238
myocardial contractility. The resulting 'luxury
inotropy' is undesirable in the CAD patient, since it
raises myocardial oxygen demand. In patients with
symptomatic CAD, the choice of a dialysate CA concentrations of 1.25 or 1.50mmol/l should be considered. Negative effects on calcium balance can be
overcome by calcium supplements per os in the interdialytic interval.
Arterial hypertension is associated with increased
LV work-load and oxygen demand. Underdiagnosis,
undertreatment, and (frequently) ignorance have contributed to perpetuate arterial hypertension in the
dialysis patient as the single most important clinical
problem in nephrological every day routine. For obvious reasons this is particularly true in the hypertensive
CAD patient. In such patients, all arguments given
above argue for dialysis sessions of long duration
which allow to titrate the patient to reach an adequate
target weight and to avoid dialysis-associated hypotension. It has been shown that such a dialysis strategy
largely avoids the hypotension problem in a general
dialysis population [10]. Ancillary drug therapy should
also be considered. Beta blockers (in patients with
normal or hyperkinetic LV function) and ACE inhibitors (in patients with a reduced LV function) are
usually effective. Antihypertensive drugs provoking
reflex tachycardia should be avoided.
In conclusion, haemodialysis patients with significant CAD constitute a large proportion of the dialysis
population and benefit from careful application of the
above principles, i.e. avoidance of hyperhydration,
arterial hypertension, dialysis-associated hypotension
and tachycardia. It appears that these goals can only
be met by haemodialysis sessions of long duration,
which permit selection of low ultrafiltration rates (or
Nephrol Dial Transplant (1996) 11: Editorial Comments
by more frequent dialysis sessions). Correction of
anaemia to achieve a target haematocrit of 35% by
erythropoietin therapy is another important measure.
Acknowledgements. I thank Prof. Ritz for stimulating discussions
and editorial help.
References
1. Manske C, Wang Y, Rector T, Wilson R, White C. Coronary
revascularization in insulin-dependent diabetic patients with
chronic renal failure. Lancet 1992; 340: 998-1002
2. Kahn J, Rutherford B, McConahay D, Johnson W, Giorgi L,
Hartzler G. Short- and long-term outcome of percutaneous
transluminal coronary angioplasty in chronic dialysis patients.
Am Heart J 1990; 119: 484-489
3. Wizemann V, Schafer R, Kramer W. Follow-up of cardiac
changes induced by anemia compensation in normotensive hemodialysis patients with left ventricular hyperthrophy. Nephron
1993; 64: 202-206
4. Wizemann V, Kaufmann J, Kramer W. Effect of erythropoietin
on ischemia tolerance in anemic hemodialysis patients with
confirmed coronary artery disease. Nephron 1992; 62: 161-165
5. Kinet J-P, Soyeur D, Balland N, Saint-Remy M, Collignon P,
Godon J-P. Hemodynamic study of hypotension during hemodialysis. Kidney Int 1982; 21: 868-876
6. Manske C, Thomas W, Wang Y, Wilson R. Screening diabetic
transplant candidates for coronary artery disease. Identification
of a low risk group. Kidney Int 1993; 44: 617-621
7. Kramer W, Wizemann V, Lammlein G et al. Cardiac dysfunction
in patients on maintenance hemodialysis. Contrib Nephrol 1986;
52: 110-124
8. Leunissen K, Kouw P, Koomann J et al. New techniques to
determine fluid status in hemodialyzed patients. Kidney Int 1993;
43 [Suppl41]: 50-56
9. Kramer W, Wizemann V, Thormann J, Kindler M, Muller K,
Schlepper M. Cardiac dysfunction in patients on maintenance
hemodialysis. The importance of associated heart diseases in
determining alterations of cardiac performance. Contrib Nephrol
1986; 52: 97-109
10. Charra B, Calemard E, Ruffet M et al. Survival as an index of
adequacy in dialysis. Kidney Int 1992; 41: 1286-1291
The use of organs from executed prisoners in China
J. D. Briggs
Renal Unit, Western Infirmary, Glasgow, UK
Key words: donation; kidneys; organ transplantation;
Amnesty International; Human Rights Watch
Introduction
Since the first successful renal transplant four decades
ago, the donation of kidneys and more recently other
organs has restored to health many patients who would
otherwise have faced certain death. As a consequence,
organ transplantation is viewed by most as one of the
success stories of medical science, despite the fact that
it is expensive in terms of money and other resources.
