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Kidneys still for sale

Print edition : Dec 13, 1997 T+T-

The buying and selling of kidneys, which is unethical and exploitative of the poor, was outlawed in 1994, but still thrives thanks to a built-in loophole in the law. And the easy availability of kidneys for a price has retarded the growth of the cadaveric transplant programme.


S. SUBHASH, 35, and R. Govindan, 37, both from the small town of Pallipalayam in Namakkal district in Tamil Nadu, were deep in debt. Subhash ran up a debt of Rs.35,000 after the tea shop he owned caught fire; Govindan, a powerloom worker, borrowed Rs.45,000 when his daughter was married. With their creditors pressing them to pay up and nowhere to go, each decided - not without reluctance and a feeling that it would all come to no good - to sell an asset he did still possess, a kidney.

Kidneys, they knew, are commodities easily marketed in centres of renal transplantation, notably Chennai and Bangalore. Hundreds of others from their town and the nearby town of Kumarapalayam had done the same thing for the same reasons, and both knew how to take their kidneys to the market.

They met a broker who was delighted to find them buyers. Subhash pledged his kidney to a cinema theatre owner from Taramangalam in Salem district, for a promise of Rs.45,000; and Govin-dan his to a lorry owner from nearby Sankari. After the surgery was over, Govindan received the promised amount of Rs.35,000 while Subhash received Rs.30,000, one-third less than he was promised. They paid back a part of their debt but began to borrow heavily once again. They were weak and unable to work as earlier. Neither has visited a doctor since the surgery. Subhash is already in debt to the tune of Rs.25,000, Govindan of Rs.10,000.

The transactions of which Subhash and Govindan were victims, the buying and selling of kidneys, are punishable by law - by the Transplantation of Human Organs Act, 1994. All organ sales that have taken place after the Central Act was adopted by various States have occurred owing to an escape clause built into the Act. Both Subhash and Govindan had to convince an official committee, the Authorisation Committee, that they were "donating" their kidneys to the people who bought them because they were motivated by feelings that were non-commercial and altruistic.

They told Frontline that this was easy enough. Each was tutored for a day by the broker and the buyer. Dressed in new clothes and with a caste mark on his forehead, Subhash appeared before the Authorisation Committee in Tamil Nadu with the fiction that he was the cinema theatre owner's nephew. His tutors had ensured that he could produce a staged photograph of himself with his 'uncle's' family to show how close he was to them. Govindan too posed as a relative of the lorry owner from Sankari. His interview before the Authorisation Committee was over in five minutes, he recalled.

Scores of similar poverty-driven sales of kidneys have taken place in Karnataka and Tamil Nadu after the Act was adopted. These unethical and exploitative transactions have been put through by misrepresentation to an Authori-sation Committee only too willing to believe the fiction.

THE Transplantation of Human Organs Act, 1994 was adopted by several State governments in 1995, the year in which the Bangalore police cracked down on an organised kidney trade of alarming proportions (see Frontline, March 10 and July 28, 1995). In recent years, Bangalore and Madras (Chennai) have specialised in kidney transplantation, developing this programme in several competitive hospitals and even nursing homes. A doctor-broker nexus profiteered from the sale of kidneys by poor Indian donors to rich Indian and, to a shocking extent, foreign, patients with End-Stage Renal Disease (ESRD).

The Act was supposed to end the trade in human kidneys. It forbids organ donation from anyone except a "near relative", defined in the Act as a mother, father, brother, sister, son, daughter or spouse. It makes punishable, with a prison term ranging from two to seven years and a fine of between Rs.10,000 and Rs.20,000, the offence of purchasing an organ for money or money's worth. It recognises, for the first time in India, the concept of brain-stem death, thus clearing the decks legally for the development of a cadaver-based organ transplantation programme.

