The illicit Organ Trade: Biographical, Anatomical, Economic and Legal Aspects

e-ISSN 2690-3458 ISSN 2690-3431 JOURNAL OF ACADEMICS STAND AGAINST POVERTY Volume 6, 2025: pages 86-102 Research Paper Journal of Academics Stand Against Poverty, 2025, 6, 86-102 The Illicit Organ Trade: Biographical, Anatomical, Economic and Legal Aspects Nater Paul Akpen College of Health Sciences, Benue State University, Makurdi, Nigeria. ORCID: 0009-0009-0446-1043 Email: akpennat[email protected] Abstract: A kidney can cost up to $ 200,000. Humans have two kidneys but normally require just one to live. Individuals can donate one to relatives for altruistic reasons. But to pay $ 200,000 - or any other amount - to obtain a kidney, no country in the world allows that. Except for Iran. This global blanket ban has pushed the trade of organs underground and it now ranks as the fourth most lucrative illegal activity – behind only drugs, arms, and human trafficking. Rising incidence of end-stage kidney disease will increase demand for replacement kidneys, both gifted and bought. This essay studies this trade using two case studies, one of a Nigerian leading legislator arrested in the UK for getting a kidney for his daughter and another on kidney demand in Iran where trade in organs is permitted. The global value of the trade is studied, and literature gaps are discussed. The inadequacies of the current system are highlighted and improvements suggested, based on best practices around the world. Keywords: 1. Organ trade 2. Organ donation 3. Organ transplant 4. Kidneys 5. Altruism 6. Nudging 2025 Journal ASAP DOI: 10.5281/zenodo.17591291 Received 4 May 2025 Revised 15 October 2025 Accepted 7 November 2025 Available online 12 November 2025 1. Background With organs damaged beyond natural and surgical repair, and with no artificial equivalents, patients were once doomed to certain death. In the 1950s, the success of organ transplantation surgery marked a notable change (Duguay, Hermon, & Smith, 2020). From then up to the present, transplantation has saved many lives. The organs for transplantation are sourced from human donors – either deceased individuals (especially in the cases of the heart, pancreas, and liver) or living individuals (especially kidneys and other tissues) (Ambagtsheer, 2017). By far, the kidney is the most sought-after organ and the most traded; it can be derived from the dead or the living. A kidney can cost up to $ 200,000 (Dahlkamp, Hofner, Hoffman, & Latsch, 2025; Caplan, Dominguez-Gil, Matesanz, & Prior, 2009). Humans have two kidneys but normally require just one to live. Individuals can donate one to relatives for altruistic reasons. But to pay $ 200,000 - The Illicit Organ Trade Journal of Academics Stand Against Poverty, 2025, 6, 86-102 87 or any other amount - to obtain a kidney, no country in the world (except Iran) allows that. That is, any kidneys bought or sold are done so illegally. This essay holds that the ban on organ trade has pushed organs “exchange” underground. As an illegal activity, organ trade now ranks as the fourth most lucrative illegal activity – only behind drugs, arms, and human trafficking. With increasing end-stage kidney disease, the demand (both for donations and purchases) for replacement kidneys would increase (de Jong, et al., 2013).. With this demand, the importance of the topic is heightened as without action, it would solidify its status a setting for systematic and persistent exploitation of both the poor who may have kidneys to sell, the sick who may have few options for organ replacement. The conclusions of this essay will be arrived at through a review of published literature. 2. A history of organ trafficking With organs damaged beyond natural and surgical repair, and with no artificial equivalents, patients were once subjected to death. In the 1950s, the success of organ transplantation surgery proved to be a notable change (Duguay, Hermon & Smith, 2020). From then up to the present, transplantation has saved many lives. The organs for transplantation come from human sources – dead humans (especially in the case of the heart, pancreas, and liver) or living humans (especially kidneys and other tissues) (Ambagtsheer, 2017). By far, the kidney is the most sought-after organ and the most traded; it can be harvested from the dead or living. With transplantation success attained in the 1950s, it soon became evident that the demand for organs outweighed the supply. The absence of a normal legal market for those organs meant that a black market for organs was going to occur. Thus, in the 1980s, the earliest reports of commercial organ trade were made, and it concerned poor Indian citizens who were selling kidneys to foreign patients; nearly 80% of kidneys procured in Indian hospitals were transplanted into patients from the Middle East, Malaysia, and Singapore (Bos, 2015). A retrospective Lancet1 report at the time had documented 131 Emirati and Omani patients who had travelled to Bombay, India – along with their doctors – and received kidneys from local "donors" who were paid. At the time, the authors of