Organ Commercialism vs. Bodily Autonomy: Issues and Challenges in the Indian Scenario

This article was written by Bipasha Saikia, a student of National Law University, Assam

Introduction

Modern technology successfully upstaged the truism of ancient Indians that the gift of life is priceless and must be cherished by those upon whom it was bestowed by Almighty. The scientific and the medical fraternity across the globe advanced their research and experimented and learnt than an array of human organs can be removed from one person (living or a corpse) and fitted onto another thereby saving the lives of desperately ill patients across the globe.[1] Known as organ transplantation, this is one of the most respected areas of medical science and it commands universal approval for saving the lives of people at the threshold of death. The practice of organ transplantation gained prominence after the end of World War II when the first kidney transplantation was performed in 1954 in America after which transplantations of organs like liver, heart, pancreas and lungs followed.[2] The discovery of cyclosporine[3] in the 1980s was a major step for developing transplantation techniques. Transplantation today is at a much advanced stage with body parts such as kidney, liver, cornea, heart as well as human bone, ligament, cartilage, skin, tissues, bone marrow etc. being amenable for transplantation. By and large two methods have become very common for obtaining the human organs: one is the method called ex vivo and the other is the method called ex morto. The ex vivo donor is described as a living donor who donates an organ to another person and the second type of donor is the ex morto, the cadaver who donates the organ after his death.[4] Once a medical curiosity, now somewhat acasual operation- organ transplantation is expanding rapidly. So much so, according to the World Health Organization (WHO), 66,000 kidneys, 21,000 livers and 6,000 hearts were transplanted in 2005 and the demand has increased ever since.[5]

Issues pertaining to organ transplantation

The most crucial problem of this form of operation is the demand for organs and the stark unavailability of the same.[6] This problem has opened up many related issues. On one side, this scientific miracle has been a positive force in saving lives and on the flipside, a criminal taint has got attached to this procedure whose consequences have threatened lives. Mainly there are two aspects to the negative side of this procedure: the illegal organ sale and human trafficking for the purposes of organ transplantation. The former includes the purchase of organs from live donors or their extraction from corpses whereas the latter includes the transport of the entire person followed by the violent removal and even the death of the donor.[7] The dangerous consequence of the scarcity of donors and the never-ending list of recipients along with the huge profit in the field of organ transplantation is that, brokers in confluence with surgeons, hospitals, police etc. has transformed this field into the dark world of organ trafficking, exploiting the lives of many a poor and reaping huge profits at the cost of human rights violations thus converting the altruistic scientific experiment of organ transplantation into a global criminal racket where organs like kidney, liver, pancreas, heart etc. used for transplantation are being bought and sold under the table. The term “organ commercialism” came into modern parlance as the illicit activity, proliferated, especially in the developing countries of the world, who became the main suppliers of organs for transplantation. The WHO in the year 2009 had defined the term organ trafficking as:

The recruitment, transport, transfer, harbouring or receipt of living or deceased persons or their cells, tissues or organs, by means of the threat or use of force or other forms of coercion, of abduction, of fraud, of deception, of the abuse of power or of a position of vulnerability, or of the giving to, or the receiving by, a third party of payments or benefits to achieve the transfer of control over the potential donor, for the purpose of exploitation by the removal of cells, tissues, and organs for transplantation.[8]

Organ Donation v. Organ Commercialism

As medical science has provided the means to prolong life, the demand for transplants has grown by approximately 33 percent each year. However, the availability of donors has only risen by about 2 percent.[9] This shortage in supply of organ donors depends on a number of factors.

 In India, the main reason behind this shortage is: lack of awareness coupled with a host of myths and superstitions surrounding the same thus leading a refusal of consent mainly from the family of the deceased person. Also, people are embroiled in a dilemma with respect to the donation of organs. The issue of organ transplantation, although a milestone in the field of medical surgery has created a conflict of interest between a person’s societal, religious and cultural beliefs and the fact that it reduces the gift of life to a mere purchase of life with donation unless the donation is for a loved-one.[10] This is precisely the reason behind the protests carried out by some sections of the world bemoaning the use of a human body as a supplier of organs thereby disrespecting the gift of life.[11]

The WHO first prohibited transplant commercialism in 1987, claiming that such trade is inconsistent with the most basic human values and contravenes the Universal Declaration of Human Rights, 1948. Its Guiding Principles on Organ Transplantation declares that organs should be “donated freely, without any monetary payment or other reward of monetary value”.