The Act, however, is far from watertight (see box on Page 67). Its biggest leak springs from a clause, Sub-section 3 of Section 9. This lays down that an unrelated donor, for reasons of "affection or attachment towards the recipient," may donate his or her kidney provided the donation is approved by the Authorisation Committee. Since the Act came into force, this clause has provided a cover for hundreds of illegal cash-for-kidney deals. ESRD patients in Karnataka and Tamil Nadu have claimed blatantly false emotional and altruistic attachment to prospective donors and made misrepresentations before the Committees to secure approval for what are in fact outright commercial transactions in kidneys. And it is not as though the Authorisation Committees and the government authorities concerned, including the police, are unaware of the racket. What they have done is to turn a Nelson's eye to it.

Dr. M.K. Mani, Chief Nephrologist at the Apollo Hospitals in Chennai, who is a leading opponent of the paid-donor transplant programme on the grounds that it is exploitative of the poor and hampers the growth of a cadaver-based programme, points out how this provision is abused. In his column 'A letter from Chennai' in the September-October 1997 issue of The National Medical Journal of India, the eminent specialist, a pioneer of kidney transplantation in India, wrote: "The stalwarts of the unrelated live donor programme continue to do as many transplants as they did before the Legislative Assembly of Tamil Nadu adopted the Act. What is more, they do them with the seal of approval from the Authorisation Committee, and are therefore a very satisfied lot. The law, which was meant to prohibit commercial dealings in human organs, now provides protection for those very commercial dealings." Dr. Mani's article is titled 'The Law is an Ass'.

In a developing country where there are pockets of medical excellence comparable with the best in the world on the one side, and a large population of the poor who are easy victims of medical malpractice on the other, the ethical dimension of human organ transplant programmes assumes particular importance. This is particularly so given the glaring absence of a national public health service in dialysis for people with renal disease.

A Frontline team examined the impact of the new legislation on organ transplantation in Tamil Nadu and Karnataka. These States lead the country in the number of cases of renal transplantation, and, less creditably, lead it in renal commerce as well. Efforts to analyse the experience of Maharashtra, another important centre, were hampered by the fact that the State's Health Services Director, Dr. S. Salunkhe, and members of the Authorisation Committee proved quite inaccessible, for reasons known only to them. A Frontline correspondent made repeated efforts to contact Dr. Salunkhe - on the telephone, by fax and by calling on his office - but all this came to nothing. Dr. Salunkhe did give one appointment, but failed to keep it. Hence, the impression among specialists, that Maharashtra's record of observance of the Transplantation of Human Organs Act, 1994 is distinctly better than the record of the two southern States, could not be verified or confirmed.

THE 1994 Act very sensibly provides for registration of hospitals claiming to have the necessary competence and facilities to perform particular organ transplantation. This is a regulatory measure intended to protect the interests of patients. It is with the Appropriate Authority, set up by the State government under the Act, that hospitals intending to do transplants must register. Approvals are granted only after the institutions fulfil certain technical, infrastructural and medical requirements. In Tamil Nadu, 34 of the 50 hospitals that were doing organ transplants before the Act have got approvals. In Maharashtra, 20 hospitals are authorised to perform transplants. In Karnataka, 14 hospitals have been given a five-year certification of registration.

ACCURATE data on the number of kidney transplants done in Tamil Nadu and Karnataka are hard to come by. Transplants may be subdivided into cadaveric transplants, live transplants from "relatives" as defined by the Act, and live transplants from others for which clearance is required from the Authorisation Committee. According to data given to Frontline by the Appropriate Authority in Tamil Nadu, the total number of organ transplants in Tamil Nadu from June 1995 to September 1997 was 1,243, of which 403 were from unrelated donors. This is, however, likely to be a slight underestimate, since independent inquiries with hospitals indicate an undercounting of the number of cadaveric transplants performed.