the Lancet report were not so concerned with the commercialisation of the kidneys – which was, if not illegal, repugnant. The concern then was the post-operative complications – not on the “donors” who were losing a kidney – but on the recipients who were gaining new kidneys (Salahudeen, Woods, Pingle, et al., 1990). In 1994, India passed an outright law, the Indian Transplantation of Human Organs Act, which made buying and selling of human organs illegal. However, this did not slow the market; the opposite was the case: over three hundred citizens of Chennai, India sold a kidney within the six years from 1994 – 2000 (Goyal, Metha, Schneiderman, et al., 2002). Given the underground nature of the trade, figures such as these may be significant undercounts. In 1988, there was a high-profile case of organ trafficking that resembled the Ekweremadu affair. For a start, it took place in the United Kingdom. It involved a well-known nephrologist (i.e., a specialist kidney doctor), an unnamed wealthy patient, and an unknown Turkish citizen . The patient had put out an advertisement in Turkish newspapers that he was in search of a kidney donor. Anyone who was willing to donate and matched the criteria was going to be paid 2000 – 3000 British Pounds. The Turkish citizen was found to match all criteria; he was recruited and taken to London for the procedure at the facility of this well-known surgeon. The donor had a letter of introduction that stated the patient was going to be supported and cared for after the transplantation. When this scheme was discovered, the nephrologist and 1 The Lancet is among the most prestigious medical journals in the world. Akpen, 2025 other doctors involved in the case lost their practising licenses. This time, the UK Human Organ Transplant Act had not yet come into force; the perpetrators had no criminal charges brought against them. It was simply a case of the medical profession disciplining members of their rank for unethical practice. The law came into force later that year (Price & Mackay, 1991). In 2000, Latvia and Germany were found to be involved in cross-national organ trafficking. The Latvian State Forensic Medical Centre had delivered human tissues to Tutogen, a German company. The German company in turn paid "compensation" to the Latvian Medical Centre. These transactions took place from 1994 to 2003 and involved the tissues of more than four hundred deceased persons. Relatives of these deceased persons, such as Ms Elberete (whose husband was the deceased) found out about this practice and reported it to the police as the tissues had been harvested and sold without consent. Criminal investigations were commenced. These investigations were concluded in 2005. The verdict? No one was found guilty (Olsena, 2008). In 2015, the case was reopened and was heard at the European Court of Human Rights. The case was Elberte v. Latvia (application number 61243/08). The court ruled that "taking and selling the tissues without consent constituted a violation of articles 3 and 8 of the European Convention of Human Rights (degrading treatment, lack of respect to private life)". On Article 8, the Court noted it was the right of Ms Elberte to consent to the removal of her husband’s tissues and that the domestic authorities had failed to provide the legal and practical conditions for exercising this right. Given the large number of people from who had their tissues removed, it was more important that proper mechanisms existed to help with the expression of wishes regarding the experts’ discretion on the matter. The court thus concluded that Latvia breached the article by not having “adequate legal safeguards against arbitrariness”. On Article 3, the Court found that the suffering of Ms Elberte extended beyond the death of a husband – she had only discovered the nature and number of tissues removed from her husband’s body during the European Court proceedings It emphasised that respect for human dignity was at the core of the European Convention. The Court’s conclusions were that the suffering caused to Ms Elberte was “degrading treatment”, an affront to dignity and thus contrary to the Article. The court-mandated the Latvian authorities to pay financial compensation (European Court of Human Rights, 2015). From Africa to Asia to Europe, and the Americas, there is a presence or the potential for the existence of organ trafficking operations. It is as much a health-related question as it is a legal question – as has been touched upon and as would be discussed more fully in the following sections. 