The Expression of Concern stems from an Australian report published online in February in BMJ Open, which urged the repudiation by English-language journals of more than 445 studies involving 85,477 organ transplants done in China. The reason? Many of the organs used were likely forcibly harvested from Chinese prisoners of conscience, such as practitioners of Falun Gong, Uyghurs, Tibetans, and underground Christians.
“We reached out for clarification of the organ source to the senior authors, but one was deceased and the other had left the institution where the research was done,” said CJASN editor-in-chief Rajnish Mehrotra, MD, MBBS, a professor of medicine at the David Geffen School of Medicine at University of California Los Angeles.
The notice also reaffirmed the journal’s commitment to publishing only research that conforms to international ethical standards, acknowledging that in this case it was unable to ascertain whether the study in question contravened these norms.
Mehrotra said that although the journal has no policy covering research from a specific country, the editors began to review all papers submitted by Chinese researchers after a 2011 article in The Lancet outlined the use of organs from executed prisoners.
“We now ask a specific set of questions of all authors submitting papers, but we tend to take authors at their word,” Mehrotra said in an interview with Medscape Medical News.
Wendy Rogers, PhD, lead author of the BMJ Open study and a professor of clinical ethics at Macquarie University in Sydney, Australia, and associates found that of the 445 studies examined, 412 (92.5%) failed to report whether organs were sourced from executed prisoners and 439 (99%) neglected to report that organ donors gave consent. Only 73% specified approval from an institutional review board. Of studies declaring that no prisoners’ organs were used for transplant, 19 of them involved 2688 transplants performed before 2010, when China had no volunteer organ donor program.
In their conclusion, Rogers and colleagues fault the international transplant research community — as well as reviewers, editors, and publishers — for their “significant lack of vigilance and failure to adhere to accepted ethical standards,” asserting they have neglected to uphold standards banning the publication of research using materials from executed prisoners.
“As a result, a large body of unethical published research now exists, raising questions of complicity to the extent that the transplant community uses and benefits from the results of this research,” Rogers and colleagues write.
So far, Rogers told Medscape Medical News, the reaction to the report’s criticisms and call for retractions has been minimal. BMJ published a news article in February that prompted the CJASN‘s expression of concern, and BMJ Open ran a thoughtful response from the Global Alliance of Eye Bank Associations.
“I’ve been contacted by only one editor of a journal identified in our article and one editor of a relevant journal not identified in the article, who are both investigating papers that may have breached ethical guidance,” she said.
No major public response has been heard, however, from The Transplantation Society or China. “The lack of engagement and leadership from the transplant community is disappointing,” Rogers said.
But retraction is no small matter, according to Mehrotra. “Retraction of a paper even 10 years later is a blemish on the authors in terms of the conduct of future research,” he said. He added that his journal would retract only after due process involving both the authors and their institutions to determine if ethical violations actually took place.
“But it’s sad that we even need to ask for retractions, since the journals should not be publishing these studies in the first place,” said Arthur L. Caplan, PhD, a professor of bioethics at New York University Langone Medical Center in New York City and columnist for Medscape Medical News .
He points out that the transplantation of organs from executed prisoners has been condemned by the World Health Organization, the World Medical Association, The Transplantation Society, Amnesty International, and the Declaration of Istanbul (a formal proclamation combating unethical practices in organ transplantation). And the condemnation extends to research studies and presentation of results at meetings.
Caplan noted that while some other countries such as India offer transplants-on-demand, China is one the few nations where the use of prisoners’ organs is government-sanctioned. According to a 2018 report by the China Organ Harvest Research Center, transplants-on-demand is a growth industry there, and the number of transplant centers in China grew exponentially in the 2000s. It notes that the United States, with 130 million registered voluntary organ donors, performs an average of approximately 6000 liver transplants per year. “In China, despite the paucity of donors, this number could be matched by just a few hospitals,” the report authors write.
In 2017, the European Parliament called on China to end the abusive practice of pillaging prisoners’ organs. However, earlier this month, the independent China Tribunal concluded that the practice continues in China.
In the domain of scientific publishing, the American Journal of Transplantation altered its editorial policies in 2011 in response to growing concerns. The journal refuses manuscripts containing data derived from executed prisoners’ organs, and it has served as a forum for donors’ rights advocacy groups such as Doctors Against Forced Organ Harvesting.
“Only about 12 or 13 journals went with the boycott, and with the passage of time, commitment to the boycott has been slipping,” he said. One of the journals that did not join Caplan’s boycott in 2011 was the New England Journal of Medicine (NEJM). In a recent email to Medscape Medical News on the question of refusing articles on transplant research from China, an NEJM spokesperson said, “We have no policy and evaluate all articles on a case-by-case basis.”
Thanks to lucrative transplant tourism driven by wealthy patients seeking on-demand grafts, forced organ donation continues to thrive in China, despite official assertions that the practice was banned in 2015. “You can still get a new liver quickly but someone has to die,” Caplan said.
He finds unpersuasive the claims by Chinese officials that the country has ended involuntary procurement. “China does not have an effective cadaver donor system but it’s still doing huge numbers of transplants,” he said.
Given the possible dubious source of organs in such large numbers of transplants, Rogers and her Australian colleagues called it unacceptable for journals to publish any papers from China with data from transplants done to the end of 2014, but warned that even those published after 2015 may involve prisoners’ organs and recommended a moratorium on all relevant papers pending an international policy summit. It is not lost on critics that some researchers may be under duress to declare that their studies used no forcibly harvested organs.
Recently, the United States, Canada, the Czech Republic, and Israel have announced actions to minimize their citizens’ participation in transplant tourism, according to Doctors Against Forced Organ Harvesting.
In Caplan’s view, that’s the kind of step more countries should be taking. “The only way to change the practice of ‘killing for parts’ is to keep the heat on,” he said. And that extends to pushing journals to refuse to publish transplant research that may be based on illicit human organ harvesting.
Clin J Am Soc Nephrol. Published online June 4, 2019. Expression of Concern