The rising trend has prompted a serious reappraisal of current legislation, while WHO has called for more protection for the most vulnerable people who might be tempted to sell a kidney for as little as US$ 1000.

Increasing demand for donated organs, uncontrolled trafficking and the challenges of transplantation between closely-related species have prompted a serious re-evaluation of international guidelines and given new impetus to the role of WHO in gathering epidemiological data and setting basic normative standards.

There are no reliable data on organ trafficking — or indeed transplantation activity in general — but it is widely believed to be on the increase, with brokers reportedly charging between US$ 100 000 and US$ 200 000 to organize a transplant for wealthy patients. Donors — frequently impoverished and ill-educated — may receive as little as US$ 1000 for a kidney although the going price is more likely to be about US$ 5000.

A resolution adopted at this year’s World Health Assembly (WHA) voiced “concern at the growing insufficiency of available human material for transplantation to meet patient needs,” and urged Member States to “extend the use of living kidney donations when possible, in addition to donations from deceased donors.”

It also urged governments “to take measures to protect the poorest and most vulnerable groups from ‘transplant tourism’ and the sale of tissues and organs, including attention to the wider problem of international trafficking in human tissues and organs.”

Earlier this year, police broke up an international ring which arranged for Israelis to receive kidneys from poor Brazilians at a clinic in the South African port city of Durban. But such highprofile successes merely scratch at the surface.

Countries such as Brazil, India and Moldova — well-known sources of donors — have all banned buying and selling of organs. But this has come at the risk of driving the trade underground.

Behind the growth in trafficking lies the increasing demand for transplant organs.

In Europe alone, there are currently 120 000 patients on dialysis treatment and about 40 000 people waiting for a kidney, according to a report last year by the European Parliamentary Assembly.

It warned that the waiting list for a transplant, currently about three years, would increase to 10 years by 2010, and with it the death rate from the shortage of organs.

In Asia, South America and Africa, there is widespread resistance — for cultural and personal reasons as well as due to the high cost — to using cadaveric organs, or those from dead bodies.

The majority of transplanted organs come from live, often unrelated, donors. Even in the United States, the number of renal or kidney transplants from live donors exceeded those from deceased donors for the first time in 2001.

Yet the Guiding Principles on human organ transplantation, adopted by the WHA in 1991, state that organs should “be removed preferably from the bodies of deceased persons,” and that live donors should in general be genetically related to the recipient.

They also prohibit “giving and receiving money, as well as any other commercial dealing”.

This year’s WHA resolution therefore asked WHO Director-General Dr LEE Jong-wook to consider updating the guiding principles in the light of current practices.

“There is a real risk that standards devised in the 1990s with the emphasis on prohibition will be undermined and we have to react to this,” said Dr Nikola Biller-Andorno, ethicist at WHO’s Department of Ethics, Trade, Human Rights and Health Law. “What is needed is a critical and thorough analysis of the different proposals that have been made particularly with regard to expanding the use of living donors, by providing incentives and/or removing disincentives.” Dr Biller-Andorno said.

Dr Luc Noel, coordinator of the newly created Clinical Procedures team in WHO’s Department of Essential Health Technologies, said part of the review process included examination of how to minimize health risks to living donors after the donation.

“Removing disincentives is a must. Adding incentives is where things get difficult,” Noel said.

For instance, should a donor in a country with no health insurance be offered free coverage in case he or she gets a complication after the operation? And would this qualify as an incentive or removing a disincentive?

A WHO consultation on organ and tissue transplantation in Madrid last October, grouping 37 clinicians, social scientists, ethicists and government officials from 23 countries, reached no consensus on how and where to draw the line between removing disincentives and providing incentives.

The Madrid consultation unanimously agreed that there should be a WHO expert advisory panel both for allogeneic transplantation, involving organs from an organism of the same species, and xenogeneic transplantation, involving those from another species, and for global safety and quality principles for the regulation of organs and tissues.

Noel said there was a need for more epidemiological data and for more global transparency — especially with regard to the long-term health, psychological and socio-economic consequences for both living donors and recipients.