The Commentary to Guiding Principle 5 states the reason for the prohibition: “Payment for cells, tissues and organs is likely to take unfair advantage of the poorest and most vulnerable groups, undermines altruistic donation, and leads to profiteering and human trafficking. Such payment conveys the idea that some persons lack dignity, that they are mere objects to be used by others.”

Thus, organ donation is allowed only on the condition that the same is not commercialized and there is no monetary exchange involved. In short, it must be voluntary and purely for altruistic purposes. Although organ trafficking is legally prohibited in many countries, the ugly tentacles of this evil has gripped many countries of the world.

The representatives of the world transplant community met in Istanbul in 2008 to discuss the growing transplant donation commerce and transplant tourism and came up with the The Declaration of Istanbul on Organ Trafficking and Transplant Tourism (hereinafter The Declaration). It defined ‘Transplant commercialism’ as a policy or practice in which an organ is treated as a commodity, including by being bought or sold or used for material gain.[12]

Issues in the Indian Scenario

The vicious cycle of Organ Trafficking and causes of Organ Donation

In India, apart from the advances made in medicine and surgery, the medical tourism sector is thriving as the services in this developing country is cheaper than most of the wealthy nations, be it for commercial surrogacy or organ transplantation. With the advent of globalization, various kinds of commodities are being traded across the globe, some legally and others illegally. Globalization has made people vulnerable in new and dangerous ways by facilitating the menace of organized crime with the use of tools like internet, cell phones, computers, instant money transfers etc.[13] The modus operandi of the people engaged in this illegal trade feeds on the existence of favorable conditions in developing countries like poor law enforcement; cheap services, poverty, inequality, etc. that has provided them a fertile ground for a flourishing black market in organ trading. Such is their influence and reach that in many cases they have been successful in making the hospitals and even reputed surgeons to look the other way while legitimizing such transactions. For a long time there was no specific legislation regulating organ transplantation in India due to which many number of kidney scams were reported leaving thousands of poor people exploited by the middlemen and the unscrupulous doctors in the country which finally led to initiation of the action to enact legislation that could punish and curb this practice. A committee was appointed by the Central Government to draft legislation on the subject. As the main focus of the proposed legislation was kidney scams, the panel of doctors in the committee for framing the law were all kidney experts and thus, the Act has largely been framed keeping in view the kidney scams only. Finally the present Act dealing with regulation of organ transplantation called the Transplantation of Human Organs Act (THOA), 1994 (hereinafter the Act) came into existence. The Act has been enacted to provide for the regulation of removal, storage and transplantation of human organs for therapeutic purposes and for the prevention of commercial dealings in human organs and for matters connected therewith or incidental thereto.[14] Organ transplant law in India does not allow exchange of money between the donor and the recipient and this is in consonance with The Declaration.

In the early 1980s anti-rejection drugs became available in India. At that time, one in three people lived in poverty and these conditions, combined with a lack of medical regulations led to a booming organ transplant in India.[15] Despite the ban, the situation in India is very much the same today. India, with its various social institutions like the caste system and the huge gap between the rich and the poor has reinforced the belief that poor and the people belonging to the lower castes are supposed to serve the rich as evident from the fact that most of these organ donors who donate, either willingly or unwillingly, belong to the low-income category.[16] People from developed countries with an ageing population often flock to developing countries for a cheaper transplant thus providing an incentive to the brokers to continue with their illegal trading. Impoverished sections of the society are often lured into by such brokers, who promise them huge sums for selling off their kidneys or other organs and poverty-stricken people, who find this to be a lucrative offer, sell off their organs for abnormally low prices, either to pay off their debts or to meet other day-to-day needs. In some cases, organs are taken without their knowing, for instance during an operation. Thus, despite a ban, the illegal organ trade continues to flourish with hospitals often performing these transplants by being complicit in such deals or being ignorant towards them.

