(2024) 22:322
Alameer et al. BMC Medicine
https://doi.org/10.1186/s12916-024-03547-0

BMC Medicine

DEBATE

Open AccessDilemma of commercial organ transplantin the Middle East
Reem M. Alameer1*, Ahmed A. Alhammadi2,3, Yusri Taha4,5, Talal Al Goufi6 and Reem S. Almaghrabi1

Abstract
In recent years, the Middle East has witnessed a significant rise in commercial transplantation activities. This practiceis driven by a multitude of factors including economic disparities, inadequate healthcare infrastructure, and cultural
attitudes towards organ donation. In this article, we try to explore the complex landscape of commercial transplantation within the Middle East, shedding light on the ethical, legal, and socio-economic dimensions of this contentious
issue.
Keywords Commercial transplant, Transplant tourism, Middle East
Background
Organ transplantation remains one of the most important advances in medicine. However, myriad medical
and ethical challenges persist. Ensuring the safety of bothorgan donors and recipients is of utmost importance. The
persistent shortage of organs despite increasing demands
is fueling illicit organ trade worldwide, especially in theMiddle East region [1]. Regional conflicts exacerbate theissue, affecting organ supply and demand in the area.
According to the World Health Organization (WHO),
commercial transplantation involves the exchange oforgans or tissues for profit, posing legal and ethical difficulties such as exploitation and inequitable access [2].

Human body ownership
The more ethically challenging question is; do we as
humans have full autonomy over our bodies, including
the right to sell our organs? Some human rights advocates assert the individual right to bodily autonomy
encompasses organ sales. However, critics do highlightthe possibility of exploitation of the less fortunate individuals who may feel pressured due to financial desperation to sell their organs, which argues against the idea of
autonomy being influenced by economic inequality andsystemic pressures. This contentious debate centers on
the intrinsic value of human life and dignity and emphasizes that certain aspects of human life are not profitable.

*Correspondence:
Reem M. Alameer
F1504050@kfshrc.edu.sa1
Section of Transplant Infectious Diseases, Organ Transplant Centerof Excellence, King Faisal Specialist Hospital and Research Center, Riyadh,Saudi Arabia
2Department of Internal Medicine, Division of Infectious Disease, Tawam
Hospital, SEHA, AlAin, United Arab Emirates
3Emirates Infectious Diseases Society, Emirates Medical Association,
Dubai, United Arab Emirates
4
Department of Infectious Diseases and Microbiology and Virology,
Newcastle Hospitals NHS Trust, Newcastle Upon Tyne, UK
5Section of Infectious Disease, Department of Internal Medicine, King
Faisal Specialist Hospital and Research Center, Riyadh, Saudi Arabia
6Saudi Center of Organ Transplantation (SCOT), Riyadh, Saudi Arabia

Islam and commercial transplant
Religious perspectives in the Middle East, including
Islamic countries, add complexity to the issue. In Islam,humans are considered stewards of their bodies, with astrong emphasis on preserving life and avoiding harm.
Selling organs may be deemed harmful, particularly if it
exploits or endangers the seller’s health. However, Islam
encourages organ donation without financial gain as anact of charity. Regulations in Islamic countries often aim
to prevent the commercialization of organ transactions
to protect vulnerable individuals from exploitation [3].
Limited literature exists on the perspectives of Middle© The Author(s) 2024. Open Access This article is licensed under a Creative Commons Attribution-NonCommercial-NoDerivatives 4.0
International License, which permits any non-commercial use, sharing, distribution and reproduction in any medium or format, as longas you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons licence, and indicate if
you modified the licensed material. You do not have permission under this licence to share adapted material derived from this article orparts of it. The images or other third party material in this article are included in the article’s Creative Commons licence, unless indicatedotherwise in a credit line to the material. If material is not included in the article’s Creative Commons licence and your intended use is not
permitted by statutory regulation or exceeds the permitted use, you will need to obtain permission directly from the copyright holder. To
view a copy of this licence, visit http://creativecommons.org/licenses/by-nc-nd/4.0/.

