Voice of Nursing in Transplant Ethics — Moral Courage

By Deborah Collins-Perrica APRN, DAFOH

In recent months DAFOH, whose mission is to raise awareness, reports an increase in membership by registered nurses from around the world. These nurses are courageously and collectively acting on an international level to help see an end to unethical forced organ harvesting.

Transplantation is one of the most ethically challenging areas of modern medicine and nursing practice. There are many aspects of concern, including organ trafficking in several regions of the world, but there is one problem that goes far beyond human trafficking in organs: unethical forced organ harvesting from prisoners and detained prisoners of conscience in China. This urgent humanitarian crisis tops the list as a primary issue of concern. The breach of the commonly agreed to free, voluntary and altruistic organ donation has been happening for over three decades in China. This concerns nurses directly, and in professional roles nurses are acting to fight this as one of the worst violations of medical ethics in modern times.

Unethical forced organ harvesting, once a niche area of medical concern, has gained global attention and condemnation as patients in need of transplant organs leave home and travel to other countries as transplant tourists in search of rapid pay-to-order treatment. Although the problem occurs in several countries, it is only in China where it is approved by law and vastly practiced, yielding profits that are purposefully used to boost the financial budget of the country’s military-run hospitals. In addition to the known dependence on executed criminals for their organs in China, even more appalling is the unprecedented harvesting of organs from prisoners of conscience, innocent people who have different thoughts or spiritual convictions than their government.

Nursing Advocacy

This spring DAFOH nurse members published articles on this topic in two major international journals of medicine and nursing: Organ transplantation in China: concerns remain,” published in The Lancet; and, “Nurse calls attention to issue of forced organ harvesting: Unethical practice widespread in China,” in Reflections on Nursing Leadership by the International Honor Society of Nursing (STTI).

In June DAFOH nurses and doctors joined other advocates against forced organ harvesting in Washington D.C., visiting congressional representatives to offer the latest information about this human rights crisis, and requesting co-sponsorship for a bipartisan resolution that was recently re-introduced in Congress, House Resolution 343, concerning forced organ harvesting.

The current 114th Congress boasts five registered nurses serving as members of the House: Karen Bass (D-CA-37), Diane Black (R-TN-06), Lois Capps (D-CA-24), Renee Elmers (R-NC-02) and Eddie Bernice Johnson (D-TX-30). All of these reps welcomed DAFOH nurses in their offices by appointment to discuss increasing awareness and the urgent need to pass protective legislation to see an end of these human rights atrocities in China and prevent collusion in the U.S.

In Seoul, South Korea, DAFOH nurses hosted a successful education booth, visited by almost 10,000 nurses, doctors and healthcare providers at the International Conference of Nurses, 2015. The role of nurse advocates for human rights in the East Asia regions is in sharp contrast to the West due to cultural differences that discourage Asian nurses from speaking out (Corfee 2015). Gender inequality, the image of women as nurses and Confucian culture often prevent these nurses, and their nursing associations, from having a voice. The lived experience of nurses subject to taking part in this barbaric practice behind the iron curtain in Mainland China is unknown. Western nursing organizations might provide much needed support.

Korea conference booth    Korea conference booth table

Nurses hosting DAFOH nursing education booth at the
International Conference of Nurses, ICN, in Seoul, South Korea

When the American Nurses Association called on 3.1 million registered nurses to acknowledge 2015 as “The Year of Ethics in Nursing,” it was a request to actively take part in updating and revising nursing’s Code of Ethics. Today, situations requiring nurses to exercise independent professional ethical judgment to act in the best interest of patients and vulnerable persons are commonplace in the complex health care environment of organ transplantation and organ procurement. It is widely held that no nurse should be forced to violate professional and ethical standards, or be punished for refusing to do so, with whistle blower protection regulations in most jurisdictions in the U.S.

Concerned professional nurses are now seeking the support of guiding institutions in getting revisions and amendments to their respective nursing codes of ethics to include guiding policies in dealing with this urgent concern. This problem affects the nursing and medical professions and is not limited by state or national borders.

Currently, the International Council of Nursing, the Royal College of Nursing Australia, The Royal College of Nursing (UK) and the American Nurses Association do not have position statements on forced organ harvesting or transplant tourism, and this limits the effectiveness of nurses as a force for change. The role of nurses as advocates, working beside doctors and other healthcare professionals, is marginalized and this excludes nurses from being a legitimate part of the debate on how to prevent collusion and find solutions to the mismatch of organ demand and supply in our own communities and abroad.

In recent months the U.S. Congress, the European Parliament, the European Union and 14 county members, Italy, Taiwan, Israel, and Australia have acted to demand immediate investigation and/or criminalization of the unethical harvesting of organs for profitable rapid transplantation in China. In June, a group of doctors, lawyers, and international activists met in the Palais des Nations, the headquarters of the United Nations, to review and offer new evidence of ongoing organ harvesting in China, and again called upon the UN to open a full investigation of the matter. This action was the result of a highly successful international grass roots initiative supported by nurses with over 2 million people signing a DAFOH petition imploring the UN High Commissioner for Human Rights to act.


For cultural reasons, voluntary organ donation by citizens in China is taboo and donations are grossly inadequate to meet the country’s reported demand of at least 300,000 people needing transplants. Thus, China has endorsed it’s reliance on harvesting organs from executed prisoners. Yet, in December 2014, China responded to growing international pressure regarding its transplant practices by announcing the cessation of involuntary organ procurement from executed prisoners by January, 2015.