Most of the organ donors are victims of natural disasters displaced from their natural communities, prisoners, mentally-ill people, or are illiterates who are not in a position to give an informed consent. These aspects make them vulnerable in the hands of the brokers, who after luring them to sell off their organ, refuse to provide for the post-operative care or disappear from the scene leaving them helpless.[17] India has recorded 86% deterioration in the health status of the victims after removal of an organ due to the lack of post-operative care.[18] They become physically inactive and thereby are no longer in a position to work in construction factories or agricultural fields thus losing their main source of income: their physical labor. Moreover, renewal of a rich person’s life at the cost of the poor, especially without an informed consent on their part is definitely a source of misery as Miran Epstein comments, “transplant ethics has been on a slippery slope almost since transplants began. The strategy of getting more organs has pushed, and continues to push, the ethical line to places that had previously been deemed immoral.”[19]

The Issue of Consent

The issue of “consent” is very important in donation of organs. The consent of donor should be free. It is needless to say that consent is free when it is not caused by coercion, fraud, intimidation and misrepresentation. The consent of donor requires mental competence to decide, voluntary freedom of choice and disclosure of the risks. However, inconsistencies in the statement of donors cannot be interpreted to be an absence of love and affection between the donor and the recipient. The donor and the recipient belonging to different caste and from different places shall not be a ground to reject the application by the donors for donation purposes by the Authorization Committee constituted for determining whether a donor is the near relative of the recipient as provided in sub-clause (3) of clause 9 of the 1994 Act.[20]

Even if the consent is not forced, the decision to sell one’s organ or not is made from the standpoint where there are no alternatives present.[21] In a fertile ground like India, lack of stringent regulations enable the continuity and the prosper of this nefarious trade. Despite the 1994 Act, the value of a poor man’s life in India is still cheap and not “sensational enough” to arouse the minds of those at the helm of affairs to sit upright and take notice of this menace on an urgent basis. The Gurgaon organ trafficking ring in India exposed the true picture of the horrifying realities of the illegal organ trading wherein some 500 kidneys were illegally harvested and transplanted at the mercy of poor laborers who were kidnapped from local market under the control and direction of a person named Amit Kumar.[22]

As already stated, consent of the donor must be free and he must donate voluntarily. However, in a situation when a person has not made any statement regarding donation during his lifetime, then, at the time of death, the consent of his family is required. Herein, the problem arises. For instance, when a person is brain-dead, even if he has pledged his organs, familial consent is necessary. There is high familial refusal rate to give consent for organ procurement and this is mostly due to superstitions, apart from emotional and religious reasons. People think that if they donate an organ, they will be born without it in the next life.[23]

Such religious beliefs are major obstacles in meeting the shortage of organ supply. In fact, figures in this regard are shocking. India has the lowest supply of organs. Only 1 in a million people donate organs.[24]

The Transplantation of Human Organs Act, 1994: An analysis through case laws

The 1994 Act prohibits trading of organs and lists out the procedure to be followed while retrieving organs from dead people and related as well as unrelated donors. Organs are allowed to be donated by near relatives- father, mother, brother, sister, child or a spouse.[25] In case of unrelated people, the Act establishes that the same has to be screened by an Authorization Committee whose job is to ensure that the organ is being donated because of “affection and attachment” to the patient and not for financial gain.[26] Thus, the paramount criterion that the Authorization Committee is to find out is whether there is commercial object between the donor and the recipient.[27] If there is a commercial angle, the donation is prohibited. The near relatives’ organ donor has to provide proof of their relationship by genetic testing or legal documents.[28] The provision of “near relative” came up for consideration in the case of Balabir Singh v. Authorization Committee and Others[29]. In this case the petitioner was in dire need of a liver transplant. His brother offered to donate part of his liver for transplantation. But the Authorization Committee declined permission for the same citing the failure of the HLA Typing test[30] conducted on the donor to establish his near relationship with the petitioner. The petitioner was thus asked to get the other tests done as specified in Sub-Clauses (ii) to (iv) of Clause (c) of Rule 4 of the Transplantation of Human Organs Rules,1995 (hereinafter The Rules) from other family members, who may be available as donors. It was later found by the Bench that in case of liver transplantation, tissue matching was not of much consequence. The relevant factors in liver transplantation were the matching of the size and condition of part of organ being removed and the matching of the blood group.[31] Valuable time was lost in establishing the true relationship between the donor and the donee that unfortunately led to the death of the donee. [32]