Alameer et al. BMC Medicine(2024) 22:322

Eastern individuals on this issue. A survey conducted in2010 examined the attitudes of the Omani population
toward transplantation. It was promising to find that 65%
of Omanis were aware that commercial transplantations
contravene Islamic and international norms, highlighting
a growing awareness and adherence to ethical standards
in organ transplantation within the region [4].

International organ trade
The 2008 Istanbul Summit marked a pivotal moment,
urging nations to condemn commercial transplantationand promote ethical organ donation, raising awarenessabout organ trafficking. This sparked a global commitment against trafficking, with significant scientific interest since then [5].
To date, international organ trade persist and eventhriving. Global Financial Integrity (GFI) reported in2020, that international organ trade generates approximately 1.5 billion dollars annually from selling roughly
12,000 illegal human organs and tissue. According to GFIestimates, prices offered to individuals for their organs
show significant variation. Payments for kidneys, forexample, range from hundreds of dollars for individuals from less developed countries to as much as $20,000to $30,000 in more developed nations [6]. Organs areobtained through coercion, exploitation, or criminal
means including kidnaping and killing of the victims.
This market thrives due to indigenous organ shortage
with some Middle Eastern countries having waiting lists
up to 10 years. Equal access to healthcare is a major principle that applies in medical communities. Nevertheless,the act of organ trade favors the affluent, disadvantaging the financially challenged. Proponents of commercial organ transplants do argue that donor compensation
increases the rate of donation which aids in saving lives
and overcoming shortages. However, commercial transactions may compromise medical protocols, leading to an
inadequate screening of donors and recipients, exposing
both parties to infection transmission, and surgical andimmunological complications that increase the rate ofharm leading to an increased rate of life lost instead ofsaving them.
Current situation in the Middle East
Organ trafficking in the Middle East has its own uniquedynamics, influenced by conflicts like those in Syria andIraq, while other countries in the region witnessed economic and industrial revolution. Literature on organ
donation in the region is scarce [7]. However, in an earlier study from 2007, it was documented that in Oman(in 2003), there were 83 cases of living nonrelated renaltransplants conducted abroad (in Iran and Pakistan).
Similarly, in Saudi Arabia (in 2006), 646 renal transplants

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were performed outside the country, while 351 renaltransplants were carried out domestically [8]. Current
data from across the region is crucially required to assess
the situation accurately.
In times of crisis and rising poverty, people may resort
to selling their organs for profit, particularly vulnerable
refugees [9, 10]. Commercial transplant targets those indire circumstances, while citizens of more stable nations
as in the Gulf region, may engage in transplant tourism
due to organ shortages and long waitlists [11]. Between
the largely impacted areas by war and the more stablecountries in the region, governments should combat
organ trading and raise awareness about the dire consequences of commercial transplantation (transplant tourism) on both donors and recipients.
In response to ethical challenges, Middle Easternnations like Saudi Arabia have implemented strict policies against commercial organ transplants. Saudi Arabia recognized early on the risks of transplant tourism
and the exploitation of vulnerable individuals, as well as
health hazards like infection transmission and surgicalcomplications. Saudi Arabia has enacted laws prohibiting
profit from organ donation and imposing severe penalties on those involved in illicit organ trade [12]. The Saudi
Center for Organ Transplantation (SCOT) oversees aframework prioritizing the well-being of donors andrecipients. Similarly, the UAE’s Federal Decree Law No(5) of 2016 bans the sale of human organs and tissues fortransplantation [13].

