctors have given reasons black market or underground/illegal dealings in organ donation, harvesting and transplantation thrive in Nigeria. They identified lack of regulation and enforcement of medical ethics, poverty, inequality and unconscionable medical practitioners as facilitators.

To address the situation, the experts seek establishment of central coordination of organ transplantation similar to the Nigerian Centre for Disease Control (NCDC), as well as direct investment, funding and legal framework for transplantation in Nigeria.

A consultant psychiatrist and former Chief Medical Director of Lagos State University Teaching Hospital (LASUTH) and Permanent Secretary, Lagos State Ministry of Health (LSMH), Prof Femi Olugbile, told The Guardian that there are no properly codified Nigerian laws on organ transplantation; though he added that there is a vague mention of it in the 2015 National Health Act.

Olugbile said the generally observed rules and regulations relate to United Kingdom (UK) and the Western world, who require the donor to be preferably a blood relation, but if there is evidence of no suitable close kin, a volunteer may be sought.

He said the problem with UK is that the volunteer must show reason why he wants to donate an organ to a particular person instead of donating to the pool because there are over 6,000 persons with chronic renal failure awaiting such voluntary donations from living or recently deceased donors in the UK. As such, Olugbile said there must be no cash or other incentive for such donation.

According to him, Western regulations are nominally adopted and loosely enforced in Nigeria and other Third World countries such as India, Pakistan, Bangladesh or Turkey. While they enforce the voluntary requirement ethically, the ‘kinship’ requirement is often cleverly circumvented.

“And they have no way of enforcing the no financial incentive requirement. Everybody needing an organ transplant would normally have the rules explained to them as detailed above and would be expected to comply. Anybody seeking or facilitating organ transplant in a foreign country must familiarise themselves with the country’s laws, as ‘ignorance is no excuse’,” he said.

Olugile said there have been allegations concerning some totalitarian societies like China, where organs are harvested from condemned criminals on death row. “There are also allegations of criminal gangs in the Middle East and elsewhere, who murder destitute persons and immigrants to harvest and sell their organs,” he said.

On the legal processes to be followed when a patient needs organ transfer, a team of medical experts in Transplant and Nephrology, who are Fellows of Academy of Medicine Specialties, led by Prof. Olayiwola Shittu of the University College Hospital (UCH) Ibadan, Oyo State, told The Guardian: “This requires a close multidisciplinary collaboration between the surgeons, physicians and psychologists/psychiatrists to ensure that the patient and the donor are in the best frame of mind and have agreed to it.

“We only practice living donor transplantation in Nigeria, especially of solid organ like the kidney. The donor is interviewed independently and assessed for suitability and fitness for organ donation. There should be no element of coercion or even inducement. Organ donation is completely altruistic, voluntary, and no reward except the satisfaction that someone has been helped. All these elements must be evident in the interview.

“The psychiatrist would assess the patient for mental fitness as well. The patient and the donor are then assessed for organ compatibility. Currently, organ purchase, sale, and forceful harvest of organ are not allowed in Nigeria. The practice of organ transplantation relies heavily on medical ethics that enunciates respect for autonomy, beneficence, non-maleficence and justice, because there is no codified legal framework. In Ibadan, we sometimes ask the donor to obtain an affidavit to confirm the relationship and the fact that he/she has not been coerced in any way.”

On what to do so that recipients, donors and sponsors do not to run foul of the laws, locally and internationally, the team said the doctors should provide the guidance in this respect. “The processes of transparent and extensive discussions are held between the recipient, donor, doctors and the relatives. Besides, the onus is on the doctors to ensure that the transplantation is desirable, the donor is suitable, and both recipient and donor are well informed. Necessary papers are available to sign. Underage donors are discouraged. The National Health Bill provisions are not robust enough on this matter,” they stated.

Reacting to the question on why syndicates involved in connecting families to people who are willing to donate one of their kidneys are thriving, the team said they are thriving because there is no regulation and enforcement of medical ethics.

“Poverty, inequality, and power of the wealthy play a role. There is also aiding and abetting by unconscionable medical practitioners. It is this inequality that the Islamic Republic of Iran tries to eliminate by instituting a well-regulated organ sale/procurement. The government gets involved in direct organ purchase and equitable distribution so that it is not only the rich who benefits. Many professional bodies frown on this. I can say that many young people have approached us to sell their kidneys, but we have refused to link them up with recipients. The reasons are, of course, economic.”

A radiologist and oncologist, Prof. Ifeoma Okoye, shared with The Guardian that: “Transplantation is the best and sometimes only form of treatment for many patients with end-stage organ failure. There are two sources that the medical community has used to provide organs for transplant purposes. The first is known as ‘Deceased Donation’, through use of organs from deceased persons, who have indicated, while alive, that they voluntarily donate their organs in the event of sudden demise, or in some cases of mass accidents with unknown corpses, who have died inter-state. The second is ‘Donation By Living Donors/‘Living Donation’, which donors can be first, second or third degree relations, such as spouses and siblings, or ‘Commercial Donors’ (Individuals who voluntarily choose to market their organs) and the last/worst option is organ harvesting of trafficked or kidnapped victims.

“Indeed, while deceased donation fails to meet the need for transplantable organs in all countries, it is almost non-existent in many countries, and it is this that has led to ever-increasing use of living donors as a source of kidneys and more recently, livers, especially in Low and Medium Income Countries (LMICs), such as Nigeria.

“Organ donation and transplantation have been the subject of extensive international interest in the past 10 years, at both governmental and professional levels. This interest has been driven by two main factors, the universal shortage of organs for transplantation and the wide international variation in donation and transplantation activity. Secondly, the need to ensure that all developments have a firm basis in legal and ethical practice with equity, quality and safety at their core.”

Okoye said organ donation and transplant rates vary widely across the globe, but there remains an almost universal shortage of deceased donors. She said the unmet need for transplants has resulted in many systematic approaches to increased donor rates, but there have also been practices that have crossed the boundaries of legal and ethical acceptability, such as commercial donors and organ harvesting of trafficked/kidnapped victims.

The radiologist said recent years have seen intense interest from international organisations, led by the World Health Organisation (WHO) and professional bodies, like The Transplantation Society, adding that their efforts have focused on the development of a series of legal and ethical frameworks, designed to encourage all countries to eradicate unacceptable practices, while introducing programmes that strive to achieve national or regional self-sufficiency in meeting the need for organ transplants.

Okoye said unfortunately, in most LMICs, such as Nigeria, with inundating challenges of poor health systems driven by poor management of the country resources, inadequate/non-existent Universal Health Care (UHC) and real poor economic indices, living donation remains the mainstay of transplantation in many such parts of the world.