In Karnataka, the Appropriate Authority was not able to provide Frontline with official data on the consolidated number of renal transplants performed in the State. Data obtained from individual hospitals put the number of renal transplants performed in Karnataka at 474 since 1995. There are no accurate data on the proportion of transplants from unrelated donors, although hospital-wise information indicates that the share was at least 36 per cent between 1995 and 1997. Hospitals and the Foundation for Organ Retrieval and Transplant Education (FORTE), a Bangalore-based non-profit trust that is helping put a cadaver programme in place in Bangalore, told Frontline that no cadaveric transplants have been done in Karnataka.

The immediate impact of the Act was a decline in the number of renal transplants in the two States. It is noteworthy that the Act seems to have stopped the flow of foreigners coming to India for kidney transplants. Doctors in Bangalore, however, reported that a number of patients were still coming from Bangladesh, bringing their "donors" with them.

Before the Act came into force, it was not illegal to pay for a kidney, and there was a steady stream of rich ESRD patients from abroad - largely from West Asia, Malaysia and Singapore - to Chennai, Bangalore and Mumbai. A network of brokers, and some doctors too, arranged for them to procure kidneys from poor donors. The precise number of foreign patients who came then is not known, but an idea can be gained by these data provided to Frontline (issue dated March 10, 1995) by Dr. S. Sundar, Nephrologist and Director, Karnataka Nephrology and Transplant Institute (KANTI): of the 184 patients who underwent renal transplants under the KANTI team in Bangalore in 1994, around 50 were from Bangladesh, 30 from Malaysia and 20 from West Asia. Of the 181 renal transplants performed by the KANTI team since 1995, about 60 were on patients from Bangladesh.

According to hospital-wise data from Karnataka collected by Frontline, the number of renal transplants in the State fell from 354 in 1994 to 149 in 1995, the year after the Act was passed. Corresponding data were not available for Tamil Nadu, but several doctors involved in renal transplants reported a similar decline in their hospitals. According to Dr. R. Ravichandran of the Vijaya Health Centre, Chennai, there was a 25-30 per cent drop in the number of transplants performed at the Vijaya Health Centre and at the Malar Hospital after the Act. Dr. K.C. Reddy of Willingdon Hospital, who runs an active kidney transplant programme, estimates that the number of transplants has come down by 40 per cent.

However, Dr. J. Amalorpavanathan, Transplant Coordinator at the Government General Hospital, Chennai, says that after a "brief lull, in fact, a halt" in kidney transplantation in Tamil Nadu immediately after the Act was enforced, the number of transplants has been increasing. He concedes that his is an "impressionistic assessment" in the absence of any hard data, especially from private hospitals; nevertheless the number of transplants has "come to the level that prevailed before the Act."

In Karnataka, according to data from the 14 hospitals authorised to perform organ transplants, 354 transplants were performed in 1994; the number fell to 149 in 1995, rose marginally to 160 in 1996, and rose further to 165 in the first 10 months of 1997.

THE main finding of Frontline's investigation is that a brisk commerce in kidneys exists within and across the States, and that the flow of kidneys is always from the poor to the rich. Although many ESRD patients have middle-class backgrounds and often find it difficult to meet the costs of treatment, their economic status contrasts with the abject poverty of the donors.

Villivakkam is the Chennai suburb that gained international notoriety in the mid-1990s for its profusion of kidney donors. It is still possible, with the right contacts which are easily made, to walk into Villivakkam and find a donor who will sell a kidney to fit a patient's specific needs. A Frontline correspondent in Chennai who attempted to "buy" a kidney as part of her investigations received six offers (four from brokers and two from hospitals) between October 1 and 3. In Bangalore, Frontline correspondents who made enquiries met with similar success. In an afternoon's visit to a major hospital in Bangalore, there were two offers for kidneys, one from a broker and another from the wife of a man who was recovering from a transplant.

In the powerloom towns of Pallipalayam and Kumarapalayam in Tamil Nadu (see Pages 73 to 76), the numbers of those who sold their kidneys before the Act appear to run into hundreds. Frontline met two persons, R. Govindan and S. Subhash, who had sold their kidneys after the Act came into force, and learnt of eight others who were at that time in Bangalore or Chennai to sell their kidneys.

