Organ transplantation

Autografts are the transplant of tissue to the same person. Sometimes this is done with surplus tissue, tissue that can regenerate, or tissues more desperately needed elsewhere (examples include skin grafts, vein extraction for CABG, etc.). Sometimes an autograft is done to remove the tissue and then treat it or the person before returning it[8] (examples include stem cell autograft and storing blood in advance of surgery). In a rotationplasty, a distal joint is used to replace a more proximal one; typically a foot or ankle joint is used to replace a knee joint. The person's foot is severed and reversed, the knee removed, and the tibia joined with the femur.

An allograft is a transplant of an organ or tissue between two genetically non-identical members of the same species. Most human tissue and organ transplants are allografts. Due to the genetic difference between the organ and the recipient, the recipient's immune system will identify the organ as foreign and attempt to destroy it, causing transplant rejection. The risk of transplant rejection can be estimated by measuring the panel-reactive antibody level.

An isograft is a subset of allograft in which organs or tissues are transplanted from a donor to a genetically identical recipient (such as an identical twin). Isografts are differentiated from other types of transplants because while they are anatomically identical to autografts, they do not trigger an immune response.

A xenograft is a transplant of organs or tissue from one species to another. An example is porcine heart valve transplant, which is quite common and successful. Another example is attempted piscine–primate (fish to non-human primate) transplant of pancreatic islets. The latter research study was intended to pave the way for potential human use if successful. However, xenotransplantion is often an extremely dangerous type of transplant because of the increased risk of non-functional compatibility, rejection, and disease carried in the tissue. In the opposite direction, attempts are being made devise a way to transplant human fetal hearts and kidneys into animals for future transplantation into human patients to address the shortage of donor organs.[9]

In people with cystic fibrosis (CF), where both lungs need to be replaced, it is a technically easier operation with a higher rate of success to replace both the heart and lungs of the recipient with those of the donor. As the recipient's original heart is usually healthy, it can then be transplanted into a second recipient in need of a heart transplant, thus making the person with CF a living heart donor.[10] In a 2016 case at Stanford Medical Center, a woman who was needing a heart-lung transplant had cystic fibrosis which had led to one lung expanding and the other shrinking, thereby displacing her heart. The second patient who in turn received her heart was a woman with right ventricular dysplasia which had led to a dangerously abnormal rhythm. The dual operations required three surgical teams, including one to remove the heart and lungs from a recently deceased initial donor. The two living recipients did well and had an opportunity to meet six weeks after their simultaneous operations.[11]

Another example of this situation occurs with a special form of liver transplant in which the recipient has familial amyloidotic polyneuropathy, a disease where the liver slowly produces a protein that damages other organs. The recipient's liver can then be transplanted into an older person for whom the effects of the disease will not necessarily contribute significantly to mortality.[12]

This term also refers to a series of living donor transplants in which one donor donates to the highest recipient on the waiting list and the transplant center utilizes that donation to facilitate multiple transplants. These other transplants are otherwise impossible due to blood type or antibody barriers to transplantation. The "Good Samaritan" kidney is transplanted into one of the other recipients, whose donor in turn donates his or her kidney to an unrelated recipient. This method allows all organ recipients to get a transplant even if their living donor is not a match to them. This further benefits people below any of these recipients on waiting lists, as they move closer to the top of the list for a deceased-donor organ. Johns Hopkins Medical Center in Baltimore and Northwestern University's Northwestern Memorial Hospital have received significant attention for pioneering transplants of this kind.[13][14] In February 2012, the last link in a record 60-person domino chain of 30 kidney transplants was completed.[15][16]

Because very young children (generally under 12 months, but often as old as 24 months[17]) do not have a well-developed immune system,[18] it is possible for them to receive organs from otherwise incompatible donors. This is known as ABO-incompatible (ABOi) transplantation. Graft survival and people's mortality is approximately the same between ABOi and ABO-compatible (ABOc) recipients.[19] While focus has been on infant heart transplants, the principles generally apply to other forms of solid organ transplantation.[17]

The most important factors are that the recipient not have produced isohemagglutinins, and that they have low levels of T cell-independent antigens.[18][20] United Network for Organ Sharing (UNOS) regulations allow for ABOi transplantation in children under two years of age if isohemagglutinin titers are 1:4 or below,[21][22] and if there is no matching ABOc recipient.[21][22][23] Studies have shown that the period under which a recipient may undergo ABOi transplantation may be prolonged by exposure to nonself A and B antigens.[24] Furthermore, should the recipient (for example, type B-positive with a type AB-positive graft) require eventual retransplantation, the recipient may receive a new organ of either blood type.[17][22]