Iran’s legal organ trading
While most Middle Eastern countries reject organ trading, Iran stands as an exception with a regulated systemallowing kidney donation for financial gain. The Iranianmodel of kidney transplantation (IMKT) was established in 1988. The government of Iran has established aunique, well-regulated, system that permits kidney donation in exchange for a financial gain by the donor. In Iran,the Kidney Foundation (KF) arranges matches betweendonors and recipients. Both donors and recipients register with the foundation and undergo needed medicalassessments. Once a matched pair agrees on a price, payment is processed through the KF, which notifies transplantation centers overseen by the Ministry of Health.
The government covers transplant costs and provides
donors with 1 year of medical coverage and potential
military exemption. Unlike the commercial transplant
practice, the medical team does not receive payment andthe recipient bears most of the cost as government compensation [16].
While this system allows for monetary compensation
for kidney transplantation but does not tolerate transplant commercialism. The system aims to overcome theAlameer et al. BMC Medicine(2024) 22:322

shortage of organ donors in the country while reducing
rates of illegal organ trade in the black market [14–16].
Donors in the IMKT are supported by law and protectedby medical insurance. Donors get paid by the recipient
and the government pays a reward to donors, a fixed 10
million Rials, equal to about 1200 USD, called the gift ofaltruism [16]. However this practice in Iran is heterogeneous and varies from one city to another with some cities like Shiraz has a growing black market [16]. Critics,
including some medical professionals, raise ethical concerns regarding the impact on donors’ health and wellbeing [15]. Some reports suggested negative impacts on
donor physical and mental wellbeing [15]. Despite its
potential, Iran’s model requires stringent laws ensuring
ethicality and equality to safeguard donor and recipient
welfare.

Role of the healthcare worker
Healthcare workers face ethical dilemmas when patients
consider commercial transplant. Torn between saving
patients’ lives and ethical concerns regarding commercial transplant, our role is to ensure patient well-being
and raise awareness about the risks of commercial transplantation for both donors and recipients. In Oman, a2015 survey found that the main reason for consideringcommercial transplantation was the lack of live-relateddonors. Shockingly, the second most common answer
was a concern about the risks of organ donation on
the health of family members being organ donors [17].
Patients often overlook the risks donors face, regardlessof kinship. The healthcare worker’s role extends beyond
individual care to broader advocacy for systemic change
in the practice. The medical community shapes policies
to ensure a safe and ethical organ donation process freefrom financial interests and human harm.
Proposed solutions
Addressing commercial organ transplants in the Middle
East requires a collaborative, multidisciplinary approach.
While conflicts persist, prioritizing solutions for refugee
issues is crucial. Both medical and non-medical communities must address the refugee crisis and prevent
organ trafficking. Initiatives promoting voluntary donations through awareness campaigns are vital. By fostering
altruism and emphasizing donation importance, communities can sustainably reduce reliance on commercial
transactions.
Conclusion
As we grapple with this ethical conundrum, a collaborative dialog between medical professionals, ethicists, religious scholars, and policymakers is essential. Finding abalance that addresses the urgent need for organs while

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upholding ethical standards, minimizing health risks,and preserving the integrity of healthcare professionals
is crucial for the region’s healthcare system. The Middle East stands at the forefront of a global discussion on
the future of organ transplantation a future that must be
shaped by careful consideration, emphasizing empathy
and universal well-being over financial status.
Acknowledgements
Not applicable.
Authors’ contributions
RM. A. formulated study conception, intellectual input, wrote the manuscript, final approval of published version. AA. A. Participated in intellectualinput, revision of the manuscript, final approval of the published version. Y.T.
Revised the manuscript, final approval of the published version. T.A. Revised
the manuscript, final approval of the published version. RS. A. Participated inintellectual input, revision of the manuscript, final approval of the publishedversion.
Funding
This research received no external funding.
Availability of data and materials
No datasets were generated or analysed during the current study.

Declarations
Ethics approval and consent to participate
Not applicable.
Consent for publication
Not applicable.
Competing interests
The authors declare no competing interests.
Received: 27 March 2024 Accepted: 29 July 2024

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