Harrowing but credible allegations indicate crimes against humanity in forced organ harvesting at scale from prisoners of conscience, writes Adnan Sharif. Medical journals should avoid potential complicity until China shows such claims to be false
In 2019, in London the informal China Tribunal concluded that crimes against humanity have been conducted (and are likely still occurring) in China, with the systematic murder of prisoners of conscience for their organs.  Parliamentary bodies in Europe, the United States, and Australia have also found this allegation credible. [2-4]
Organ donation and transplantation in China are largely secret: official statistics of donation and transplant activity are sparse, unvalidated, and have been systematically falsified, research shows. 
Implausible official data
China reported 19,462 solid organ transplants from 5818 deceased donors in 2019.  China used to source organs from judicially executed prisoners (not prisoners of conscience).  It used to deny this, then claimed the practice ceased in 2015. It now reports just 2.13 million people on its fledgling voluntary organ donor register. 
In any country, only a tiny fraction of registered donors die in circumstances that facilitate organ donation. In the UK last year, 26 million registered people yielded only 790 actual deceased donors (0.003%).  However, the UK system is well established, and positive public attitudes towards it yielded a further 790 non-registered actual deceased donors last year.[10,11]
Almost all the 5818 actual donors China reports therefore cannot have been registered on its voluntary system. But China has historically low public support for organ donation, and no evidence indicates that this has changed.  Organ donation may be terminated in China if just one close relative refuses permission. [13,14] Japan has similar cultural obstacles to organ donation and has failed over decades to change attitudes despite projects to raise awareness.  Very few of the explanted organs from deceased donors that China reports can have been donated voluntarily, therefore.
Far more transplants
In fact, evidence of a vast infrastructure of facilities and staff dedicated to big volume solid organ transplantation indicates that organ donation and transplantation activity far exceed China’s official figures, with estimates of up to 90,000 transplants a year.  The Tianjin First Center Hospital alone, for example, has boasted that its 46,000 m2 organ transplant centre had over 500 beds, enough for thousands of transplants a year. [17,18]
In addition, hospitals’ claims of improbably short waiting times, and reports of transplants scheduled in advance, could indicate organs available on demand.[1,7,18] This is possible with deceased donors only if the timing of death is known or planned.
Multiple prisoner of conscience eyewitnesses have described non-indicated medical testing and imaging consistent with organ donation requirements, corroborated by statements from whistle-blower healthcare staff. [1,18]
Persecution of minority groups like Falun Gong practitioners is Chinese state policy.  Recent concern has focused on Uyghur Muslims and their internment in concentration camps.[1,7,18] However, it is not necessary to be affiliated to Falun Gong practitioners or Uyghur Muslims (I am neither) to sympathise with their persecution or to be shocked by the allegations of mass killing for forced organ harvesting.
Collectively, the evidence was sufficient for the China Tribunal’s seven strong panel to infer unanimously, “beyond reasonable doubt,” that prisoners of conscience are being killed on demand to supply China’s highly profitable transplant tourism industry.[1,7,18] Take just one example, the Beijing 309 military hospital, which declared transplantation its most profitable revenue generator, growing from 30 to 230 million yuan between 2006 and 2010. 
No smoking gun
China dismisses external criticism as politically motivated or Sinophobia. It consistently denies that prisoners of conscience have ever been killed extrajudicially for their organs. China and others criticise circumstantial evidence, reliance on witness testimonies, and the lack of any “smoking gun” of incriminatory evidence.
However, independent verification is impossible in authoritarian China. China’s denial is affirmed by the global professional body The Transplantation Society (TTS), based on reviews of just a handful of hospitals on visits organised by China. When a 2006 report concluded mass organ harvesting from Falun Gong practitioners in China, TTS asked for the United Nations Commission for Human Rights to investigate.[22,23]
No investigation occurred. China has not agreed to repeated requests for inspection from organisations including the UN Committee Against Torture and Amnesty International. Representatives of China’s organ donor system, the World Health Organization, and TTS did not accept invitations from The BMJ to submit a counterargument to this article.
Research could be unethical
Given credible allegations, and absence of evidence to the contrary, can we be sure that Chinese practice conforms to international law and ethical norms? If not, research linked to unethical transplantation is itself unethical.
Many journals already have policies refusing transplantation research that uses organs from executed prisoners. However, more than 90% of 445 Chinese transplant-related studies published between 2000-2017 failed to conform to these policies, researchers found, warning journals of “complicity and moral hazard.” (Some journals subsequently retracted some of these papers.)
Although never officially endorsed by China, the Declaration of Istanbul prohibits organ trafficking, transplant tourism, and exploitation of donors. It requires authorities “be accountable for organ donation, allocation and transplantation practices to ensure standardization, traceability, transparency, quality, safety, fairness and public trust.” Persistence of allegations of forced organ harvesting damages public trust in organ donation, transplantation, and healthcare professions in general.
Concerns have been raised about illegal transplantation or transplant tourism in other countries, including Egypt, India, and the Philippines. But none are as opaque as China, which is unique for the allegations of state sanctioned mass forced organ harvesting from prisoners of conscience. Until independent investigators are allowed unhindered access for thorough inspection of organ donation and transplantation activity in China, we cannot accept unsubstantiated claims of reform.
Ensuring ethical practice in China requires a robust international response rather than flaccid engagement. Until practice in the country can be ethically assured, medical journals should decline translational or clinical transplantation research from China, especially when deceased organ donors are used.