Limited success has been achieved in ABO-incompatible heart transplants in adults,[25] though this requires that the adult recipients have low levels of anti-A or anti-B antibodies.[25] Renal transplantation is more successful, with similar long-term graft survival rates to ABOc transplants.[22]

Until recently, people with obesity were not considered appropriate candidate donors for renal transplantation. In 2009, the physicians at the University of Illinois Medical Center performed the first robotic renal transplantation in an obese recipient and have continued to transplant people with a body mass index over 35 using robotic surgery. As of January 2014, over 100 people who would otherwise have been turned down because of their weight have successfully been transplanted.[26] [27]

• Heart (deceased-donor only; porcine xenograft attempted)
• Lung (deceased-donor and living-related lung transplantation)

• Kidney (deceased-donor and living-donor; porcine xenograft attempted)
• Liver (deceased-donor, which enables donation of a whole liver; and living-donor, where each donor can provide up to 70% of a liver)
• Pancreas (deceased-donor only; a very severe type of diabetes ensues if a live person's entire pancreas is removed)
• Intestine (deceased-donor and living-donor; normally refers to the small intestine)
• Stomach (deceased-donor only)
• Uterus (deceased-donor only)[28][29]
• Testis[30] (deceased-donor and living-donor)
• Penis (deceased-donor only)

• Hand (deceased-donor only), see first recipient Clint Hallam
• Cornea (deceased-donor only) see the ophthalmologist Eduard Zirm
• Skin, including face replant (autograft) and face transplant (extremely rare)
• Islets of Langerhans (pancreas islet cells) (deceased-donor and living-donor)
• Bone marrow or adult stem cell (living-donor and autograft)
• Blood transfusion, whole blood or fractionated blood products (living-donor and autograft)
• Blood vessels (autograft and deceased-donor)
• Heart valve (deceased-donor, living-donor and xenograft [porcine/bovine])
• Bone (deceased-donor and living-donor)

In living donors, the donor remains alive and donates a renewable tissue, cell, or fluid (e.g., blood, skin), or donates an organ or part of an organ in which the remaining organ can regenerate or take on the workload of the rest of the organ (primarily single kidney donation, partial donation of liver, lung lobe, small bowel). Regenerative medicine may one day allow for laboratory-grown organs, using person's own cells via stem cells, or healthy cells extracted from the failing organs.[31]

Deceased donors (formerly cadaveric) are people who have been declared brain-dead and whose organs are kept viable by ventilators or other mechanical mechanisms until they can be excised for transplantation. Apart from brainstem-dead donors, who have formed the majority of deceased donors for the last 20 years, there is increasing use of after-circulatory-death donors (formerly non-heart-beating donors) to increase the potential pool of donors as demand for transplants continues to grow.[32] Prior to the legal recognition of brain death in the 1980s, all deceased organ donors had died of circulatory death. These organs have inferior outcomes to organs from a brain-dead donor.[33] For instance, patients who underwent liver transplantation using donation-after-circulatory-death allografts have been shown to have significantly lower graft survival than those from donation-after-brain-death allografts due to biliary complications and primary nonfunction in liver transplantation.[34] However, given the scarcity of suitable organs and the number of people who die waiting, any potentially suitable organ must be considered. Jurisdictions with medically assisted suicide may co-ordinate organ donations from that source.[35]

Living related donors donate to family members or friends in whom they have an emotional investment. The risk of surgery is offset by the psychological benefit of not losing someone related to them, or not seeing them suffer the ill effects of waiting on a list.

Diagram of an exchange between otherwise incompatible pairs

A "paired-exchange" is a technique of matching willing living donors to compatible recipients using serotyping. For example, a spouse may be willing to donate a kidney to their partner but cannot since there is not a biological match. The willing spouse's kidney is donated to a matching recipient who also has an incompatible but willing spouse. The second donor must match the first recipient to complete the pair exchange. Typically the surgeries are scheduled simultaneously in case one of the donors decides to back out and the couples are kept anonymous from each other until after the transplant. Paired-donor exchange, led by work in the New England Program for Kidney Exchange as well as at Johns Hopkins University and the Ohio organ procurement organizations, may more efficiently allocate organs and lead to more transplants.

