shlachterPORTFOLIO
  • Intro
  • On leaving the Fort Worth Star-Telegram
  • Mother Teresa
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  • Sacred Dentistry
  • No Dancin' in Anson
  • Mexico/Travel
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  • India's Kidney Bazaar
  • Profile: Dick DeGuerin
  • Brazil: Life is sweet for its super-rich sugar barons
  • Brazil 2: Living on the edge
  • Afghanistan 2
  • Diet Scam
  • Shlachter Family Pilgrimage to Poland
  • Dian Fossey: An Expert Nearly As Elusive As Her Subjects
  • Hungary, again caught in history
  • Bullying becomes a lesson in double standards
  • All too quiet flows the Danube
  • Indiana Jones of the insect world: Hans Herren
  • Brazil 3: Ranchers embracing change
  • Brazil 4: Bread basket to the world?
  • Being a perfect target
  • Day laborers killed, deprived of seat belts, seats
  • Tom's Great Pakistani Adventure
  • Death threats, smear campaigns rocked Texas Rangers' bankruptcy
  • Inside Bangalore Call Centers
  • Bangalore: Pursuing the Indian Dream
  • Leaving Texas for the 'Good Life' in Bangalore
  • Death in a small, good Texas town
  • Fruit Cake Caper
  • 'Anyone here been abducted -- and is a Southern Baptist?'
  • Weimar, from Bach to Buchenwald
  • Man kills child after over-drinking at a Texas Hooters bar, where he had numerous binge sessions
  • BIZARRO TEXAS: Rodeo pro, injured by feisty camel, turns to Asia's illicit rhino horn trade
  • A Fort Worth Zoo Run-In
Picture
Surgeon K.C. Reddy
Picture
Lakshmi Natarajan, kidney seller

India

The kidney bazaar: a matter of life, debt and ethics
October 6, 1991

By Barry Shlachter

    MADRAS, India - The frail young woman quietly awaits her turn in a
 Madras hospital. She's one of a dozen impoverished Indians hoping to sell a
 kidney to a stranger.
    It's the last resort for Varantha Muthulakshmy, a 31-year-old mother of
 two. She has been harassed by creditors who had lent her husband money
 before he abandoned the family.
    "I can't bear this debt anymore; I can't bear to go home," said the
 4-foot-11 housemaid, neatly dressed in a pale red sari. "If I can sell my
 kidney for 27,500 rupees ($1,100), I'll pay the debt and save the rest
 for my eldest daughter's wedding dowry."
    And if, for medical or other reasons, she cannot sell a kidney?
"I'll poison my children," she said with grim determination. "Then kill
 myself."
    Advanced surgical skills and grinding poverty have combined in India to
 create an open trade in human body parts - kidneys bought and sold in
 an unregulated organ bazaar - that has embarrassed the government and
 divided the medical profession.
    Such transactions also occur in Brazil, Turkey, Egypt and parts of

 Eastern Europe. China, though officially rejecting such reports, is
 believed to have profited from the export of organs removed from executed
 prisoners.
    But in terms of sheer volume and openness, India is considered to be
 unparalleled. Some hospitals advertise kidney transplants in the Yellow
 Pages; others send promoters abroad to recruit potential recipients.
    Though condemned by the World Health Organization and international
 medical societies, the practice flourishes in Bombay, Calcutta and Madras,
 where the poor sell their kidneys to middle-class Indians and to
 wealthy gulf state Arabs, Malaysians and Singaporeans who fly in for
 one-stop transplants.
    However, the ethical issue is not as cut and dried as many critics
 suggest. Indians with renal failure who need a transplant but don't have a
 related donor currently have no practical alternative.
    India still operates under an early 19th century law that makes the
 removal of organs from brain-dead patients a crime, preventing creation of
 a Western-type cadaver donor system. Forty-six nations have changed
 the definition of death during the past two decades to take advantage of
 such systems.
    To surgeon K.C. Reddy, the trade in human organs in India comes down to
 the maxim, "Buy or let die."
    Reddy is one of scores of Indian surgeons transplanting purchased
 kidneys but is among only a few willing to defend it openly at international
 conferences. Still, he would like to see the practice regulated to
 weed out what he calls a "mafia" of unscrupulous kidney brokers.