3. A biographical sketch of Sen. Ike Ekweremadu: Case study “Ike Ekweremadu … you have been convicted of conspiracy to commit an offence of human trafficking. You brought a young man to London to exploit him. The exploitation was the proposed donation of a kidney in return for a reward, the reward being money and a chance to work in the United Kingdom.” [Sentencing Remarks of Mr Justice Johnson, Central Criminal Court, 5 May 2023] Mr Ike Ekweremadu and his wife Beatrice were absent at their son, Lloyd’s wedding. This is unthinkable in the Nigerian context as it is the parents of the bride and groom who fret over every aspect of the wedding ceremony. A grand wedding is the greatest honour that a parent gives to their children. The Illicit Organ Trade Journal of Academics Stand Against Poverty, 2025, 6, 86-102 89 While the parents were absent as they were commencing prison sentences in the United Kingdom, ministers of the central government, two former heads of the Nigerian legislature, and politicians of the highest calibre were present. In his down moments, Mr. Ekweremadu was not abandoned. Indeed, Lloyd, the new groom, was made a government commissioner in his state. How much influence could Mr. Ekweremadu wield from prison? The cream of Nigeria’s elite attended his event while he was in prison, and a much-respected former Nigerian president wrote officially to the United Kingdom government (perhaps influenced by the arguments of lobbyists) requesting that Mr Ekweremadu be pardoned (Aworinde, 2023). If Mr Ekweremadu could appear to command such consideration from prison, could the kidney donor who had reported Mr Ekweremadu hope to remain safe in Nigeria? Perhaps, this provides a glimpse into the arguments that were made in court by the defendants. More broadly, this shows the sophistry and seriousness of international organ trafficking. Mr. Ekweremadu was born in 1962 – two years after Nigeria's independence from Britain (Ijaseun, 2022). His father was an Igwe, head of a royal family, from Nigeria's Eastern region among the Ibos, that fiercely independent and entrepreneurial ethnic group who call themselves the Jews of Africa. When he completed secondary school (i.e., high school), he earned the highest distinction possible – a Grade 1. This was an early step in his ladder climb. For a university education, he chose to study law. He trained at the University of Nigeria, Nsukka (UNN). He was admitted to the Nigeria Bar in 1987. Thereafter, he topped things up with master’s and Doctorate degrees. His entry into politics was at the grassroots. Even here, he excelled: he was named the Best Local Government Council Chairman of the Year. With this A grade in grassroots politics, he moved a step higher. He became chief of staff to the governor of his state and later became the cabinet secretary of the same state. From here, he contested elections and won a senatorial seat in 2003. He was re-elected four times in 2007, 2011, 2015, and 2019. He was the deputy Senate president of Nigeria from 2015 to 2019. He soon outgrew the ponds of Nigeria, becoming First Deputy Speaker of the Economic Community of West African States (ECOWAS) parliament. After 20 years as a senator, he had plans to retire from the senate chamber. That he is now holed up in a British prison is not the climactic conclusion that he would have hoped for. His crime? He had conspired to harvest a kidney in the United Kingdom. He was not doing this for financial reasons (Judiciary of England and Wales, 2023). His daughter, Sonia, was diagnosed with nephrotic syndrome and needed a kidney transplant. The conspiracy was that Mr Ekweremadu got the individual from whom the kidney was to be harvested to pose as both an altruistic donor and a relative. This individual was no donor and was no relative (Judiciary of England and Wales, 2023). In the absence of an altruistic donor, Mr Ekweremadu's sick daughter would have been added to an organ transplant waiting list. No organs are legally sold on the open market. Kidney transplants are not only repugnant but illegal in all countries of the world except Iran (Ambagtsheer, 2017). Mr Ekweremadu fell from grace because he attempted to purchase a kidney in a country where it was illegal to do so. As the UK's prohibition of the organ trade renders conduct such as Mr Ekweremadu's illegal, it enables criminal syndicates to operate in the UK an underground organ harvesting market that cannot flourish in Iran (due to the legality of buying organs). Moreover, demand for organs is more easily met through financial incentives mobilized by a market than through reliance on altruistic motives, which results in long waiting lines for kidney transplants and many patients not receiving needed replacement kidneys. Prohibition of trade in organs fuels criminality and fails to meet the needs of patients. Akpen, 2025 Why do people sell their body parts? How does regulation affect the illicit financial flows attributable to organ harvesting and trade? How large is this trade? Examination of these questions can start with a brief history of organ trafficking. 