Transplants involving live unrelated donors "will always be from the poor, and the poor cannot protect themselves from the possible ill-effects of the donation," wrote Dr. Mani in The Hindu of August 19, 1990. "This is one form of exploitation of the poor, and I think it reprehensible for anyone, most of all medical practitioners, to take part in it."

This central truth behind the trade was confirmed by Frontline's independent investigations. The live unrelated donors whom its correspondents met were, without exception, poor - and in most cases, desperately poor. Powerloom workers deeply in debt, manual labourers, slum dwellers, in one case a bank employee who needed money, and a hotel worker.

IN the two years since the Act came into force, middlemen (and women) have reappeared, and they have learnt how to manipulate the new law. Brokering is explicitly banned by the Act under threat of severe penalties, but continues nevertheless. "The trade which was taking place in an open market earlier is now happening in a covert market," said Dr. Chikkananjappa, President of the Karnataka Medical Council, which uncovered the kidney racket involving doctors and brokers in Bangalore hospitals in 1995.

There was a time when middlemen operated brazenly: one broker even used to flash a card inscribed "Government Approved Kidney Agent"; another is reported to have had tables in the canteen of a well-known nursing home in Chennai reserved for him with a board saying "Kidney Agent". That is no longer the case, but the broker is still in the picture and shows much ingenuity.

Sekhar, a broker in Pallipalayam town who used to hold public meetings of prospective donors every Sunday, went underground after he was beaten up by a group of protestors led by activists of the local unit of the Communist Party of India (Marxist). He is back at work, but operates clandestinely.

Some brokers started as donors themselves. For instance, Palaniyamma from Pallipalayam has arranged several sales in the post-Act period, and reportedly works for a bigger broker in Namakkal. In Villivakkam, Frontline's correspondent met former donors Lakshmi and Tamilarasi (names changed on request), who made offers of kidneys.

In Bangalore, Frontline correspondents met five brokers who arrange kidneys for patients at two well-known hospitals. One of them said that in addition to the Rs.60,000 that was the cost of the kidney, he would charge Rs.10,000 to have the deal okayed by the Authorisation Committee.

There is substantial money to be made in the trade. A kidney costs the recipient between Rs.50,000 and Rs.70,000; of this, the broker takes about Rs.20,000 to Rs.25,000 as his commission. In keeping with the growing sophistication of the trade, the commission is higher if the blood group is rare or if there are caste or language specifications.

WITH organ sale now illegal, those private hospitals and doctors who used to play a direct role in arranging, and profiting from, cash-for-kidney transactions can no longer do so. However, there are hospitals in which doctors or other hospital employees are known to put patients in touch with brokers or prospective donors through other patients who have used the broker's services.

Frontline found that in respect of live donor programmes, hospitals that do renal transplants fall into four categories. The categorisaation is based on information given to Frontline by the hospitals and on independent verification.

The first category is made up of hospitals that do not transplant kidneys from any donor who is unrelated, under the meaning the Act, to the recipient. This category comprises the Sri Ramachandra Medical College and Research Institute (which also does cadaveric transplants) in Porur near Chennai and the Kasturba Medical College and Hospital in Manipal, Karnataka. A potential member of this category is the Air Force Command Hospital in Bangalore. The hospital has been authorised to perform renal transplants, but has yet to begin to do so. Doctors at the hospital told Frontline that their live donor programme will involve only relatives as defined by the Act.

A second category of hospitals screens donors in order to try and ensure that they are actual relatives, although not necessarily related as defined in the Act, and that no coercion or commercial transaction is involved in the donation. Transplantation from those other than near relatives is done only after obtaining approval from the Authorisation Committee. This category includes Apollo Hospitals in Chennai, the Christian Medical College and Hospital in Vellore in Tamil Nadu, and St. John's Hospital and Bangalore Hospital in Bangalore. These hospitals do not do renal transplants when the donor is not a relative on the grounds that these are unethical and exploitative of the poor and, moreover, would be illegal in most cases. CMC, a pioneering, highly regarded and accessible institution, relaxed the ban on transplants involving unrelated donors in 1982 but reimposed it in 1985. Dr. Chakko K. Jacob, who heads the renal transplantation unit, said: "We realised quickly that there was a lot of money in the transactions for kidneys and that it was unethical. Also the 'donors' were invariably from among the poor."