    "I am not ashamed," the British-trained physician said of his purchase
 of kidneys for patients. "I can sleep nights."
    But to many Western medical ethicists, such as Dr. Art Caplan, 41, of
 the University of Minnesota at Minneapolis, the commercial trade in
 organs is patently unacceptable because it puts the kidney seller through
 life-threatening surgery solely for money.
    The need for cash might also prompt people with diseases such as AIDS
 or hepatitis to conceal their condition in order to sell organs, Caplan
 said. Moreover, because surgeons profit from the surgery, such
 commercial kidney transactions might reinforce the notion that doctors are
 partly motivated by greed, he said by telephone.
    "The danger is in starting to treat people as if they were merely a
 source of organs," Caplan said. "We don't view our body as property or
 want to dehumanize people as portable organ farms."
    The stocky, 49-year-old Reddy, whose surgical team has not lost a donor
 in 850 transplants - 600 of them involving purchased kidneys - not
 only is convinced of the merits of the practice, he believes that India
 might well be trailblazing for the West, where the morally acceptable
 cadaver donor system has yet to meet the demand for transplant organs.
    "I'm not an ethicist, I'm not a philosopher," said Reddy, who practiced
 in Maryland before returning to India in 1983. "But those selling a
 kidney may not have an option for survival. What useful purpose is served
 by telling him and the (prospective recipient) to go to hell?"
    The Star-Telegram has learned that the Indian government, stung by
 foreign criticism of the open organ bazaar, is preparing a law banning
 commercial kidney sales. But Reddy asserted that such legislation would be
 impossible to enforce.
    "What is needed is regulation," said Reddy, vice president of the
 Indian Society of Organ Transplantation. "Banning doesn't help."
    He and other supporters of the organ trade argue that the practical
 benefits outweigh any ethical concerns:
    - No cadaver donor system exists in India.
    - Kidneys are sold voluntarily by Indians, for whom selling is often a
 once-in-a-lifetime chance to escape poverty.
    - Moreover, India, which possesses a proud, non-Western culture, should
 not be tailoring its national medical policy to U.S. or European
 needs, Reddy and his supporters say.
    There's also a heavy donor need. Few Indians who suffer kidney failure
 live beyond four years on dialysis, largely because of the poor
 conditions and impure water available. Moreover, only a fraction of the
 necessary dialysis equipment exists for 60,000 new renal failure cases each
 year. And the cost for most is prohibitive: $200 a month, or about
 two-thirds the average annual per capita income.
    "I cannot live with dialysis. It's torture," said K. Sahadevan, 54, one
 of Reddy's patients, who is back on dialysis after a kidney donated by
 his sister failed.
    The blood-cleansing procedure is done three days a week, four hours a
 day, preventing Sahadevan from working as a railroad computer
 programmer. With no other relative able to donate an organ, Sahadevan said he
 will cash in his pension to buy a stranger's kidney.
    No practical alternative exists for Indians who need a transplant but
 don't have a willing related donor.
    Anuradha Rao, executive director of the Madras-based Consumer Action
 Group, is among those uncomfortable with a trade in which the poor sell
 and the rich buy. Nonetheless, she said it would be a mistake to ban
 organ sales.
    "Assuming it's on a voluntary basis with minimal health risks and the
 recipient has no access to a freely donated kidney (from a family
 member, for example), it should be allowed as a last resort," said Rao, who
 has family in Arlington.
    Lost in the debate so far has been the fact that organ sales have
 quietly broken down Hindu caste barriers. Most kidneys are bought from
 low-caste, even so-called untouchable, Hindus, and the recipients include
 high-caste Brahmans.
    "Those who follow a strict Brahman way of life might object but I
 haven't heard of any," said Ramakrishna Dikshitar, 72, a scholar of
 Hinduism's holy Vedic scriptures.
    And while Pope John Paul II condemned Eastern European kidney sales in
 June as "shameful abuses," Hinduism lacks a hierarchical structure to
 issue religious pronouncements - and wouldn't if it could, Dikshitar
 said. "Even if money changes hands, it is still in keeping with Hindu
 belief to help others," he said.