Paired exchange programs were popularized in the New England Journal of Medicine article "Ethics of a paired-kidney-exchange program" in 1997 by L.F. Ross.[39] It was also proposed by Felix T. Rapport[40] in 1986 as part of his initial proposals for live-donor transplants "The case for a living emotionally related international kidney donor exchange registry" in Transplant Proceedings.[41] A paired exchange is the simplest case of a much larger exchange registry program where willing donors are matched with any number of compatible recipients.[42] Transplant exchange programs have been suggested as early as 1970: "A cooperative kidney typing and exchange program."[43]

The first pair exchange transplant in the US was in 2001 at Johns Hopkins Hospital.[44] The first complex multihospital kidney exchange involving 12 people was performed in February 2009 by The Johns Hopkins Hospital, Barnes-Jewish Hospital in St. Louis and Integris Baptist Medical Center in Oklahoma City.[45] Another 12-person multihospital kidney exchange was performed four weeks later by Saint Barnabas Medical Center in Livingston, New Jersey, Newark Beth Israel Medical Center and New York-Presbyterian Hospital.[46] Surgical teams led by Johns Hopkins continue to pioneer this field with more complex chains of exchange, such as an eight-way multihospital kidney exchange.[47] In December 2009, a 13 organ 13 recipient matched kidney exchange took place, coordinated through Georgetown University Hospital and Washington Hospital Center, Washington DC.[48]

Good Samaritan or "altruistic" donation is giving a donation to someone that has no prior affiliation with the donor. The idea of altruistic donation is to give with no interest of personal gain, it is out of pure selflessness. On the other hand, the current allocation system doesn't assess a donor's motive, so altruistic donation isn't a requirement.[49] Some people choose to do this out of a personal need to donate. Some donate to the next person on the list; others use some method of choosing a recipient based on criteria important to them. Web sites are being developed that facilitate such donation. Over half of the members of the Jesus Christians, an Australian religious group, have donated kidneys in such a fashion.[50]

Monetary compensation for organ donors, in the form of reimbursement for out-of-pocket expenses, has been legalised in Australia,[51] and strictly only in the case of kidney transplant in the case of Singapore (minimal reimbursement is offered in the case of other forms of organ harvesting by Singapore). Kidney disease organizations in both countries have expressed their support.[52][53]

In compensated donation, donors get money or other compensation in exchange for their organs. This practice is common in some parts of the world, whether legal or not, and is one of the many factors driving medical tourism.[54]

In the illegal black market the donors may not get sufficient after-operation care,[55] the price of a kidney may be above $160,000,[56] middlemen take most of the money, the operation is more dangerous to both the donor and receiver, and the receiver often gets hepatitis or HIV.[57] In legal markets of Iran[58] the price of a kidney is $2,000 to $4,000.[57][59][60]

An article by Gary Becker and Julio Elias on "Introducing Incentives in the market for Live and Cadaveric Organ Donations"[61] said that a free market could help solve the problem of a scarcity in organ transplants. Their economic modeling was able to estimate the price tag for human kidneys ($15,000) and human livers ($32,000).

In the United States, The National Organ Transplant Act of 1984 made organ sales illegal. In the United Kingdom, the Human Organ Transplants Act 1989 first made organ sales illegal, and has been superseded by the Human Tissue Act 2004. In 2007, two major European conferences recommended against the sale of organs.[62] Recent development of web sites and personal advertisements for organs among listed candidates has raised the stakes when it comes to the selling of organs, and have also sparked significant ethical debates over directed donation, "good-Samaritan" donation, and the current US organ allocation policy. Bioethicist Jacob M. Appel has argued that organ solicitation on billboards and the internet may actually increase the overall supply of organs.[63]

In an experimental survey, Elias, Lacetera and Macis (2019) find that preferences for compensation for kidney donors have strong moral foundations; participants in the experiment especially reject direct payments by patients, which they find would violate principles of fairness.[64]

Many countries have different approaches to organ donation such as: the opt-out approach and many advertisements of organ donors, encouraging people to donate. Although these laws have been implemented into a certain country they are not forced upon very one as it is an individual decision.