Adnan Sharif, Department of Nephrology and Transplantation, Queen Elizabeth Hospital, University Hospitals Birmingham, Edgbaston, Birmingham, United Kingdom and Institute of Immunology and Immunotherapy, University of Birmingham, Edgbaston, Birmingham, United Kingdom
Competing interests: I have read and understood the BMJ Group policy on declaration of interests and declare the following interests: I am secretary of the international non-government organisation Doctors Against Forced Organ Harvesting.
Provenance and peer review: Commissioned; externally peer reviewed.
 China Tribunal. Final judgement and summary report. 2020. https://chinatribunal.com/final-judgement-report/
 European Parliament resolution of 12 December 2013 on organ harvesting in China. 12 December 2013. http://www.europarl.europa.eu/sides/getDoc.do?type=TA&language=EN&reference=P7-TA-2013-0603
 H.Res.343 – Expressing concern regarding persistent and credible reports of systematic, state-sanctioned organ harvesting from non-consenting prisoners of conscience in the People’s Republic of China, including from large numbers of Falun Gong practitioners and members of other religious and ethnic minority groups. 114th Congress (2015-6) US House of Representatives. 13 June 2016. https://www.congress.gov/bill/114th-congress/house-resolution/343/text
 Compassion, Not Commerce: An Inquiry into Human Organ Trafficking and Organ Transplant Tourism: Human Rights Sub-Committee. House of Representatives Joint Standing Committee on Foreign Affairs, Defence and Trade. November 2018. https://www.aph.gov.au/~/media/02%20Parliamentary%20Business/24%20Committees/244%20Joint%20Committees/JFADT/Foreign%20Affairs%20Defence%20and%20Trade/Organ%20Harvesting%20Inquiry/Full%20report.pdf
 Robertson MP, Hinde RL, Lavee J. Analysis of official deceased organ donation data casts doubt on the credibility of China’s organ transplant reform. BMC Med Ethics 2019; 20(1): 79.
 Global Observatory on Donation and Transplantation. http://www.transplant-observatory.org
 Sharif A, Fiatarone Singh M, Trey T, Lavee J. Organ procurement from executed prisoners in China. Am J Transplant 2014; 14: 2246-52
 Xu S D L. China to stop using organs from executed prisoners for transplantations BMJ 2015; 350 :h239
 Statista. Number of people registered to donate their organs in China from 2010 to June 19, 2020 https://www.statista.com/statistics/993334/china-number-of-registered-organ-donors/
 NHS Blood and Transplant: Organ Donation and Transplantation Activity Report 2019/20. https://nhsbtdbe.blob.core.windows.net/umbraco-assets-corp/19220/activity-report-2019-2020.pdf
 Optimisa Research: NHSBT Organ Donation 2013 research: Understanding current attitudes and behaviours towards organ donation within England. http://qna.files.parliament.uk/qna-attachments/885326/original/Optimisa%20NHSBT%20organ%20donor%20FINAL%20report%20140813%20(2).pdf
 Dandan N. The Long March to Changing Chinese Minds About Organ Donation. Sixth Tone. 16 March 2018. https://www.sixthtone.com/news/1001926/the-long-march-to-changing-chinese-minds-about-organ-donation
 Fan R, Wang M, Family-Based Consent and Motivation for Cadaveric Organ Donation in China: An Ethical Exploration. Journal of Medicine and Philosophy 2019; 44(5): 534–553
 Pan XT, Ma J, Liu W, et al. Investigation and Strategic Analysis of Family Barriers to Organ Donation in China. Transplant Proc 2020; https://doi.org/10.1016/j.transproceed.2020.09.017
 Akabayashi A. Nakazawa E, Ozeki-Hayashi R, et al. Twenty Years After Enactment of the Organ Transplant Law in Japan: Why Are There Still So Few Deceased Donors? Transplant Proc 2018; 50(5): 1209-1219
 Kilgour D, Gutmann E, Matas D. Bloody harvest / the slaughter. An update. 22 June 2016. https://endtransplantabuse.org/an-update/
 Major Events of Tianjin First Central Hospital. https://archive.is/8PGKB
 Robertson M. Organ procurement and extrajudicial execution in China: a review of the evidence. 8 Jun 2020 https://ssrn.com/abstract=3598791
 Department of Foreign Affairs and Trade. Country Information Report People’s Republic Of China. 3 October 2019. https://www.dfat.gov.au/sites/default/files/country-information-report-china.pdf
 China’s Organ Transplant Problem. https://thediplomat.com/2017/03/chinas-organ-transplant-problem/
 Wu Y, Elliott R, Li L, Yang T, Bai Y, Ma W. Cadaveric organ donation in China: A crossroads for ethics and sociocultural factors. Medicine 2018; 97: 10
 Matas D, Kilgour D, An Independent Investigation Into Allegations of Organ Harvesting of Falun Gong Practitioners in China. 6 July 2006. https://organharvestinvestigation.net/report20060706.htm
 Tibell A. The Transplantation Society’s Policy on Interactions With China. Transplantation 2007; 84: 292-294
 Rogers W, Robertson MP, Ballantyne A, et al. Compliance with ethical standards in the reporting of donor sources and ethics review in peer-reviewed publications involving organ transplantation in China: a scoping review. BMJ Open 2019; 9(2): e024473.
 Dyer O. Journals retract 15 Chinese transplantation studies over executed prisoner concerns. BMJ 2019; 366: l5220.
 Martin DE, Assche KV, Dominguez-Gill B, Lopez-Fraga M, Gallont RG, Muller E, et al. Strengthening Global Efforts to Combat Organ Trafficking and Transplant Tourism: Implications of the 2018 Edition of the Declaration of Istanbul. Transplantation Direct 2019; 5: e433
 Cyranoski. D. Startling China organ claims raise alarm about transplant research. Nature 2019; 570: 425-426