The Act was supposed to end the trade in human organs. It makes punishable, with a prison term ranging from two to seven years and a fine between Rs.10,000 and Rs.20,000, the offence of purchasing an organ for money or money’s worth.[33] Such elaborate provisions could not be criticized as being inadequate as they cover the procedure in case of both related as well as unrelated donors. Yet, this Act has not been able to stop the illegal trading of organs despite the 2011 Amendment that has enhanced the punishment for a person indulging in organ trading, that has failed to produce a deterrent effect.[34] Firstly, it did not register much success which is evident mainly from the kidney scams reported in the years 2002, 2003 and 2004 through the fortuitous fact of it being the only lucrative human organ accessible illegally from live donors.[35] The loophole in this Act in the form of Section 9(3) has been the shelter ground for hundreds of illegal cash-for-kidney deals. This section provides that:

If any donor authorizes the removal of any of his human organs before his death under Sub-Section (1) of Section 3 for transplantation into the body of such recipient, not being a near relative, as is specified by the donor by reason of affection or attachment towards the recipient or for any other special reasons, such human organ shall not be removed and transplanted without the prior approval of the Authorization Committee.[36]

  The “compassionate donor” provision has been abused by many. Poor people with absolutely no attachment to the recipients are forced or lured to sell off their organs in the garb of a relative or a near one of the recipient under the very noses of the Authorization Committee. The poor donors, on a prior basis, are fed all the relevant family information that they may be asked by the Authorization Committee for the screening test.[37] The inactive approach of these committees has failed to bring such matters to light. Dr. Sandeep Guleria, a professor at the All India Institute of Medical Sciences (AIIMS), estimates that about 64 per cent of all renal transplants in India in early 2001 were from unrelated donors.[38] In most cases, even on grounds of suspicion, they fail to report matters to the police to verify the “real” identity of the donors and any link between the two parties or investigate if any money has been transferred illegally. In state after state, Authorization Committees have rejected a microscopic percentage of applications under this clause, turning a blind eye to what are obviously financial transactions. For example, the Karnataka Authorization Committee approved 1,012 of the 1,017 applications it received from January 1996 to February 2002. [39]

The case of Balbir Singh has brought to fore the need to re-examine and review the statutory provisions and rules of 1995 in the backdrop of difficulties which have surfaced from time to time, resulting in paradoxical situations. Stringent requirements and conditions were prescribed under the Rules to prevent unscrupulous and commercial practices. These have to be harmonized with the emergent needs of as critical patient requiring transplantation which necessitates a quick and responsive mechanism.[40] This is where the conflict lies. On one hand, stringent provisions are a must to curb commercial dealings; however, such provisions may act as a hindrance when establishing the true relationship between the donor and the recipient as they become time-consuming and this leads to the loss of life of the donor, as happened in this case.

The medical practitioner needs to perform a number of functions in this context. Firstly, he is to comply with the requirements specified under Rule 4 of The Rules before removing a human organ from the body of a donor. Secondly, he is also required to satisfy himself regarding proper state of health for donation of the organ. Matter does not end here. The medical practitioner is further required as per Form 3 of the Act to certify that the donor and the donee are related to each other and the fact of this relationship is established by the results of the tests to be conducted under Sub-clause (c) of Clause 4.[41] All such provisions complicate the entire procedure in cases of emergency. Another case where the Committee has made an error of judgment is the case of B L Nagaraj & others vs. Kantha & Others[42]. In this case, the prospective recipient, filed a writ petition before the High Court of Karnataka against the order of the Authorization Committee which rejected the application for organ donation by the sister-in- law of the recipient on the grounds that near relatives were not considered donors. The High Court while allowing the writ petition held:

“There is no provision in the Act which prohibits the person who is not a ‘near relative’ by definition, from donating his kidney merely because the ‘near relative’ has not been considered as donors by the family for kidney transplantation. The Committee has misdirected itself in this regard while refusing permission to the petitioners.”[43]

Other issues in the Indian scenario

Another major problem about this issue with respect to India is that well-known hospitals and doctors get in the papers for colluding in the sale and transplant of these organs, working with brokers and hospitals. Some people get arrested and some hospital licenses are suspended. A few months later everything is forgotten. Despite being hailed as a “moral victory” and a “strong message being sent by the Indian society”, even after the lapse of 20 years, the Indian law has been observed more in the breach.  The industry has always had the support of those in power, and those in power have ways to get their dirty work done, as illustrated by the story of Amit Kumar’s career. Senior Delhi police officials have confessed to picking up one of Kumar’s associates but letting him free in exchange for Rs 20 lakh handed over by Kumar himself.[44]