Two books, Kidney for Sale By Owner by Mark Cherry (Georgetown University Press, 2005) and Stakes and Kidneys: Why Markets in Human Body Parts are Morally Imperative by James Stacey Taylor: (Ashgate Press, 2005), advocate using markets to increase the supply of organs available for transplantation. In a 2004 journal article economist Alex Tabarrok argues that allowing organ sales, and elimination of organ donor lists will increase supply, lower costs and diminish social anxiety towards organ markets.[65]

Iran has had a legal market for kidneys since 1988.[66] The donor is paid approximately US$1200 by the government and also usually receives additional funds from either the recipient or local charities.[59][67] The Economist[68] and the Ayn Rand Institute[69] approve and advocate a legal market elsewhere. They argued that if 0.06% of Americans between 19 and 65 were to sell one kidney, the national waiting list would disappear (which, the Economist wrote, happened in Iran). The Economist argued that donating kidneys is no more risky than surrogate motherhood, which can be done legally for pay in most countries.

In Pakistan, 40 percent to 50 percent of the residents of some villages have only one kidney because they have sold the other for a transplant into a wealthy person, probably from another country, said Dr. Farhat Moazam of Pakistan, at a World Health Organization conference. Pakistani donors are offered $2,500 for a kidney but receive only about half of that because middlemen take so much.[70] In Chennai, southern India, poor fishermen and their families sold kidneys after their livelihoods were destroyed by the Indian Ocean tsunami on 26 December 2004. About 100 people, mostly women, sold their kidneys for 40,000–60,000 rupees ($900–1,350).[71] Thilakavathy Agatheesh, 30, who sold a kidney in May 2005 for 40,000 rupees said, "I used to earn some money selling fish but now the post-surgery stomach cramps prevent me from going to work." Most kidney sellers say that selling their kidney was a mistake.[72]

In Cyprus in 2010 police closed a fertility clinic under charges of trafficking in human eggs. The Petra Clinic, as it was known locally, brought in women from Ukraine and Russia for egg harvesting and sold the genetic material to foreign fertility tourists.[73] This sort of reproductive trafficking violates laws in the European Union. In 2010 Scott Carney reported for the Pulitzer Center on Crisis Reporting and the magazine Fast Company explored illicit fertility networks in Spain, the United States and Israel.[74][75]

There have been concerns that certain authorities are harvesting organs from people deemed undesirable, such as prison populations. The World Medical Association stated that prisoners and other individuals in custody are not in a position to give consent freely, and therefore their organs must not be used for transplantation.[76]

According to former Chinese Deputy Minister of Health, Huang Jiefu, the practice of transplanting organs from executed prisoners is still occurring as of February 2017.[77][78] World Journal reported Huang had admitted approximately 95% of all organs used for transplantation are from executed prisoners.[78] The lack of a public organ donation program in China is used as a justification for this practice. In July 2006, the Kilgour-Matas report[79] stated, "the source of 41,500 transplants for the six-year period 2000 to 2005 is unexplained" and "we believe that there has been and continues today to be large scale organ seizures from unwilling Falun Gong practitioners".[79] Investigative journalist Ethan Gutmann estimates 65,000 Falun Gong practitioners were killed for their organs from 2000 to 2008.[80][81] However 2016 reports updated the death toll of the 15-year period since the persecution of Falun Gong began putting the death toll at 150,000[82] to 1.5 million.[83] In December 2006, after not getting assurances from the Chinese government about allegations relating to Chinese prisoners, the two major organ transplant hospitals in Queensland, Australia stopped transplantation training for Chinese surgeons and banned joint research programs into organ transplantation with China.[84]

In May 2008, two United Nations Special Rapporteurs reiterated their requests for "the Chinese government to fully explain the allegation of taking vital organs from Falun Gong practitioners and the source of organs for the sudden increase in organ transplants that has been going on in China since the year 2000".[85] People in other parts of the world are responding to this availability of organs, and a number of individuals (including US and Japanese citizens) have elected to travel to China or India as medical tourists to receive organ transplants which may have been sourced in what might be considered elsewhere to be unethical manner.[86][87][88][89][90]