Without an organ source China has not shut down transplant operations. Instead, an unprecedented offer was made (and rejected by Taiwan) to trade in organs with Taiwan, and to advertise transplant tourism opportunities.

In addition to ignoring global condemnation, China has now attempted to white wash it’s actions by re-defining prisoners as “citizens” who, by virtue of their citizenship, have the right to “voluntarily” donate organs as free people do in other countries. This is in violation of WHO, and all other governing medical authorities.

But, prisoners of conscience are not convicted criminals. Of urgent concern is that China, despite extensive evidence from international sources, has not publicly admitted to dependence on exploiting prisoners of conscience, does not allow any transparency, and is not cooperative in ensuring that ethical standards are met. This makes any announcement to end the killing by 2015 a hollow promise. International ethical guidelines clearly state that prisoners, deprived of their freedom are not in the position to guarantee free, voluntary donation, and one cannot guarantee that coercion by the prison is not involved. There is actually no process or right for appeal for death row candidates in China and executions usually take place within seven days after the death sentence.

Investigators report that prisoners of conscience are persecuted, detained, tortured and medically monitored in prisons and re-education camps and make up a living organ donor bank for China’s lucrative transplant industry. Renowned for the health benefits of their spiritual practice, Falun Gong adherents are reportedly the primary organ source, with minority Uyghurs, Tibetans, and House Christians also subject to this atrocity. Investigative journalist and China expert, Ethan Gutmann, reports that organ transplantation financially supports China’s military hospital system and is a highly profitable billion dollar business. In the past decade a rapidly growing transplant industry, with over 160 facilities, developed in China turning forcibly harvested kidneys and livers from prisoners into $200,000 in profit per body, reducing a human being into a biomass almost overnight. Everyone is making money off of it-the middlemen, the doctors and hospitals, the pharmaceutical companies and many others.

Using official testimonies from survivors, victim’s families, investigator reports, Chinese healthcare professional’s accounts, and China’s own public data it is estimated that tens of thousands of prisoners have been killed for their organs in China since about 2000. In 1989, the Tianaman Square Massacre, with the killing of an estimated 3,000 students, became common knowledge for concern and condemnation globally, and everyone stood in opposition. But, 30 to 50 times more people have been executed in China for forced organ seizure, this being prorated over the last 15 years, and the global outcry has been muffled. Can the massacre go on unnoticed and unopposed just because it is kept in secret and insidiously distributed over the years? Do the numbers drive the degree of concern, or is the murder of even one vulnerable person harvested important enough for the world to take action?

In conclusion, nurses have an obligation to face these challenges with courage, confidence and skill, needing education, guidelines and protective legislation. A nurse’s unwitting inaction may adversely affect patient wellbeing and fail patient advocacy. With ethical and legal issues at stake when and how do nurses decide to act within long held guidelines meant to ensure moral restraint? Are nurses mandated, as whistle blowers, to truthfully report instances of collusion with transplant abuse, and if so, to whom should they report?

As a profession, nurses have a vested interest in health policy and human rights, and according to their codes of ethics around the world, should act as benevolent leaders in human rights to promote ethical practices with an enduring voice to speak for those who do not have a voice.


  1. ANA Position Statements on Ethics and Human Rights; https://www.nursingworld.org/MainMenuCategories/EthicsStandards/Ethics-Position-Statements
  2. Collins-Perrica, D. (2015). Nurse calls attention to issue of forced organ harvesting: unethical practice widespread in China. Reflections on Nursing Leadership. The International Honor Society of Nursing (STTI). May, 2015; https://www.reflectionsonnursingleadership.org/Pages/Vol41_2_NoteFeature_Collins-Perrica.aspx
  3. Collins-Perrica, D., & Kerr, L. (2015). Organ transplantation in China: concerns remain. The Lancet. February, 2015; https://www.thelancet.com/journals/lancet/article/PIIS0140-6736(15)60485-8/fulltext
  4. Corfee, A.(2015). Transplant tourism and organ trafficking: ethical implications for the nursing profession. Nurs Ethics. May 22, 2015.
  5. Gutmann, E. (2014). The slaughter: mass killings, organ harvesting, and Chinas secret solution to its dissident problem. Amherst, NY: Prometheus.
  6. Matas, D., & Trey, T. (Eds.). (2012). State organs: transplant abuse in China. Seraphim Editions, Niagara Falls, ON, Canada.
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  8. South Korean media coverage of DAFOH at the ICN. (Korean); https://media.daum.net/press/newsview?newsid=20150623094822632; https://www.newswire.co.kr/newsRead.php?no=795593; ICN media coverage. https://en.minghui.org/html/articles/2015/7/1/151344.html (Retrieved from the Internet 7/12/15)
  9. Whistleblower Protection Laws for Healthcare Workers. National Nurses Unitedhttps://www.nationalnursesunited.org/pages/whistleblower-protection-laws-for-healthcare-workers. (Retrieved from the Internet 7/19/15).
  10. WHO | The state of the international organ trade: a provisional picture based on integration of available information. https://www.who.int/bulletin/volumes/85/12/06-039370/en/ (Retrieved from the Internet 7/24/15).