AS attested by recent news reports, Pakistan is being sucked back into the vortex of kidney trade and transplant tourism.

After an initial drop in cases following the promulgation of the Transplantation of Organs and Tissue Ordinance 2007, ratified as law in 2010 and criminalising such practices, unscrupulous physicians are back in business.

Foreigners are having transplants with kidneys bought from indigent Pakistanis; our terrible variation on Dubai’s ‘fly and buy’ scheme has been resuscitated.

Kidney-failure patients from around the world are being welcomed in Pakistan, helped to procure visas, assisted with travel arrangements and provided free pick-up services from airports. Conveniently located are clinics where their purchased goods — kidneys — await transplantation into their bodies. After this came to light, a criminal case was registered against a team of physicians connected to renowned hospitals in Lahore and caught red-handed in private clinics.

The evolution and subsequent trajectory of organ transplantation provide an interesting study for ethicists and sociologists.

The first successful kidney transplant took place in the US in the 1950s with the donation of a kidney by a twin to his brother.

Surgeons who pioneered transplantation approached the new discipline with the hope of providing a new lease of life for patients, but also treaded with a sense of ethical trepidation.

Historically, operations had only been conducted on patients needing treatment. But for the first time, now, surgeons were submitting healthy persons — the donors — to an operation that carried potential risks without direct benefit to them. In doing so, physicians were transgressing a central ethical premise: ‘above all, do no harm’. Professional concern was tempered to some extent because altruistic donors were willing to accept the risks to help a beloved family member. Nevertheless criteria were developed to ensure that the decision to donate was voluntary and free from coercion.

With the passage of time, however, kidney transplantation became a ‘routine’ surgical procedure. In developing countries such as Pakistan, which lacked deceased-donor programmes, living individuals remain the primary source for kidneys. It became evident that kidney transplantation could be a lucrative business for physicians and hospitals if a ready supply of kidneys was made available; and what could be better than paying money to the impoverished to ‘donate’ their kidneys? The language of sacrifice and love that defined the act of organ donation soon morphed into the market idiom of supply and demand and ‘organ shortages’, reducing human kidneys into disembodied commodities for sale.

Some physicians, including many in Pakistan, continue to argue that the sale of organs is an ethical transaction between a vendor and a buyer, a win-win situation for both. According to this view, persons who sell their kidneys are autonomous agents exercising their right to choice, and that preventing the poor from selling kidneys to make money worsens their situation.

This line of argument chooses to ignore the contextual realities within which these transactions occur. This was highlighted by the Centre of Biomedical Ethics and Culture at the Sindh Institute of Urology and Transplantation (SIUT) in the first psychosocial study conducted on the subject in Pakistan. The study involved in-depth interviews and the psychological screening of kidney vendors and their families in rural Punjab. Our findings, some of which are presented here, revealed profound physical and psychological repercussions on vendors and their families, and negative implications for the medical profession.

Kidney vendors and their families repeatedly cited compulsion (majboori) as the reason for selling a kidney. They did not perceive it as a ‘choice’. The majority had either been unable to pay off loans, the commonest reason for selling a kidney, or had accumulated new debts. They expressed regret regarding their actions and would not advise anyone to sell a kidney.

Half the vendors had sufficiently high anxiety and depression levels (two had attempted suicide) to require psychiatric consultation. Almost all reported a combination of debilitating symptoms including physical weakness, the inability to perform manual labour, sexual impotency, terror about losing the other kidney, feelings of emptiness, hopelessness and uselessness. They expressed perceptions of being reduced to an adhoora (incomplete) man. Many expressed contempt for those who had received their kidneys. Wives reported husbands as frequently short-tempered, and exhibiting a loss of interest in their children.

Equally distressing was the bitterness and anger expressed towards the medical profession. For many, hospitals were nothing but places of business involved in choree ka kaam (theft), and physicians and staff were referred to as jhootay (liars), daqa shahi (kings of thieves) and dhokay baz (deceivers) out to make money. Some likened their experience in the hospitals as a noose around their necks where ‘they sucked our blood’.

By its very nature, the field of organ donation and transplantation cannot be a purely medical matter. More than any other medical discipline, it raises profound questions about professional ethics, existing power and socio-economic disparities, and the values that define a society.

The figure of the Roman god Janus, with two faces turned in opposite directions, is a good metaphor for kidney transplantation in Pakistan. One face represents the way it began in the 1980s — a partnership between ethical physicians and selfless family members ready to donate a kidney to help kin. The other face reflects the re-emergence of a system in which kidneys are bought and sold as business transactions between strangers with the active collusion of transplant professionals and hospitals. We must decide which face Pakistan wishes to present to the world.

The writer is a professor and chairperson of the Centre of Biomedical Ethics and Culture, SIUT.

cbec.siut@gmail.com