The 1994 Act aimed at increasing the cadaver-based transplantation. However, the cadaver-based transplant programme has not taken off in this part of the world. In India, doctors estimated that less than 600 organ transplants were from cadavers between 1994 and 2003.[45]

One reason is the lack of infrastructure to obtain organs as soon as they become available. The infrastructural requirements indicate that the excised organs have to be cryogenically preserved until compatible recipients are found. This means storage systems, computerized databanks and medical information networks between organ banks and hospitals of a sophistication alien to India today. The number of such hospitals in India can be counted in one’s fingertips.[46]

Also, law enforcement agencies like the police have played a very dismal role by establishing a connivance with such surgeons who conduct these operations or by turning a blind eye towards such practices.

Poverty eradication programmes are in dire need as this sole evil has created “organ depots of impoverished donors in many parts of the country.” One pocket is the Pallipalayam-Kumarapalayam belt in Tamil Nadu, which sends a regular stream of donors to Madras, Bangalore and Bombay. This belt’s malady is rampant unemployment; in the organ trade parlance, the area is known as “kidneypalayam”.[47]

In the Indian context, there arise some religious and moral issues as well like – If a heart is removed from a cadaver, does it mean that the latter is now devoid of a ‘soul’? Will removal of organs in any way affect the process of ‘rebirth’ or resurrection?

Developmental steps taken by the Government

Despite the grim scenario, India has also witnessed success stories in this regard. Tamil Nadu has set an example by appointing an administrator to chart out its deceased donor programme in 2008. The government issued a diktat to hospitals to identify brain death compulsorily, and floated a novel organ-sharing formula between public and private hospitals. The scheme worked and in 2012 Tamil Nadu managed to get 78 cadaver donations.[48]

Andhra Pradesh’s Jeevandan Scheme has streamlined procedures and deceased donor numbers have doubled from 13 in 2012 to 24 in the first half of 2013. It has helped 100 patients in 7 months.[49]

With about 10 lakh bodies pledged in the state, West Bengal gets the maximum number of body donation in the country and its capital gets most of these. Corneal and bone marrow transplants are performed more frequently in Kolkata.[50]

Suggestions and Recommendations

The organ trade especially the kidney trade in India has the tacit support of people in power who profit from it. Another concern is the attempt to build public support for a regulated trade. For years there has been local and international pressure to permit a government-regulated trade in organs as a way of meeting the demand for kidneys and giving the poor an opportunity to make some money.[51] If people can sell sperm and ova, why shouldn’t they sell a kidney or any other organ? In fact, the government’s failure to provide social welfare is given as a justification – if the government cannot look after its people, the least it can do is allow them to sell a body part. Certainly, if a poor man wants to donate his organs because of his financial status and earn some money for a decent living, why should the Government forbid him from doing so? It is a question of his bodily autonomy and if he has validly consented to the same after knowing about the implications, why should the Government deny him his rights over his body? “What is wrong if a farmer in a debt trap sells his kidney, instead of committing suicide?” The clinicians feel that, when the law itself provides a clause in the form of sub-clause 3 of clause 9 of the 1994 Act to help people whose own family members refuse to donate or those who do not have a fit or matching donor, why should they refuse any arrangement between the donor and recipient.[52] There have been proposals that organ “donors” be provided health insurance to ensure that they get proper healthcare after “donation”. This ironic and tragic issue of organ trafficking is already at the forefront of international concern. It has correctly been stated that “no other field of medicine has raised so many ethical, moral, legal and social issues as has organ transplantation.” On the one hand, the unselfishness and optimism of providing a new life to ill patients through voluntary organ donation demonstrates the very best of human nature. Some sections of the international community are advocating for the legalization of organ trading, like the model followed in Iran, so that such dealings are no longer performed illegally and are regulated by the Government.  However, on the flip side, such an argument in fact allows the government to abandon its responsibility to the poor: let them sell their organs instead. Surely this is not the way to bettering people’s economic conditions. “Were there no organ shortage, no one would propose kidney sale as a way of equalizing economic conditions.” Thus, the Government must deliberate to resolve this conflict: whether a person who wishes to sell off an organ for some quick money for purposes like treatment of a dear one, daughter’s marriage, repayment of family debts etc. should be allowed to do so, on the grounds of bodily autonomy or should the Government initiate serious measures to eradicate poverty and uplift the vulnerable sections of the society. The Government must make a sincere attempt to resolve the conflict between organ trade seen from the perspective of human rights violations and selling of organs to wriggle out of poverty. Whilst the people who advocate the ban in organ trade must also provide an answer regarding the conditions of the society that such a donor lives in: the corruption there, the poverty, the unemployment, the illiteracy etc. But the issue remains: why do poor people continue to sell their organs even when they are aware of the dire consequences of the same? On the other side of the spectrum, can the Government shun its responsibility towards the patients of End Stage Kidney Disease (ESKD)? Should such patients be allowed to die in thousands each year?