4. The anatomy of an organ trafficking operation The organ trafficking operation is organised and complex. Like the human anatomy, which is organised and complex, organ trafficking has many moving parts. The figure below gives a sense of this. Figure 1. Basic modes of trafficking in human beings for the removal of organs Source: OSCE (2020) The broker is the centrepiece of the organ trafficking operation. The broker is the head or the heart – if not both head and heart – of the operation. Naturally, the other facilitators are instrumental in the whole operation. However, the brokers are the sine qua non of the whole operation. One may think that the recipient of a kidney the donor, or the skilled surgeon should be the most critical component of the operation: this is not the case. An attempt at connecting the donor and the recipient is maze-like, often circuitous, and labyrinthine. It is the broker who can navigate this labyrinth and bring the willing buyer in contact with the willing seller. The broker contacts nearly all facilitators of the operation; the recipient contacts only the broker (aside from the operating surgeon). That is, the recipient The Illicit Organ Trade Journal of Academics Stand Against Poverty, 2025, 6, 86-102 91 would make no real “business-like” contact with any of the other facilitators except “surgical contact” with the medical professional and "organ contact" with the donor. 4.1. Defining a broker While the definition for a broker is bereft of uniformity, the following has been offered: An intermediary between a kidney buyer and seller who connects the two using his/her knowledge of medical personnel and facilities that engage in illegal transplantations. The broker’s key asset in this market is his/her greater knowledge of other stakeholders to whom the seller does not have direct access. (Yea, 2010) At the head of an organ trafficking syndicate is a broker who usually has an international character and is a founder of the criminal network. The broker is the strategic manager of the whole operation and usually makes first contact with potential recipients (through the Internet or verbal recommendation). The broker sometimes approaches suppliers directly or commissions scouts to search for willing individuals. It is also not rare for suppliers to eventually become brokers themselves (Caplan et al., 2009). With most networks, the broker further establishes and regulates the supply of recipients, receives, and passes on all payments, and oversees the matching and recruitment of organ suppliers (Bos, 2015). That the broker has sole access to the organ recipient is key to the profitability of the organ trafficking operation. As would be seen, from an economic standpoint, the recipient pays the most and from a health standpoint, he gains the most. Through a tactful manipulation of the economic status and health needs (sometimes desperate health needs) of the organ recipient, the broker emerges as the biggest winner of the organ trafficking operation. There may be more than one broker in large transnational networks. But always, the broker would aim to set prices for the transplant operation that would be most profitable to himself (Codreanu et al. 2013). Doctors, directors of hospitals or tissue-matching laboratories may be the brokers. lso, retrospective evidence arising from actual prosecutions shows that the more the brokers acted as “business executives” the more likely it is that vulnerable people would be donors (Bos, 2015). Brokers commonly exploit suppliers’ vulnerabilities – mostly poverty and illiteracy – through deceit, coercion, abduction, or fraud (Yea, 2010). For example, a broker had told a Brazilian supplier that he was going to be “healthier with just one kidney” (Scheper-Hughes, 2011). There is no medical evidence supporting this: it is all deceit. A Hindu supplier had to undergo circumcision to pass as a relative of his Muslim recipient (Moniruzzaman, 2012).2 Passports are often seized after border crossing to ensure that the suppliers cannot return to their countries of origin without first “donating” their kidneys. The brokers also organise a scheme to deceive the authorities. Suppliers are coached on questions they would be asked and how they would respond to them, and how it is important to deny that they would receive any kind of payment for the organ that they were “donating.” In the Ekweremadu affair, Dr Obeta was the broker. The kidney supplier in the affair was promised residency and employment in the United Kingdom. Dr Obeta had also arranged for false documents that strove to show the supplier as a relative of the Ekweremadus. 2 While Muslims are required by their faith to be circumcised, Hindus are not. Akpen, 2025 4.2. Suppliers Some brokers have insisted that some suppliers have approached them themselves, put pressure on them to arrange for organ sale and have been “disappointed, frustrated or angry” if they fail to pass medical tests and are therefore ineligible to supply a kidney (Yea, 2010). Some researchers consider such suppliers victims of “systemic” vulnerabilities and exploitation (Lundin, 2012). Moreover, coercion is typically low at recruitment and increases progressively as the transplantation nears (Moniruzzaman, 2012). As the process for selling the kidney unravels – the need for surgery (for one who perhaps has never had surgery), international travels (sometimes through dangerous illegal routes), and post-donation complications, the donor’s resistance to the sale increases. If the donor knew all these earlier, his recruitment would most likely have been unsuccessful. It is therefore clear that “information asymmetry” is an important principle in the broker-supplier relationship (Mendoza, 2010). 