The third category consists of hospitals which do not go into the antecedents of the live unrelated donors and simply leave it to the Authorisation Committee to decide.

Finally, there are hospitals where doctors - or, in some cases, receptionists and Public Relations Officers - put prospective recipients in touch with patients who have used brokers. Two leading hospitals in Bangalore and an established one in Chennai are in this dubious, law-breaking category. In the latter, a doctor offered to put Frontline's correspondent, who posed as someone whose relative needed a kidney, in touch with "people who can help you find a donor." The doctor's conduct was clearly prosecutable under the 1994 Act.

THE function of the Authorisation Com-mittee in each State is to screen applications from recipients and "unrelated" donors and grant approvals only to those cases where it is convinced that the donor is offering his or her kidney for love and not money. Given the built-in loophole, it is the strictness and conscientiousness of the Authorisation Committee in a State that determine how far the Act can meet its objective of ending commerce in human organs. In Tamil Nadu, 1,153 cases came up before the Authorisation Committee between May 1995 and May 1997; of these, 517, just under 50 per cent, were rejected. In Karnataka, the Committee rejected merely 9 out of 90 applications in 1997.

Frontline's investigations and interviews with patients and donors reveal that the monitoring mechanism of the Authorisation Committees as they function today in Tamil Nadu and Karnataka has been largely ineffectual. These Committees have not been able to stop the thriving organ trade. Their attitudes and the consequential failure to weed out fraudulent claims of kidney "donation" are directly responsible for the relative strength of the paid-donor programme, and all the ills associated with it, vis-a-vis the live related and cadaver programmes. This is not to suggest that the Authorisation Committees are corrupt or are in league with brokers and unscrupulous doctors. But what is undeniable is that they are not doing the job entrusted to them under the 1994 Act. It bears emphasis that this failure is mainly a function of attitudes - to practical cases and to medical ethics and standards, against the backdrop of poverty and need and the rising demand for kidneys.

In practice, when a patient and an unrelated donor come before the Committee, they are asked for a Tahsildar's certificate, a ration card and a copy of the voters' list to establish the identity of the donor. The donor and the recipient are interviewed separately and questioned on details relating to the family. Now that the general pattern of questioning has been set, brokers have no difficulty in tutoring those who go before the Com-mittee.

The Committee does not enquire into the very real possibility, the probability, even the virtual certainty, of money changing hands in numerous cases. Nor does it seem to have any interest in referring suspicious cases to the police for investigation.

"It is difficult to establish whether money has changed hands," an Autho-risation Committee member explained in Bangalore. "We see if they know each other at least for a few years." Dr. Chikkanan-jappa, however, says: "If an unrelated person develops affection overnight, the catalyst can only be money." In Karnataka, according to an official source, the Com-mittee is under great pressure from doctors and hospitals to give approval to cases they are interested in. "There is a very big network operating here, with doctors, brokers, patients and donors involved. They have money power and muscle power," noted a senior Karnataka government official.

Dr. Mani's comment on the system, in his article 'The Law is an Ass', cannot be improved on: "Dozens of slum dwellers from Chennai have this great and transcending love for millionaires from Kanpur and Calcutta, whom they could not have met more than a few weeks earlier. Truly this is love at first sight."