Non-Government Organizations like MOHAN (Multi-Organ Harvesting Aid Network) has been working towards the promotion of the deceased donor programme in India; they are of the firm belief that if executed properly, it is capable of overcoming the shortage of organs.[53] To bridge the demand-supply gap in case of organs, India can adopt the Spanish system of “presumed consent” were everyone, post death, is considered a donor unless one has opted out of the process in his life time. Awareness about the benefits of organ donation in saving lives must be effectively spread and associated superstitions of the same should be done away with religious injunctions.

Conclusion

In a country mired with a number of social evils, ethics like “the gift of life must be cherished”, “poor should not be seen as supplier of organs for the rich,” have little role when compared to the gravity and the seriousness of the socio-economic conditions in a poor man’s society. Advocates of bodily autonomy argue that the right to make decisions about one’s body does not violate one’s dignity but ensures that they have a greater sense of control over themselves. They cite examples prevalent in today’s society that are somewhat analogous to organ trade like surrogacy, joining the military etc. Thus, they have the complete right over the decision to sell or not to sell off their organ. The Government by framing stringent provisions to restrain organ commercialism has infringed on this right of bodily autonomy. This is the main conflict of interest. The poor should be given their right of bodily autonomy or the Government should take urgent steps for the upliftment of their status in all spheres. As mentioned above, the Government can also introduce the presumed consent laws in India wherein every adult shall be considered a donor unless he/she opts out of the same. This will surely ensure a smooth flow of organs for transplantation purposes and will also eliminate incentives on the part of the brokers to indulge in organ trafficking or human trafficking for organ trade as they will not receive any profit when the very act is legalized and there is enough supply of organs.

[1] Ranee Khooshie Lal Punjabi, “The Sum of a Human’s Parts: Global Organ Trafficking in the Twenty-First Century,” Pace Environmental Law Review, Volume 28, Issue 1, 2010

[2] “Human Organ Trafficking,” UNA GB Model U.N., United Nations Association of Greater Boston.

[3] Cyclosporine injection is given together with a steroid medicine to prevent the body from rejecting a transplanted organ (e.g., kidney, liver, or heart). It belongs to a group of medicines known as immunosuppressive agents. When a patient receives an organ transplant, the body’s white blood cells will try to get rid of (reject) the transplanted organ. Cyclosporine works by suppressing the immune system to prevent the white blood cells from trying to get rid of the transplanted organ. Cyclosporine is a very strong medicine. It can cause side effects that can be very serious, such as high blood pressure, kidney problems, or liver problems. It may also decrease the body’s ability to fight infections; http://www.mayoclinic.org/drugs-supplements/cyclosporine-intravenous-route/description/drg-20067296

[4] “How to stop Organ Trafficking? A Critique of the Transplantation of Human Organs Act in India,”

http://www.supremecourtcases.com/index2.php?option=com_content&itemid=1&do_pdf=1&id=15820

[5] Supra note 1

[6] supra note 2

[7] supra note 5

[8] WHO, Global Glossary of Terms and Definitions on Donation and Transplantation, 2009 http://www.who.int/transplantation/activities/GlobalGlossaryonDonationTransplantation.pdf.

[9] supra note  7

[10] Ibid

[11] Supra note 9

[12]  The Declaration of Istanbul on Organ Trafficking and Transplant Tourism, International Summit on Transplant Tourism and Organ Trafficking, August 13, 2008.