4.3. Brokering in court Testimonies against brokers in the law courts are rare: recipients and suppliers tend not to file complaints against them, as such brokers rarely get sentenced. This is especially pitiable as the broker is the most important member of the organ trafficking network. It is possible that they also benefit the most from the enterprise – indeed, they may be the very ones that make it lucrative. They may also be the only ones that can make a business out of organ trade: there are just so many kidneys that a recipient would need, or a supplier can donate within a lifetime. Doctors, hospitals, recruiters, etc. can make also make a business out of organ trafficking. Without them, the business cannot even exist. But the pay differential between say the surgeon and the broker is wide – wide enough to suggest that a surgeon cannot fund a trafficking network – unless and until he becomes a broker himself. This is often the case whereby surgeons, hospitals, enforcers, and local recruiters can become brokers. Indeed, a Turkish company, Trans Transplantsyon, had offered kidney transplant services to UK citizens, amongst others. The transplantations were to take place in India or Russia; the fee was 22, 000 British Pounds. They had facilitated four hundred successful transplants; had operated in continental Europe for over six years and had planned to set up an office in London (Bos, 2015). Trans Transplantyson fit the role of broker – four hundred times over. In the Ekeweremadu affair, the broker was sentenced. But even then, his jail time was less than the sentence of the other defendants. This is consistent with literature elsewhere (Codreanu et al., 2013). 5. Quantity surveying of the illicit organ trade At its most fundamental level, the purpose of the organ trade for the broker is exploitation to obtain material or financial benefit. The greater the exploitation, the greater the benefits that are obtained. Organ trade consists overwhelmingly of kidney trade (as kidney diseases that require kidney transplants are usually end-of-life cases thus heightening the urgency and propensity for exploitation) (de Jong et al., 2013). As a result, estimations of the financial aspects of organ trade take kidney trade as a point of reference from which to extrapolate. Information gaps exist that make estimation of the financial aspects of the illicit organ trade difficult. These gaps will be discussed below. Once their discussion is exhausted, the best available data on illicit organ trade will be examined from three standpoints. Namely, the cost of buying, the cost of selling, and the link between buyers and sellers. The Illicit Organ Trade Journal of Academics Stand Against Poverty, 2025, 6, 86-102 93 5.1. Accounting for literature gaps Organ donors do not meet organ recipients. However, after a successful transplant, organ donors meet with the money of organ recipients. How does this happen? Most studies are silent on the institutions or actors from whom donors receive their payments. While the role of brokers or middlemen is established, other actors receive payments. These include physicians, staff of hospitals, and various kinds of companies. If literature does not identify these individuals, whatever figure is arrived at may only capture sums due to brokers and suppliers. This is the first gap in illicit organ trade literature. Second, it is unclear how money flows in the illicit organ trade. Because bank accounts are often not owned or used by the poor, money is paid to organ suppliers (who are usually poor) by hand (Tong, et al., 2012). This makes it unclear how much is exchanged concerning organ transplantation. Transaction also do not leave a trail for determining inbound and outbound funds – assuming that courts give warrants to eliminate bank secrecy. Brokers and transplant doctors and hospitals may also be paid this way. Consequently, figures reported upon may only represent those of one or a few members of an extensive, often cross-border, operation. Taken together, these two gaps make estimating the profitability of the illicit organ trade is difficult – perhaps an impossibility. (Anecdotally, the exchanges between donor and recipient can be known through interviews of past donors and recipients and covertly posing as either donors or recipient.) However, it is a lucrative business as the succeeding paragraphs within this section would show. 5.2. The cost of buying Many people find organ trade repugnant and hold that organs should not be sold or bartered (Roth, 2015). That is why organ buying is often called "organ donation" and paid-for organs are often described as "gifts". These euphemisms are used to escape or weaken the prevalent repugnance. Buying is used here to convey certain points with greater clarity. The individual buying the organ is the organ recipient (the one who originally paid money for the organ and the one whose body would eventually house the bought organ). The World Health Organisation and