Its emotive appeal too assures it a high profile in the
news media. However, the successful application of
organ transplantation has probably resulted in more
problems and dilemmas than any other form of medical
treatment not only within medical science itself but in
other fields, particularly those of ethics and the law.
At the top of this list of problems is the difficulty of
obtaining an adequate supply of healthy donor organs
and distributing them fairly. No country in the world
has as yet come even close to the ideal of an adequate
number of organs for all in need. This large gulf
between supply and demand, together with the desire
239
Nephrol Dial Transplant (1996) 11: Editorial Comments
on the part of some governments and medical communities to raise their scientific profile, has sometimes
resulted in considerable pressures to develop successful
transplant programmes. These pressures have led on a
number of occasions to the failure to observe ethical
standards and legal requirements.
In recent years one of the most blatant examples of
disregard for acceptable ethical behaviour in the field
of transplantation has taken place in the People's
Republic of China in the form of the use of organs
from executed prisoners for the purpose of
transplantation.
The death penalty
China is far from being alone in having a death penalty
and the list of countries which have abolished this
form of punishment is much shorter than is the number
which have so far retained it. However, China is unique
in the world today in the scale of its use and the
breadth of crimes which carry this sentence. In comparison with the late 1970s there are now 150% more
crimes which carry the death penalty and around 35%
of all criminal offences are now punishable by death
[1]. Numerous non-violent crimes now carry the death
penalty, including corruption, embezzlement and drug
trafficking. Also it has been reported that police officers
have come under increased pressure to meet 'arrest
quotas' in order to show their enthusiasm for the
national campaign against crime. While the total
number of executions is not published by the government, Amnesty International estimated the figure to
be in the region of 20000 in 1983 and to have remained
high subsequently [2]. While there is no direct evidence
to link the rising demand for donor organs with the
escalating number of executions in recent years,
Human Rights Watch/Asia has suggested that a causeand-effect relationship might exist [1].
Also, accurate statistics are available of the number
of renal transplants performed, and these have risen
from 840 in 1988 to 1905 in 1992 [3,4], this rise being
in the absence of any national programme of voluntary
cadaver organ donation. While the Chinese government used to deny that the organs of executed prisoners
were used for transplantation, they have more recently
admitted that the practice does take place, although
not on the large scale which outside observers have
reported. One such observer who used to be a transplant surgeon in China estimated that more than 90%
of the kidneys transplanted came from executed
prisoners [5]. Also, a Hong Kong surgeon reported in
a study of 26 patients in his hospital who had undergone renal transplant operations in China that 75% of
them had received their kidneys from executed
prisoners [6].
police officials, and corroboration is seldom possible.
Nonetheless the consistency of the accounts strengthens
their validity. The legally approved mode of execution
in China is by a bullet through the back of the head,
although there have been reports of the shot being
fired elsewhere when tissues such as cornea are
required. Certification of death has been said often to
be perfunctory and to be followed by the bringing of
a mobile operating theatre to the place of execution in
which the organ removal takes place. More disturbing
still are accounts of organs being removed on the night
prior to the execution, of executions being deliberately
botched so that the prisoner does not die immediately,
and of the illegal use of lethal drugs rather than a
gunshot in order to avoid trauma to the body [1].
Consent for organ donation
A fundamental ethical rule in the practice of organ
donation is that of freely given consent. Even in
countries with so called 'opting out' or presumed
consent legislation, there still exists the opportunity on
the part of the individual to decide against organ
donation. In the case of a condemned prisoner in
solitary confinement and shackled by handcuffs and
leg irons, as occurs in some Chinese jails, it would be
naive to pretend that consent can be fully informed
and certainly cannot be freely given. Also there are
statements from a number of observers, including a
former judge, that often no attempt is made to seek
consent from the prisoner or the family [1]. There are
other accounts of coercion of the family by the offer
of a financial reward in exchange for permission for
organ donation and of the opposite approach consisting of the threat of imposition of cremation and
other charges should consent be withheld. Finally the
usual practice of cremation shortly after carrying out
the sentence precludes the family from determining if
organ donation had taken place.