    Others agreed.
    "Ethically, I find nothing wrong with it," said Sriran Panchu, 39, an
 attorney who practices consumer law in Madras.
    There's no problem as long as prospective donors are carefully screened
 and given ongoing medical care, Panchu said. Prohibiting kidney sales
 would only invite corruption, forcing the practice underground, he  warned.
    "Why aren't kidney purchases allowed in the United States?" the
 attorney asked. "In some ways, I think we are more advanced."
    Such views are not uncommon among Indian intellectuals and
 professionals. And they point to a deeper issue: Should the West impose its moral
 or ethical perspective on a foreign society with widely divergent
 traditions and outlook?
    Dr. John Dossetor, 66, director of the Biomedical Ethics Division at
 the University of Alberta in Edmonton said: "I am strongly in favor of it
 being illegal in our culture. But I don't believe we have the right to
 make it illegal for everybody else."
    Referring to a move by the Transplantation Society, an international
 group of transplant surgeons, to deny membership to anyone involved in
 the commercial organ trade, Dossetor said, "I have problems when it is
 applied to countries outside the affluent world."
    Dossetor, a professor of internal medicine, suggests that there are
 cases even in the West in which the sale of a kidney is ethical, if, for
 example, the money is used to save another life. He cited the instance
 of a father selling a kidney to pay for his child's leukemia treatment.
    Opposition to organ sales is not confined to physicians in the West.
 Some Indian doctors also condemn the practice, and have openly feuded
 with proponents.
    "No money should be involved in organ donation, for that automatically
 makes it a trade in flesh," said Madras surgeon M.K. Mani, who said in
 a newspaper column that he gives credence to accounts of patients
 learning after surgery that a kidney had been extracted without their
 permission.
    Christian Medical College in Vellore, like Mani's Apollo Hospital in
 Madras and state-run institutions across the country, accepts only
 transplant patients who have relatives willing to donate kidneys. But doctors
 acknowledge that occasionally money and property quietly change hands
 between family members.
    "There is coercion, whether it's economic or psychological, when
 non-related donors are involved," J.C.M. Shastry, the college's chief of
 nephrology, said by telephone.
    Organ brokers routinely buttonhole kidney patients outside doctors'
 offices, asking them their blood type, then displaying a list of medically
 compatible donors. "There's a lot of money in it," Shastry said. "It's
 hard to resist the temptation to make a fast buck."
    Because of his hospital's ban on kidney sales, Shastry sends patients
 without donors to Reddy, the Madras surgeon who has successfully snapped
 the brokers' stranglehold on the organ trade - by buying direct from
 people offering their kidneys for a price.
    "Reddy is trying to do it  methodically, in a correct way, but he's in a minority, a very  
small minority," Shastry said.
    Reddy weeds out ill or alcoholic candidates, has them screened by a
 staff psychologist, then has an independent psychiatrist explain the
 risks. Reddy pays $1,100 per organ, provides three years' medical care and
 agrees to a free transplant should the remaining kidney fail.
    The surgeon tries to deflect criticism that only the rich get
 transplants by performing one free operation a month for a poor patient.
 Acknowledging that most organ sellers are slum dwellers, Reddy also cites the
 case of a medical student who sold a kidney so he could continue
 studies after his father died.
    Like many sellers, Lakshmi Natarajan's husband settled a debt ($400)
 with his kidney money, and had enough left over for his sister's wedding
 dowry. (India has banned dowries that force many families into debt,
 but the law is rarely enforced.)
    "We were left with no money, so then I (too) sold my kidney," said
 Natarajan, a tiny woman by any standard. She contracted directly with the
 Pandalai hospital and used the money she earned to build a small brick
 house.
    The home contains two extra rooms that the Natarajans rent to boarders
 in Villivakkam, a slum on the outskirts of Madras where several hundred
 people have likewise cashed in on the demand for kidneys.
    Natarajan also bought jewelry and had three vendors' carts made. She
 uses one to sell kolom, a powder for making threshold designs to ward
 off evil. Her husband peddles the stuff from a bicycle. They rent out the
 remaining two carts.