Council of Europe estimate that the amount paid for a kidney range from $10,000 to $200,000 (Dahlkamp, et. al., 2025; Caplan, et al., 2009). These figures are dependent on the buyer's country of origin. Buyers from Turkey, Egypt, and Korea paid sums that ranged from $20,000 to $75,000 per kidney (de Jong, et al., 2013). In Pakistan, local buyers were charged differently from foreign buyers: while local buyers were charged $2,800 - $13,500, foreign buyers paid $20,000 - $30,000 (de Jong, et al., 2013). In the Philippines, a kidney could cost a buyer anything from $65,000 to $85,000 (Turner, 2009). An Israeli syndicate charged Israeli kidney buyers $100,000 to $120,000; non-Israeli kidney buyers were charged $125,000 to $135,000 (Lundin, 2012). In 2012, a US organ broker confessed to selling kidneys to buyers who paid $160,000 (Cohen, 2013). In some of these cases, there are disparities between what is paid by the local buyer and foreign buyer. Guesses may be made about the origins of these disparities. First, buyers paid for packages that in addition to the kidney they were buying included screening, transportation, accommodation, organ transplantation costs, and hospital stay costs (de Jong, et al., 2013). Disparities may have therefore arisen for the cost of international travel, for example. Second, committing a crime across international borders may have required bribing officials from different countries (immigration, customs, health regulation officers, etc) to get cover – and more so than would have been required for local transplants. Akpen, 2025 Third, there may have been a disparity between local and foreign transplants as foreign buyers may have been thought of as having greater facility for payments. This pattern is seen, for example, in the tourism industry where tourists are charged differently from locals. Fourth, it may be logistically difficult to match foreigners to local kidneys. Organ transplantation has the greatest chance of success when the tissue type of the donor matches that of the recipient. Thus is a transplant between identical twins is usually a nearly perfect transplantation situation. Potentially, the foreigner may significantly differ from most of the available local donors. The difficulty in getting a suitable donor would translate to higher fees. The buyer has no direct financial gain from “buying” a kidney – in a comparable way that the buyer of a Ferrari has no direct financial “gain” from buying the luxury vehicle. Whatever financial benefit may arise indirectly whereby the kidney buyer lives for longer and thus may be economically productive for longer. His real benefit is a medical one whereby by buying a kidney he or she reverses what a death sentence. 5.3. The cost of selling The price received by sellers, just like the price paid by buyers, varies worldwide. Individuals have received between $1000 and $2500 as payment for their kidneys or liver in countries such as India, Pakistan, Bangladesh, Colombia, and the Philippines (de Jong, et al., 2013). In Iran, where organ trade is legal and regulated by the government, sellers are paid a standard $1,219 by the government and buyers may reward sellers with gifts (de Jong, et al., 2013). In Israel and Turkey, sellers have been given between $7,500 and $20,000 (Mendoza, 2012). In a 2003 criminal case, police found that an international organ trade syndicate paid up to $20,000 to individuals for kidneys but later discovered that poor Romanians and Brazilians were willing to accept far less (de Jong, et al., 2013). As far as the cost of selling goes, it appears that the poorer the seller, the lesser the price. But poverty is only one factor that drives the costs of organs down. In the same criminal case, it was found that going rates of $10,000 due to sellers went down as the sellers were in excess – a sort of "donor/seller waiting list”. Prices for the organs went down to $3,000 (de Jong, et al., 2013). The same pattern was seen in Bangladesh where the average selling cost of $1,400 per organ went down due to abundant organ supply. Supply is therefore a factor affecting the cost of selling in the illicit organ trade. Other factors are desperate need for cash, lack of pricing information, seller’s reference point and context ($1000 is a plump sum for an individual who earns $100 per annum; it would not be plump for one who earns $500 per month). But the selling costs discussed above are only the agreed-upon costs. It sometimes varies from what individuals are eventually paid. Sellers are usually paid on an incremental basis with the balance to be paid when the transplant is done. It has been reported that 25-50% of the amount negotiated by the seller is often withheld indefinitely (Tong, et al., 2012). Non-financial costs of selling a kidney are the following: declining health status, inability to do labour-intensive work, and thus worsening economic conditions. It appears, therefore, that selling a kidney does not erase the very conditions that may have necessitated the sale in the first place. 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