• 1869: First skin autograft-transplantation by Carl Bunger, who documented the first modern successful skin graft on a person. Bunger repaired a person's nose destroyed by syphilis by grafting flesh from the inner thigh to the nose, in a method reminiscent of the Sushrutha.
• 1905: First successful cornea transplant by Eduard Zirm (Czech Republic)
• 1908: First skin allograft-transplantation of skin from a donor to a recipient (Switzerland)
• 1931: First uterus transplantation (Lili Elbe).
• 1950: First successful kidney transplant by Dr. Richard H. Lawler (Chicago, US)[133]
• 1954: First living related kidney transplant (identical twins) (US)[134]
• 1954: Brazil's first successful corneal transplant, the first liver (Brazil)
• 1955: First heart valve allograft into descending aorta (Canada)
• 1963: First successful lung transplant by James D. Hardy with patient living 18 days (US)
• 1964: James D. Hardy attempts heart transplant using chimpanzee heart (US)
• 1964: Human patient lived nine months with chimpanzee kidneys, twelve other human patients only lived one to two months, Keith Reemtsma and team (New Orleans, US)
• 1965: Australia's first successful (living) kidney transplant (Queen Elizabeth Hospital, SA, Australia)
• 1966: First successful pancreas transplant by Richard C. Lillehei and William Kelly (Minnesota, US)
• 1967: First successful liver transplant by Thomas Starzl (Denver, US)
• 1967: First successful heart transplant by Christian Barnard (Cape Town, South Africa)
• 1981: First successful heart/lung transplant by Bruce Reitz (Stanford, US)
• 1983: First successful lung lobe transplant by Joel Cooper at the Toronto General Hospital (Toronto, Canada)
• 1984: First successful double organ transplant by Thomas Starzl and Henry T. Bahnson (Pittsburgh, US)
• 1986: First successful double-lung transplant (Ann Harrison) by Joel Cooper at the Toronto General Hospital (Toronto, Canada)
• 1990: First successful adult segmental living-related liver transplant by Mehmet Haberal (Ankara, Turkey)
• 1992: First successful combined liver-kidney transplantation from a living-related donor by Mehmet Haberal[135] (Ankara, Turkey)
• 1995: First successful laparoscopic live-donor nephrectomy by Lloyd Ratner and Louis Kavoussi (Baltimore, US)
• 1997: First successful allogeneic vascularized transplantation of a fresh and perfused human knee joint by Gunther O. Hofmann
• 1997: Illinois' first living donor kidney-pancreas transplant and first robotic living donor pancreatectomy in the US. University of Illinois Medical Center
• 1998: First successful live-donor partial pancreas transplant by David Sutherland (Minnesota, US)
• 1998: First successful hand transplant by Dr. Jean-Michel Dubernard (Lyon, France)
• 1998: United States' first adult-to-adult living donor liver transplant University of Illinois Medical Center
• 1999: First successful tissue engineered bladder transplanted by Anthony Atala (Boston Children's Hospital, US)
• 2000: First robotic donor nephrectomy for a living-donor kidney transplant in the world University of Illinois Medical Center
• 2004: First liver and small bowel transplants from same living donor into same recipient in the world University of Illinois Medical Center
• 2005: First successful ovarian transplant by Dr. P. N. Mhatre (Wadia Hospital, Mumbai, India)
• 2005: First successful partial face transplant (France)
• 2005: First robotic hepatectomy in the United States University of Illinois Medical Center
• 2006: Illinois' first paired donation for ABO incompatible kidney transplant University of Illinois Medical Center
• 2006: First jaw transplant to combine donor jaw with bone marrow from the patient, by Eric M. Genden (Mount Sinai Hospital, New York City, US)
• 2006: First successful human penis transplant (later reversed after 15 days due to 44-year-old recipient's wife's psychological rejection) (Guangzhou, China)[136][137]
• 2008: First successful complete full double arm transplant by Edgar Biemer, Christoph Höhnke and Manfred Stangl (Technical University of Munich, Germany)
• 2008: First baby born from transplanted ovary. The transplant was carried out by Dr Sherman Silber at the Infertility Centre of St Louis in Missouri. The donor is her twin sister.[138]
• 2008: First transplant of a human windpipe using a patient's own stem cells, by Paolo Macchiarini (Barcelona, Spain)
• 2008: First successful transplantation of near total area (80%) of face, (including palate, nose, cheeks, and eyelid) by Maria Siemionow (Cleveland Clinic, US)
• 2009: Worlds' first robotic kidney transplant in an obese patient University of Illinois Medical Center
• 2010: First full facial transplant by Dr. Joan Pere Barret and team (Hospital Universitari Vall d'Hebron on 26 July 2010, in Barcelona, Spain)
• 2011: First double leg transplant by Dr. Cavadas and team (Valencia's Hospital, La Fe, Spain)
• 2012: First simultaneous robotic bariatric surgery (sleeve gastrectomy) and kidney transplantation (university of Illinois at Chicago). (1). (2)
• 2012: First Robotic Alloparathyroid transplant. University of Illinois Chicago
• 2013: First successful entire face transplantation as an urgent life-saving surgery at Maria Skłodowska-Curie Institute of Oncology branch in Gliwice, Poland.[139]
• 2014: First successful uterine transplant resulting in live birth (Sweden)
• 2014: First successful penis transplant. (South Africa)[140]
• 2014: First neonatal organ transplant. (UK)[141]
• 2018: Skin gun invented, which takes a small amount of healthy skin to be grown in a lab, then is sprayed onto burnt skin. This way skin will heal in days instead of months and will not scar.
• 2019: First drone delivery of a donated kidney, that was then successfully transplanted into a patient. (US)[142]
• 2021: First transplant of both arms and shoulders performed on an Icelandic patient at the Édouard Herriot Hospital. (FR)[143]
• 2022: First successful heart transplant from a pig to a human patient. (US)[144] The recipient later died as the pig's heart was infected with porcine cytomegalovirus.[145]