    This from the sale of one kidney.​
    But the Natarajans' success story is a rarity.
    "Most who sell a kidney spend the money left and right getting drunk,"
 she said through an interpreter. None of several other kidney sellers
 interviewed had made as dramatic an improvement in living standard as
 the Natarajans.
    Would I do it again?" Natarajan asked, echoing the question.
"If it's only a question of money, I would, but no one thinks about
 health."
    She said her surgeon, Reddy, asked her before the operation, "Are you
 concerned you might die?"
    "I told him, ‘I don't care if I die. My children would benefit.’ No one
 I know has died from donating a kidney. If someone had, no one would
 sell," she said.
    Like others, Natarajan defended the practice largely on economic and
 humanitarian grounds. "Not only do we get cash, we have given added days
 to let someone else live," she said.
    But not all organ sellers are so expansive. A group of Natarajan's
 kidney-selling neighbors, their money spent, has filed a lawsuit against
 Reddy, claiming they were promised post-operation bonuses but were never
 paid.
    Reddy dismisses the allegations, maintaining that they have been
 fabricated by kidney brokers whose livelihood he has hurt by buying directly
 and cutting them out of his transactions.
    At Vijaya Hospital in Madras, as with most of the 80 or so other
 clinics, nursing homes and hospitals that do commercial kidney transplants in
 India, "patients themselves arrange for the organs, and the doctors
 only check up on whether the patient is fit for surgery," a hospital
 spokesman said.
    This lack of control can result in mismatched organs and attendant
 diseases, critics say. The British medical journal Lancet found that one in
 five Arabs who received kidneys in Bombay between 1984 and 1988 died
 within one year, a much higher death rate than in the West. Some had
 contracted AIDS and hepatitis.
    The survey of 122 patients found that 81.5 percent lasted more than a
 year.
    Reddy contended that that survival rate is excellent for a Third World
 country. Of his critics, he said, "As long as they don't provide us a
 solution, they have no right to criticize us."
    Nevertheless, the Indian government reacted to foreign attacks in the
 summer by drafting a bill that would outlaw the commercial trade in
 organs, setting a maximum punishment of $400 in fines and seven years'
 imprisonment.
    The measure is to be presented to Prime Minister Narasimha Rao's
 Cabinet soon and most likely will be introduced in Parliament in November,
 said L.M. Singhvi, India's high commissioner to London and a
 constitutional law expert whose committee drafted the proposal.
    The bill would for the first time permit a determination of brain death
 at selected Indian medical centers with the aim of encouraging a
 cadaver organ donor system, he said. Currently, a doctor faces criminal
 action for removing an organ from a person whose heart is still beating,
 though there may be no brain activity.
    But even those close to the committee question whether the law, if
 enacted, can be enforced.
    "It won't work," said one government official, who spoke on condition
 of anonymity. "But it's the only law that will pass, and then perhaps it
 can be amended."
    In Madras, Reddy said a ban would be challenged immediately in court by
 patients demanding that the government either permit kidney sales or
 provide sufficient dialysis equipment, which the nation cannot afford.
    Moreover, he said that the proposed law would not stop kidney sales-
 "There would be enough loopholes in it to fly a Boeing 747 through it" -
 and that public acceptance of brain death would be difficult to obtain
 in India.
    He also said that cultural beliefs would prevent a workable cadaver
 donor system from evolving in the country.
    "If my daughter was left brain dead from a car accident, neither her
 mother, the wife of a doctor, nor I myself would permit the removal of
 her organs," Reddy said. "As long as her heart beats, I'd still count on
 a miracle, and we Indians believe in miracles. I know that when her
 organs are carved out, no miracle could save her.
    "This is her father thinking," he added. "As a transplant surgeon, I'd
 be seen as a bloody hypocrite."
    But Professor Devinayaka Sundaram, chairman of Madras University's
 sociology department, believes that the Indian public would come to accept
 a cadaver system as it has other medical advances, such as vaccination
 against smallpox.
    "The success of a cadaver donor program depends on the extent to which
 commercial interest is discouraged," he said. "It's a question of time.  Like blood
donation, organ donation will be eventually institutionalized."


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