Illegal kidney transplants: facilitating, concealing and laundering

With this question, Frederike Ambagtsheer, Assistant Professor and criminologist at the Department of Internal Medicine, Division of Nephrology & Transplantation at the Erasmus MC Transplant Institute, outlines the dilemma faced by kidney patients. 

Globally, an estimated two to seven million people die each year from chronic kidney failure. The demand for kidneys consistently and structurally exceeds supply. In many countries, patients do not survive the waiting list or become too unwell to undergo transplantation. This gap between demand and supply provides fertile ground for an international market that is officially prohibited, yet persistently present.

An ERC Starting Grant funds the multidisciplinary research project Walls of Secrecy and Silence in the Human Organ Trade: Facilitating, Concealing and Laundering Illegal Transplants. The project is led by Ambagtsheer and conducted in collaboration between Erasmus MC and Erasmus School of Law. At its core lies the question of how illegal transplants are facilitated, concealed and laundered — and what this implies for efforts to combat organ trafficking.

Trade, organ trafficking and ‘transplant tourism’

“In public debate, different terms are often used interchangeably. Legally, however, important distinctions exist. Organ trafficking concerns the buying and selling of organs, or mediating such transactions, for financial or material gain. Where coercion, deception, abuse of vulnerability or other forms of exploitation are involved, international instruments refer to trafficking in persons for the purpose of organ removal (THBOR), as set out in the United Nations Palermo Protocol (2000),” says Ambagtsheer.

“In addition, there is the phenomenon of ‘transplant tourism’: patients and donors who travel across borders for transplantation. That is not illegal per se,” Ambagtsheer adds. “It becomes problematic where it is accompanied by exploitation or organ trading. In practice, however, it proves extremely difficult to draw a clear line between lawful transplant travel and illegal practices. Legal complexity, cross-border arrangements and limited international cooperation hamper effective enforcement.”

The figures underscore that difficulty. To date, only sixteen convictions for organ trafficking have been recorded worldwide in the case law database of the United Nations Office on Drugs and Crime. For trafficking in persons for the purpose of organ removal, the number stands at six. “That stands in stark contrast to the scale the phenomenon is believed to have according to international estimates. It is also striking that all officially reported illegal transplants took place within medical institutions, with the involvement of medical professionals. At the same time, successful prosecutions of hospitals, clinics or physicians are virtually non-existent,” Ambagtsheer notes.

Networks in plain sight

Earlier research shows that illegal transplants do not occur in obscure back rooms, but in operating theatres of recognised hospitals. “In South Africa, physicians collaborated with foreign intermediaries to facilitate hundreds of illegal kidney transplants. Patients paid sums that could exceed one hundred thousand euros per transplant; donors received only a fraction of that amount,” Ambagtsheer explains, referring to her previous research.

Researchers also identified problems in Kosovo. “Donors were paid less than agreed or pressured to recruit additional donors. In several cases, corruption, complex financial constructions and cross-border money flows frustrated prosecution. Ultimately, principal suspects were frequently acquitted or received comparatively lenient sentences,” Ambagtsheer says.

What these cases have in common is that they are intertwined with established medical infrastructure and existing healthcare systems. Illegal transplants make use of lawful institutions, professionals and procedures. This renders detection not only legally, but also institutionally, complex.

‘Walls of Secrecy and Silence’

The project also involves Professor of Kidney Diseases and consultant nephrologist Marc Hemmelder, affiliated with Erasmus MC, and Associate Professor of Criminology Robby Roks of Erasmus School of Law.

“The central premise of the research project transcends disciplinary boundaries. For that reason, the collaboration between Erasmus MC and Erasmus School of Law is of particular importance. Frederike, who studied criminology at Erasmus School of Law and has worked at Erasmus MC for many years, fulfils an important and unique bridging role,” says Roks.

The collaboration combines criminology, law and medical expertise. Together with two PhD candidates, the team examines how medical and legal practices may, sometimes inadvertently, facilitate, conceal or legitimise illegal transplants. The researchers combine online research into recruitment and brokerage practices with ethnographic fieldwork in known hotspots of organ trafficking. In addition, they analyse recent criminal cases in, among other jurisdictions, Costa Rica, the United Kingdom, Thailand and Türkiye. The project further examines how criminal networks interact with medical institutions and where their activities intersect. By bringing together these different perspectives, the project aims to expose the “walls of secrecy and silence” that sustain illegal transplantation practices.