Since 2000, there have been approximately 2,200 lung transplants performed each year worldwide. From 2000 to 2006, the median survival period for lung transplant patients has been 5.5 years.[146]

One of the driving forces for illegal organ trafficking and for "transplantation tourism" is the price differences for organs and transplant surgeries in different areas of the world. According to the New England Journal of Medicine, a human kidney can be purchased in Manila for $1000–2000, but in urban Latin America a kidney may cost more than $10,000. Kidneys in South Africa have sold for as high as $20,000. Price disparities based on donor race are a driving force of attractive organ sales in South Africa, as well as in other parts of the world.

In China, a kidney transplant operation runs for around $70,000, liver for $160,000, and heart for $120,000.[79] Although these prices are still unattainable to the poor, compared to the fees of the United States, where a kidney transplant may demand $100,000, a liver $250,000, and a heart $860,000, Chinese prices have made China a major provider of organs and transplantation surgeries to other countries.

In India, a kidney transplant operation runs for around as low as $5,000.

In the United States, tissue transplants are regulated by the US Food and Drug Administration (FDA) which sets strict regulations on the safety of the transplants, primarily aimed at the prevention of the spread of communicable disease. Regulations include criteria for donor screening and testing as well as strict regulations on the processing and distribution of tissue grafts. Organ transplants are not regulated by the FDA.[147] It is essential that the HLA complexes of both the donor and recipient be as closely matched as possible to prevent graft rejection.

In November 2007, the CDC reported the first-ever case of HIV and Hepatitis C being simultaneously transferred through an organ transplant. The donor was a 38-year-old male, considered "high-risk" by donation organizations, and his organs transmitted HIV and Hepatitis C to four organ recipients. Experts say that the reason the diseases did not show up on screening tests is probably because they were contracted within three weeks before the donor's death, so antibodies would not have existed in high enough numbers to detect. The crisis has caused many to call for more sensitive screening tests, which could pick up antibodies sooner. Currently, the screens cannot pick up on the small number of antibodies produced in HIV infections within the last 90 days or Hepatitis C infections within the last 18–21 days before a donation is made.

Nucleic acid testing is now being done by many organ procurement organizations and is able to detect HIV and hepatitis C directly within seven to ten days of exposure to the virus.[148]

Both developing and developed countries have forged various policies to try to increase the safety and availability of organ transplants to their citizens. Austria, Brazil, France, Poland and Spain have ruled all adults potential donors with the "opting out" policy, unless they attain cards specifying not to be. However, whilst potential recipients in developing countries may mirror their more developed counterparts in desperation, potential donors in developing countries do not. The Indian government has had difficulty tracking the flourishing organ black market in their country, but in recent times it has amended its organ transplant law to make punishment more stringent for commercial dealings in organs. It has also included new clauses in the law to support deceased organ donation, such as making it mandatory to request for organ donation in case of brain death. Other countries victimized by illegal organ trade have also implemented legislative reactions. Moldova has made international adoption illegal in fear of organ traffickers. China has made selling of organs illegal as of July 2006 and claims that all prisoner organ donors have filed consent. However, doctors in other countries, such as the United Kingdom, have accused China of abusing its high capital punishment rate. Despite these efforts, illegal organ trafficking continues to thrive and can be attributed to corruption in healthcare systems, which has been traced as high up as the doctors themselves in China and Ukraine, and the blind eye economically strained governments and health care programs must sometimes turn to organ trafficking. Some organs are also shipped to Uganda and the Netherlands. This was a main product in the triangular trade in 1934.