In effect, the Authorisation Comm-ittees seek evidence of mere acquaintance. Such acquaintance is relatively easy to establish, particularly to a committee that is waiting to be convinced. "We basically want to help the person suffering from kidney failure," one Authorisation Committee member in Bangalore admitted to Frontline. In his article 'The Law is an Ass', Dr. Mani recounts responses from two members of the Authorisation Committee in Tamil Nadu when he asked them how they could bring themselves to sanction patently commercial transactions in kidneys: "One of them denied there was any commercial transaction at all. 'He tells me he loves the recipient. Who am I to say he does not?"' The other member's response was different. Dr. Mani quotes him as saying: "I sanction the transplant on purely humanitarian grounds. Some of the patients actually cry and beg that permission be given." However, Dr. Mani points out, "nowhere in the Act is there a clause which permits the sale of organs for humanitarian purposes."

COGNISABILITY of the offences under the 1994 Act does present a problem. The primary authority for initiating prosecution is the Appropriate Authority. (The head of the Appropriate Authority in Tamil Nadu is the Director of Medical and Rural Health Services, Dr. (Captain) M. Kamatchi; in Karnataka, it is the Director of the Department of Health and Family Welfare, Dr. V.G. Shetty.) The Act says that a court is to take cognisance of an offence under the Act when a complaint to it is made by the Authority or by a person who has given 60 days' notice to the Authority of an intention to file a complaint before the court. Again, it comes down mainly to attitudes - towards the well-established practice and towards enforcement of the law.

According to the Appropriate Authorities in Tamil Nadu and Karnataka, no prosecutions have been initiated in the two States since the Act was passed. This is surely suspicious, given the rampant nature of the trade. When you come to think of it, every case rejected by the Authorisation Committee is, prima facie, a fit case for police investigation.

Documentation obtained by Frontline reveals that the Appropriate Authority in Tamil Nadu is indeed aware - acutely aware - of violations of the Act. In a letter dated April 3, 1996 addressed to all hospitals and nursing homes that had applied for registration under the Act, Dr. Kamatchi, who is Chairman of the Appropriate Authority in Tamil Nadu, complained that "some of the nursing homes keep on sending commercial donors, which cannot be accepted." He added that "sometimes, they send the same rejected commercial donors to different patients," and warned that "it has been decided to hand over these people to police for prosecution." Dr. Kamatchi's letter explained that donors were not briefed by surgeons or medical officials about the dangers of undergoing nephrectomy and living with one kidney, and that many "boys and girls aged 20 years and unmarried are sent to donate kidneys for patients past 50 years." It emphasised that donors had to come from the same area as recipients: "There is already a criticism that the kidneys of the people of Tamil Nadu are being traded." It admitted that the Authorisation Committee actually received complaints regarding the illegal contracts involved in the kidney trade: "The Committee sometimes gets letters from next of kin of the Donors regarding payment problems." It also complained that some nursing homes lacked the basic facilities required of renal transplant facilities.

Dr. Kamatchi's circular letter to the relevant hospitals and nursing homes in the State is a remarkable admission, and indictment, of ground realities. It raises the fundamental question: why is the system so unserious about minimum enforcement of the law banning commerce and racketeering in human organs?

A RELATED, partly consequential, feature of the failure to enforce the 1994 Act is the slow progress made by the cadaver-based transplantation programme in the country as a whole. One of the main objectives of the Act in recognising brain-stem death was to facilitate a cadaver-based transplantation programme, which would ultimately replace the paid-donor programme. Yet it is the transplant programme involving live unrelated donors that flourishes.

Tamil Nadu has made a significant start in cadaveric kidney transplants, with Chennai's Apollo Hospitals accounting for 53 of about 110 cadaveric transplants performed in India, according to Dr. J.V. Thachil, Chief Urologist at the Apollo Hospitals, Chennai.

Doctors and FORTE in Karnataka confirm that not a single cadaveric transplant has been performed in Kar-nataka.