[13] Ibid

[14] Transplantation of Human Organs Act, 1994

[15] G.A Plenary, “Trafficking of Human Organs and Medical Tourism,”

[16] Sunil Shroff, “Legal and Ethical Aspects of Organ Donation and Transplantation,” Indian Journal of Urology, 351, 348-355, 2009

[17] supra note 11

[18] Alexis A. Aronowitz  and Elif Isitman, “Trafficking of Human Beings for the Purpose of Organ Removal: Are (International) Legal Instruments Effective Measures to Eradicate the Practice?”, Groningen Journal of International Law, 2013.

[19] supra note 17

[20] Ibid

[21] S. Malligamma @ Malligavva and Ors v. State of Karnataka, AIR 2005, Karnataka 74

[22] Simon Robinson, “India’s Black Market Organ Scandal, Time, New Delhi, February 1, 2008

content.time.com/time/world/article/0,8599,1709006,00.html

²³Pritha Chatterjee, “Religion, superstition come in way of cadaver organ donation, says study” The Indian Express, 2013

http://archive.indianexpress.com/news/religion-superstition-come-in-way-of-cadaver-organ-donation-says-study/1147723/

[24] “Only one in a Million Indians Donate Organs”, DNA, 2013

http://www.dnaindia.com/india/report-only-one-in-a-million-indians-donates-organs-1879110

[25] Sub-clause (3), Clause 9, Chapter II, Transplantation of Human Organs Act, 1994

[26] AIR 2005 Karnataka 74

[27] Ibid

[28] Sunil Shroff, “Organ donation and transplantation in India – legal aspects and solutions to help with shortage of organs, Journal of Nephrology and Renal Transplantation, 2009

[29] AIR 2004 Delhi 413

[30] Human leukocyte antigen (HLA) testing is to match organ and tissue transplant recipients with compatible donors. It identifies the major HLA genes a person has inherited and the corresponding antigens (proteins) that are present on the surface of their cells. These antigens help the body’s immune system distinguish which cells are “self” and which are “foreign” or “non-self.” Any cells that are recognized as “non-self” can trigger an immune response, including the production of antibodies. HLA testing also includes screening transplant recipients for the presence of antibodies that might target the donated tissue or organ as part of an immune response. HLA testing is important in medicine when transplanting tissue or an organ(s)

https://labtestsonline.org/understanding/analytes/hla-testing/tab/test/

[31] Ibid

[32] Ibid

[33] Debra Budiani Saberi and  Sean Columb, “A human rights approach to Human Trafficking for Organ Removal,” Springer, 2013

[34] A.M.M Patnaik, Jagadeesh Naik and V. Narayana Rao, “Kidney Transplantation in India: Hopes and Despairs, A Scientific study of ethics, commerce and law, J Indian Academic Forensic Med., Vol. 35, No. 2, April-June 2013

[35] supra note 4

[36] UNODC and Human Trafficking

https://www.unodc.org/unodc/en/human-trafficking

[37] “The issue of combating the illicit trade of human organs,” 2004

www.gemun.it/studyguides/shr2.doc

[38] Sheri R. Glaser, “Formula to Stop the Illegal Organ Trade: Presumed Consent Laws and Mandatory Reporting Requirements for Doctors,” Human Rights Brief 12, 20-22, 2005

[39] Sandhya Srinivasan, “Will the law against organ sale remain a moral victory?”

http://infochangeindia.org/public-health/analysis/will-the-law-against-organ-sale-remain-a-moral-victory.html,

[40] supra note 32

[41] Transplantation of Human Organ Act, 1994

[42] AIR 2004 Delhi 413

[43] AIR 1996 Kant 82

[44] supra note 28

[45] Ibid

[46] supra note 34

[47] Anupam Goswami, “The great and bloody organs bazaar,” Down to Earth, 1995

http://www.downtoearth.org.in/node/27703, accessed on November 6, 2014

[48] Jadhav Rajeev S., “Global Organ Trafficking in Twenty First Century,” 2013

[49] Ibid

[50] “Organ Donation in India: A Story of Shame,” September 16, 2003. http://www.maamatimanush.tv/articles.php?aid=205, accessed on November 5, 2014

[51] Ibid

[52] supra note 32

[53] supra note 45