Three years ago, in New York, one of Dr. Thomas Diflo's patients on a long waiting list for a kidney transplant showed up with a new problem: She no longer needed a kidney, but suddenly needed after-transplant care.
"She had just returned from a trip to China and, to my surprise, had undergone a transplant while she was there," said Diflo, of New York University Medical Center, where he is director of kidney transplants.
The woman, a Chinese-American, was vague about where the kidney had come from, but others who have come to Diflo for treatment have been more forthcoming, confiding that they got the organs of executed Chinese prisoners.
Kidneys, livers, corneas and other body parts from these prisoners are being transplanted into American citizens or permanent residents who otherwise would have to wait years for organs. Many of the patients come back to the United States for follow-up care, which Medicaid or other programs pay for.
The transplants in China, which doctors in both countries say are increasing, has presented the American medical establishment with an ethical quandary: Should American doctors treat patients who have received organs from executed prisoners and, if so, would they be tacitly condoning the practice and encouraging more such transplants.
Or should they rebuke patients who, in desperation, participate in a process that mainstream transplant advocates condemn as morally wrong?
"That's a decision that has to be made by each individual physician," said Dr. Thomas McCune, a transplant physician in Norfolk, Va., and chairman of the patient care and education committee of the American Society of Transplantation.
Executed prisoners are China's primary source of transplantable organs, though few of the condemned, if any, consent to having their organs removed, people involved with the process say. Some of the unwitting donors may even be innocent, having been executed as part of a surge of executions propelled by accelerated trials and confessions that sometimes were extracted through torture.
The American transplantation society says that decisions to donate organs must be made freely and without coercion or exploitation of any sort. It opposes any organ donations by prisoners, even to their relatives, because the circumstances of incarceration make it impossible to ensure that the decision is not colored by secondary benefits, like an improved diet, that a prisoner may stand to gain. Donations from death row inmates are even more suspect.
Various initiatives are under way to protest the harvesting of organs from China's prisoners. One bill would bar entry to the United States of any doctors from China who want American transplant training. Chinese transplant specialists now travel freely to the United States to take part in seminars and other activities that help hone their skills.
But American doctors say there is little they can do to stop the flow of prisoner organs to the United States because the Chinese supply is growing just like the American demand.
More transplantable organs are available in China because more people are being executed. This year, 5,000 prisoners or more are likely to be put to death during a nationwide anticrime drive. Many of them will be stripped of their vital organs, though there is no available data to say how many. Government policy allows the harvesting if the prisoner or the prisoner's family has given written consent, or if the body is not claimed after execution. In practice, though, the rules are often ignored and illegal harvesting tolerated.
Meanwhile, China has made great strides in transplant techniques, having performed 35,000 kidney transplants since its first successful one in 1961. As a result, transplant centers have opened around the country, some with special wards catering to high-paying foreign patients.
Most of the organs are transplanted into Chinese citizens, but a growing number are going into foreigners, particularly Southeast Asians, Japanese and Americans, who would otherwise face years of illness or the risk of death if they were to wait for transplants in their home countries.
Hospitals welcome foreign patients because they pay as much as 10 times the price local patients pay for the same operation. For an American patient, the Chinese charges are somewhat below the comparative cost in the United States.
It is hard to say how many Americans are receiving such organs each year. Anecdotal evidence in both countries suggests the number is small but growing and cuts across various regions. I think this is pretty widespread," said Dr. Diflo. "You'll see it anywhere you have an Asian community."
All five hospitals that do kidney transplants in Shanghai say they treat foreign patients.
More than 78,350 Americans are awaiting organ transplants, according to the United Network for Organ Sharing, a nonprofit group that matches donors to transplant patients in the United States. Among them, about 50,000 need a kidney and that number is expected to double within the decade.
Dr. Stephen Tomlanovich, a kidney transplant specialist at the University of California, San Francisco, has several patients who traveled to Shanghai or Guangzhou to receive kidneys that he suspects came from executed prisoners. The patients involved told him that they were not certain of their organs' origins and Tomlanovich accepted that.
But if presented with a clear case in which an organ came from an executed prisoner, he says he would probably decline to treat the patient.
"I guess I would explain that it makes me uncomfortable and might affect my care," he said by telephone from San Francisco. "I would attempt to find the patient care within some other medical system."
After Diflo was asked to monitor the level of medication taken by patients who conceded that they had been given organs from executed prisoners, he went to his hospital's ethics board to discuss his misgivings. The board supported his decision to continue treating the patients.
"Certainly what they've done from my point of view is ethically and morally wrong," Diflo said. "But they're in need of medical care and we can't punish them."