Doctors who oppose paid-donor transplants on ethical and social grounds also argue that as long as paid-donor transplants are allowed, the cadaver-based programme will not take off. They are not in the least opposed to transplants involving live related donors, which clearly confer advantages on the recipient from the standpoint of minimising the risk of organ rejection. Doctors and hospitals of a different character are beneficiaries of a donor-broker-recipient deal and a profit-driven hospital has a clear financial stake in keeping a paid-donor programme going. The plea of hospitals that prosper on paid-donor programmes - that they are unaware or innocent of the thriving trade in kidneys taking place in their very corridors - is quite disingenuous.

There are, no doubt, social, religious and other attitudinal barriers to cadaveric organ transplant in India, but these are not insurmountable, as Apollo Hospitals' very successful cadaveric transplant programme has shown. But as long as rich patients are able to buy kidneys from the poor at a price, there is no incentive for cadaveric transplants.

Dr. Mani makes this point forcefully in his article 'The Law is an Ass': "With a poor man's kidney available for the asking, and at a cheap price, why wait for a cadaver organ? Think of what would happen if the unrelated live donor programme did not exist. The patients who take unrelated live donor kidneys are by and large rich and influential. If they had to remain on dialysis they would exert pressure on the Government to do something to establish cadaver transplantation." This distinguished nephrologist is known to have refused to budge from his stand against the paid-donor programme when a senior Tamil Nadu Minister sought his help recently trying to locate an unrelated donor for a VVIP with ESRD.

Despite the well-established link between the paid organ transplant programme and organ trafficking, there are still many who defend it on the ground that it is a transition-phase necessity. Dr. K.C. Reddy, who has done close to 2,000 renal transplants in Willingdon Hospital, Pandalai Nursing Home and Guest Hospital, goes one step further in defending the paid-donor programme. In 1993, he coined the phrase "To buy or let die", arguing that "banning the (trade) option in order to remove the unscrupulous elements is like throwing the baby out with the bathwater". And how is the "monetary value" of the kidney to be determined? It depends on the country, he told Frontline. "In India, for instance, if the Government gives a compensation of Rs.25,000 to the family of an accident victim, then that is the price of a kidney."

This kind of reasoning, based on "harsh realities", conflicts with the ethical argument against a paid-donor programme. Which is to say that a human organ cannot be valued, particularly when it belongs to a person who is poor and therefore vulnerable to exploitation; the rich cannot - and must not - be allowed to prey on the poor for organs. Dubbing the practice of a paid transplant "totally unethical," the Canada-trained Dr. Thachil, who with his team has done hundreds of kidney transplants, says bluntly that it is criminal to exploit the poor in order to keep less than one per cent of the population alive.

"The loss of a vital organ and the risk to life is surely worth more than a few thousand rupees," argues Dr. Mani in his article 'The Law is an Ass'. Raising the fundamental issue of human rights, he notes that "the very idea (of paid-donor transplants) dehumanises the donor, and turns him into a biological machine which has grown the kidney."

Is the Transplantation of Human Organs Act, 1994 fundamentally flawed because, under specific Indian socio-economic conditions, Section 9(3) provides a cover for illegal and highly exploitative cash-for-kidney deals? The doctors interviewed by Frontline offered two different viewpoints. The radical view, held by Dr. Thachil and Dr. Mani, among others, is that even though there is a case for kidney donation based on genuine love and there is also a case for including second-degree relatives in the definition of relatives under the Act, Section 9(3) is so abused that it has to be scrapped - if the trade is to be stopped. The second type of medical opinion among those who want commerce in organs to be ended favours retaining Section 9(3) but ensuring it is rigorously adhered to.

The trade in kidneys in India constitutes a serious violation of the human rights of the poor and the vulnerable. Frontline's investigation shows that the law as it stands, medical and official attitudes towards it, and its overall non-serious observance have meant a shocking failure to respond to the social and ethical issues at stake.

This feature was written with inputs from PARVATHI MENON in Bangalore and Pallipalayam, ASHA KRISHNAKUMAR and V. SRIDHAR in Chennai, RAVI SHARMA in Bangalore and LYLA BAVADAM in Mumbai.