Indonesia, Singapore and Kidney Trade

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The Times: Inside the kidney trade
A pound of flesh for sale: As MPs debate the shortage of organs, David Rowan talks to a practitioner in the booming trade of 'transplant tourism'

If you happen to need a new kidney in a hurry, Jim Cohan has a business proposition for you. From his office in Los Angeles, he can offer you a fresh replacement, fitted in any of the ten countries he regularly deals with. He describes his kidneys as "the healthiest young organs, from hard-working people, many of them vegetarians, and generally in the best of health".

Not only will Cohan source your new kidney but he will arrange the transplant in the foreign hospital, all the tests and medication, your food, accommodation and follow-up care, and even the flights for you and your partner. There is the small matter of his $125,000 (£66,000) fee, but he sees that as a small price for a second chance at life. Besides, as his website boasts, he will "manage every step, from the time the recipient leaves home to the time of their return".

His customers - four or five hundred over the past dozen years, he claims - do not seem to mind that Cohan, 63, is by trade a nutritionist, with no medical qualification. After all, they hope to return with a new organ, he takes his commission and not too many questions are asked about what happens at the other end. As Cohan tells it, his partner hospitals use kidneys taken only from cadavers, obtained "through government-regulated programmes" in accordance with local laws. But his management role doesn't extend to vetting the individual hospitals, which may be in the Philippines, South Korea, Taiwan, Singapore, China, South Africa or South America. "I deal with reputable hospitals and have never had to send someone back for a replacement or another operation." He could not, however, produce one of his successful transplant patients by the time we went to press, saying there might be a problem getting them to co-operate with the media.

Depending on your viewpoint, he is either a benevolent entrepreneur who saves lives, or a cynical middleman out to profit from sick people's desperation. By matching patients from countries where organs are scarce with foreign transplant teams better stocked with supplies, he is, in effect, an organ broker. Cohan dislikes the term, preferring to see himself as an "international organ transplant co-ordinator". "I'm not involved in buying, selling or trafficking organs," he stresses. "I just co-ordinate things - if you need a kidney, I'll send you to a country where presumed consent applies."

"Presumed consent" is the legal assumption that organs and tissue may be taken from a brain-dead patient unless he or she has previously registered a refusal. In countries that hold to presumed consent, such as Spain or Singapore, transplant waiting lists tend to be far shorter than those in Britain or the US, where donors must actively agree to have their organs reused. But, as lurid media exposes regularly reveal, the trade does not rely solely on donors who are dead. With kidneys fetching between a few hundred and a few thousand $on the international black market, there are strong incentives - from Moldova to the Maldives - for the healthy poor to sell their body organs.

"That goes on," Cohan admits, stressing that he never solicits from live donors.

He claims that what he does is ethical. "As long as a few thousand people die every year who are on the (transplant) waiting lists, I don't think there's anything wrong with it. Everyone wins."

Although he insists that the operations he arranges are legal in the host country, he has at times had to convince law-enforcement agencies. In 1998 he spent five months in an Italian jail on charges of organ-trafficking and criminal association but he was released after no evidence was brought that he had broken any laws. He has faced separate investigations by Interpol, the FBI and the California attorney-general's office, but each time no offence has been proved.

So J Cohan & Associates continues its high-turnover trade, with customers invited by his website and through e-mail solicitations to send an initial $500 "good faith" deposit and a photograph, followed by a further $10,000 with their completed application form. Once that has been banked, and provided that funds are available for the full $125,000, "within a couple of days you can be on the plane". Nor is the menu limited to kidneys: for $240,000 Cohan can also find you a heart, liver or lung.

His numerous critics sneer at his claim to take just 2 or 3 per cent of his fee as commission, with the majority going to the hospital. If his claimed transplant rate is to be believed, his business will already have generated tens of millions of pounds. He protests that his motivation is altruistic rather than financial.

Protected by a loophole in US law, Cohan is just one of the more visible practitioners of today's booming trade in "transplant tourism". More typically, these deals are brokered by less media-friendly middlemen who pay cash to live donors. In India you can pay as little as $300 for a kidney, in Indonesia the rate is $2,000, in Turkey $5,000 and in Israel $20,000. And, although the sale of organs is illegal in Britain, there is growing evidence that the mismatch between supply and demand - with 19,500 people on dialysis but just 1,775 kidney transplants last year - is prompting NHS patients to look to the global market.

The National Kidney Federation, which represents renal patients, has serious concerns about the lack of quality control in this unregulated transplant trade.

"We started to notice that people in our local groups were disappearing, going abroad for 'holidays' and not coming back," Timothy Statham, the chief executive, says. "Presumably they died." Statham, who has had arguments with Cohan over the latter's attempts to contact his members, worries that dire kidney shortages are being exploited.

Two years ago, the documentary-makers Brian Woods and Kate Blewett set out to follow the trade from Brazil and Birmingham to Israel and India. They came away convinced that partial legalisation was the only way forward. "We started out thinking there'd be this murky world of deception. But, in fact, you find lots of people who think it should be legalised," Woods says. In the meantime, the unregulated broker holds all the cards. One broker introduced Woods to Srinivasan, a 38-year-old Indian man from Guntur, Andhra Pradesh, who sold his kidney and cornea after running up business debts of £5,000. He was paid £1,000 for his cornea, not realising that the market rate was £2,400. Now he is looking to sell half of his liver.

Shimrit Orr, an Israeli woman who obtained a kidney last year from a live donor, has nothing but contempt for the Israeli broker who arranged the operation at St Augustine's hospital in Durban. "I paid $125,000. The donor got $20,000, the hospital got $40,000, the hotel and flights might have been $10,000. So that's something like $55,000 for the broker."

Some kidney specialists believe that only legalisation of the trade will stop the profiteering and minimise the risks. Last May, Nadey Hakim, a transplant surgeon at St Mary's Hospital, London, and president of the Royal Society of Medicine's transplant committee, urged the Government to license the sale of human organs in the UK as a way of eroding transplant tourism. Such a Bill is going through the Israeli parliament. If passed, it will make Israel the first country to legalise the live organ trade by paying compensation to those who "donate" a kidney to the state.

Not everyone is convinced. Robert Evans, a British MEP, has been building support in the European Parliament to make it illegal for any European to go elsewhere in the world to buy an organ from a healthy live donor. Evans, who estimates that 1,000 Europeans travel abroad each year to buy a kidney, believes the trade is unethical. A better solution to the organ shortage, he believes, is for presumed consent to become the norm.

The National Kidney Federation also favours a change in the law to presumed consent, together with more transplant surgeons and a "change in culture" in A&E units so that organ donation is considered a priority when a patient dies. Even today, the wishes of donor card- holders may be overruled by their families: 49 per cent of relatives say no when asked by surgeons for organs at the point of death. The issue has been prompting impassioned arguments in recent weeks at Westminster, where two conflicting Bills have been examining the issues surrounding presumed consent. Earlier this month, the Labour MP Siobhain McDonagh introduced a Bill supporting presumed consent. But although she has the backing of bodies such as the British Medical Association, the Government has made clear its firm opposition. Instead, the Human Tissue Bill, currently passing, will specifically require active consent for organ donation.

In the meantime, the unregulated trade will continue and yet more British kidney patients will spend their savings travelling to foreign lands in search of a new future. For Jim Cohan, who hopes that they discover his website first, this means that business prospects continue to look healthy.