In April 2015, a paper in the Journal of Medical Ethics welcomed the ban by the Chinese government as “a step in the right direction,” but noted that China remains plagued by a crucial shortage in available organs.
Some academics disagreed with the authors’ take on the issue, noting that the paper fails to note that many organs may continue to be harvested from Chinese prisoners of conscience; ultimately, the journal received a letter asking to retract the paper. The journal decided not to, and instead asked the authors to issue a lengthy correction, for instance changing the language about the government decision (“law” became“guideline”), and allowed critics to publish a rebuttal to the paper in May 2016.
One of the authors of the May rebuttal told Retraction Watch that she still believes the original paper should be retracted, as even the corrected version provides a “very positive” and “sanitized” account of organ procurement in China.
A WELCOME MOVE?
For years, Chinese officials have neglected to provide data about the number of organ transplants in the country, and the source of these organs.
In February 2015, a study published in Liver Transplantation revealed some worrying figures — namely, that the number of transplants was much higher than the number of voluntary donors. Specifically, a total of 6416 transplants from 2326 voluntary donors was carried out between April 2011 and August 2014. Here’s a graph from the 2015 paper:
Furthermore, the Red Cross Society of China organ donor registry has reported 7667 transplants in just 2015. As the rebuttal to the Xiang et al study notes, however, an investigation into transplant numbers by the Tianjin First Central Transplant Centre found that an estimate of around 5,000 liver transplants took place in 2015 within that one institution alone.
All these figures raise a pressing question: Where are all the extra organs coming from?
Many have long suspected that the additional organs have come from executed prisoners. But according to a 2015 government release (added to the 2015 paper by Yu-Tao Xiang at the University of Macau in China and colleagues as part of its correction in 2016):
On Jan 1 this year, China banned the use of executed prisoners’ organs for transplants, making donations by citizens the only legitimate source.
In “China to halt using executed prisoners’ organs for transplants: a step in the right direction in medical ethics,” — which yet to be cited, according to Thomson Reuters Web of Science — Xiang et al write that the move from the government has been received with “ambiguity” from the public. On the one hand, it is a “great step” to protect prisoners, but on the other, it will reduce the number of organs available for transplants. They add:
China has one of the lowest levels of organ donation with only 0.6/1 000 000 people offering organs while alive or postmortem. The low donation rate finds its explanation in the traditional Confucian culture teaching that the body is offered by the parents at birth and therefore it must be kept intact after death; otherwise, the soul cannot be reincarnated.
But the authors of the rebuttal, “Smoke and mirrors: unanswered questions and misleading statements obscure the truth about organ sources in China,” which is yet to be indexed, claim that Xiang and colleagues are misrepresenting the facts by claiming that prisoners are no longer a source of transplanted organs in China:
When Chinese officials announced that organ harvesting from executed prisoners would end by January 2015, they did not include prisoners of conscience, leaving legal and regulatory loopholes regarding this vulnerable population. Claims about new guidelines to create an ethical source of transplant organs in China distract attention from this question, while keeping silent on the fact that the 1984 provisions permitting the use of organs from prisoners remain in force.
Data on the number of executed prisoners remains a “state secret,” note the rebutters, led by Wendy Rogers from Macquarie University in Sydney, Australia:
Amnesty International no longer publishes estimates of judicial executions in China, commenting only that ‘available information indicates that thousands of people are executed and sentenced to death in China each year’ (ref. 10, p. 2). Dui Hua estimates that 2400 prisoners were executed in 2014. By contrast, in the same year, 35 prisoners were executed in the USA.
Rogers and her co-authors write that the language of the Xiang et al paper remains misleading:
…when people are being killed for their organs, a mere ‘step in the right direction’ is insufficient and unacceptable in medical ethics.
Rogers told us the correction to the paper is not adequate:
The article still presents a very positive and sanitised account of organ procurement in China, one that cannot be supported by a rigorous examination of the available evidence. As we argue in the rebuttal, there is a lot of what seems to be deliberate confusion and obfuscation about the numbers of organ transplantations occurring in China. Various figures are published in different places; there is no consistent reporting; and practices that are initially denied (eg of organ harvesting from executed prisoners) are later acknowledged.
She voiced further concerns about policy-making around organ procurement in China:
…China is trying to convince the world that it has established an ethical system of organ donation and that this article was part of that effort. But as we point out in the rebuttal, there is no new regulation banning the use of organs from executed prisoners…The lack of legislation makes it difficult to believe that China is serious about stopping the use of organs harvested from prisoners, including prisoners of conscience.
The Xiang et al paper is “so poor” that is should be retracted, added Rogers.
The editors of the Journal of Medical Ethics, however, disagree, and have sent us a statement explaining their decision:
We subsequently received a letter of complaint calling for the paper to be retracted. This was discussed at length by the editorial committee and we decided that the threshold for retraction had not been reached but that publication of a correction, along with a response from the authors of the complaint letter, would be appropriate. We felt that although the Xiang et al. paper may have given a misleadingly positive impression of the ethical progress that had been made in China in this area due to (i) the omission of information about ongoing unethical practices and (ii) the use of the term ‘new law’ for an announcement with no robust legal standing, it did not contain clear evidence of bad faith on the part of the authors nor clear factual errors that could not be dealt with via publication of a correction and response. In addition, the changes required to the paper would not have altered the decision to publish had they been present in the original.
We suggested a correction and response as a way forward to the lead authors of the original manuscript and the complaint letter, and there was no disagreement from either. We asked the authors of the original manuscript to draft a correction, ran this by the lead author of the complaint letter, and requested revisions to the correction in the light of the comments that the lead author of the complaint letter suggested. The correction was then revised accordingly and ultimately published. We have also since published the response piece written by the authors of the complaint letter.
Like many issues in medical ethics, this is one on which there are strong views and contested arguments and factual claims. In general our approach at the Journal is not to censor controversial viewpoints or claims, but to encourage open debate. There are fundamental differences between papers written in scientific journals (which present scientific evidence) and those in ethics journals (which analyse and debate evidence from elsewhere). It is generally not appropriate in ethics journals to retract material on the grounds that others disagree with the substance of the views presented.
We’ve previously reported on another case of authors retracting a paper which suggested that most students from one Chinese institute held negative views about cadaveric organ donation; the retraction was criticized for being a consequence of political criticism.
Here’s a link to the the mega-correction notice the journal issued for the paper in March 2016, in which they revise the language of the original paper, saying they “misrepresented the term ‘law’” and changing references.
We’ve reached out to Yu-Tao Xiang, and we’ll update the post with anything else we learn.
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