Involvement of the medical profession
Inevitably doctors are closely involved in the donation
process at two stages. Firstly they have to take blood
samples and determine the suitability of the prisoner
as an organ donor prior to the execution. Secondly
they have to be in attendance at the time of the
execution so that they can immediately remove the
organs. This involvement clearly contravenes United
Nations ethical guidelines regarding the relationship
of health personnel and prisoners [7].
Conclusions
Procedure of organ procurement from executed
prisoners
Almost inevitably the evidence regarding this aspect is
based on accounts by witnesses, most often court or
What should the attitude of the international transplant community be to the system of organ donation
which currently exists in China? The answer surely
must be that irrespective of any local difficulties, prob-
240
lems, or deficiencies in the supply of organs, all countries are expected to adhere to the rules and ethical
guidelines agreed by recognized bodies such as the
United Nations and international professional organisations such as the Transplantation Society. Thus the
deviations from accepted practice in organ donation
which take place at the present time in the People's
Republic of China should be unequivocally condemned. Having stated their position, should professional associations in the field of transplantation seek
to influence the system of organ donation in China or
any other country in which unacceptable practices at
present occur? Again the answer must surely be yes,
by means of the imposition of such measures as seem
practical and likely to influence policy within these
countries.
These sanctions would consist of a policy of not
cooperating with Chinese transplant units which could
not clearly show total lack of involvement with organ
donation from executed prisoners. The sanctions might
include refusal to accept medical or other personnel
for training and refusal also of abstracts submitted to
scientific meetings, manuscripts to medical journals
and invitations to delegates to attend congresses.
Appropriate organizations should also be asked to
cease or avoid involvement with these same transplant
units, for example bodies awarding research grants
and companies supplying immunosuppressive drugs.
Finally the medical profession in countries around
China, in particular Hong Kong, should be asked to
dissuade their patients from travelling to mainland
China for the purpose of receiving an organ transplant.
In summary, the practice of obtaining organs for
transplantation from executed prisoners should be
strongly condemned. From a pragmatic point of view
it is harmful to the public image of transplantation far
beyond the boundaries of China. Of much greater
Nephrol Dial Transplant (1996) 11: Editorial Comments
importance, it is a gross violation both of human rights
and of the ethical guidelines which have been drawn
up by various international organizations to set the
standards of acceptable practice both within and outwith the medical profession.
Postscriptum
Comment on behalf of the Council of the EDTA/ERA
The Council of EDTA/ERA has taken note of documentation of the use of organs from executed prisoners
for organ transplantation. It condemns this practice,
wherever it occurs.
Jacques Bernheim
on behalf of the Council EDTA/ERA.
References
1. Organ procurement and judicial execution in China. Human
Rights Watch/Asia 1994; Vol 6: No9
2. Amnesty International. China: death penalty figures recorded for
1993. ASA, London, April 1994
3. Zhonghua Yixuehei Dierci Quanguo Qiguan Yizhixueshu Huiyi
Jiyao. Journal of Chinese Organ Transplantation 1991; 12: 41
4. Zongjie Guoqi, Zhouwang Weilai, ba Woguo Quiguan Yizhi
Gongzuo Tuixiang Qianjin. Journal of Chinese Organ
Transplantation 1994; 15
5. Guttmann RD. On the use of organs from executed prisoners.
Transplant Rev 1992; 6: 189-193
6. Siu-foon PC. Prisoners' kidneys used in transplants. Hong Kong
Stdard, 8 January, 1991
7. Principles of medical ethics relevant to the role of health
personnel, particularly physicians, in the protection of prisoners
and detainees against torture and other cruel, inhuman or
degrading treatment or punishment. Adopted by the General
Assembly of the United Nations on 18 December 1982
(Resolution 37/194), Principle 3.