Starting on 1 May 2007, doctors involved in commercial trade of organs will face fines and suspensions in China. Only a few certified hospitals will be allowed to perform organ transplants in order to curb illegal transplants. Harvesting organs without donor's consent was also deemed a crime.[149]

On 27 June 2008, Indonesian, Sulaiman Damanik, 26, pleaded guilty in Singapore court for sale of his kidney to CK Tang's executive chair, Tang Wee Sung, 55, for 150 million rupiah (S$22,200). The Transplant Ethics Committee must approve living donor kidney transplants. Organ trading is banned in Singapore and in many other countries to prevent the exploitation of "poor and socially disadvantaged donors who are unable to make informed choices and suffer potential medical risks." Toni, 27, the other accused, donated a kidney to an Indonesian patient in March, alleging he was the patient's adopted son, and was paid 186 million rupiah (US$20,200). Upon sentence, both would suffer each, 12 months in jail or 10,000 Singapore dollars (US$7,600) fine.[150][151]

In an article appearing in the April 2004 issue of Econ Journal Watch,[65] economist Alex Tabarrok examined the impact of direct consent laws on transplant organ availability. Tabarrok found that social pressures resisting the use of transplant organs decreased over time as the opportunity of individual decisions increased. Tabarrok concluded his study suggesting that gradual elimination of organ donation restrictions and move to a free market in organ sales will increase supply of organs and encourage broader social acceptance of organ donation as a practice.

In the United States 24 states have no law preventing discrimination against potential organ recipients based on cognitive ability, including children. A 2008 study found that of the transplant centers surveyed in those states 85 percent considered disability when deciding transplant list and forty four percent would deny an organ transplant to a child with a neurodevelopmental disability.[152][153]

The existence and distribution of organ transplantation procedures in developing countries, while almost always beneficial to those receiving them, raise many ethical concerns. Both the source and method of obtaining the organ to transplant are major ethical issues to consider, as well as the notion of distributive justice. The World Health Organization argues that transplantations promote health, but the notion of "transplantation tourism" has the potential to violate human rights or exploit the poor, to have unintended health consequences, and to provide unequal access to services, all of which ultimately may cause harm. Regardless of the "gift of life", in the context of developing countries, this might be coercive. The practice of coercion could be considered exploitative of the poor population, violating basic human rights according to Articles 3 and 4 of the Universal Declaration of Human Rights. There is also a powerful opposing view, that trade in organs, if properly and effectively regulated to ensure that the seller is fully informed of all the consequences of donation, is a mutually beneficial transaction between two consenting adults, and that prohibiting it would itself be a violation of Articles 3 and 29 of the Universal Declaration of Human Rights.

Even within developed countries there is concern that enthusiasm for increasing the supply of organs may trample on respect for the right to life. The question is made even more complicated by the fact that the "irreversibility" criterion for legal death cannot be adequately defined and can easily change with changing technology.[154]

Surgeons, notably Paolo Macchiarini, in Sweden performed the first implantation of a synthetic trachea in July 2011, for a 36-year-old patient who had cancer. Stem cells taken from the patient's hip were treated with growth factors and incubated on a plastic replica of his natural trachea.[155]

According to information uncovered by the Swedish documentary "Dokument Inifrån: Experimenten" (Swedish: "Documents from the Inside: The Experiments") the patient, Andemariam went on to develop an increasingly terrible and eventually bloody cough to dying, incubated, in the hospital. At that point, determined by autopsy, 90% of the synthetic windpipe had come loose. He allegedly made several trips to see Macchiarini for his complications, and at one point had surgery again to have his synthetic windpipe replaced, but Macchiarini was notoriously difficult to get an appointment with. According to the autopsy, the old synthetic windpipe did not appear to have been replaced.[156]

Macchiarini's academic credentials have been called into question[157] and he has recently been accused of alleged research misconduct.[158]

Left ventricular assist devices are often used as a "bridge" to provide additional time while a patient waits for a transplant. For example, former US vice-president Dick Cheney had such a device implanted in 2010 and then 20 months later received a heart transplant in 2012. In year 2012, about 3,000 ventricular assist devices were inserted in the United States, as compared to approximately 2,500 heart transplants. The use of airbags in cars as well as greater use of helmets by bicyclists and skiers has reduced the number of persons with fatal head injuries, which is a common source of donors hearts.[159]