Suffering from bile duct cancer and with no family to support him and little money for treatment, Xu Bao, 35, vowed that if he suffered an early death he would give something back to society. He decided that he would donate his corneas to fellow Chinese waiting for transplants.
It was a remarkable gesture in a country where organ donations are rare, and executed prisoners have been the main source of transplant organs. Local news media in Hefei, the city where Mr. Xu was being treated, gathered at his hospital bedside in April to report as he signed documents declaring his intentions. Representatives from two organizations, the Red Cross Society of China office in Mr. Xu's home province of Anhui and the Aier Ophthalmology Hospital, came to finalize the arrangements.
Then, Mr. Xu said, things turned ugly. The two representatives challenged each other over whose organization would have the rights to his corneas.
''They started to argue,'' Mr. Xu said in a telephone interview. ''They treated me as if I were just a commercial transaction. I said, 'You people really have no conscience'.''
The experience soured him on the idea, and he decided not to donate, after all.
The story reinforced public doubts about organ donations, long an uncomfortable subject in China. Traditional values and suspicion of underground organ sales have contributed to China having one of the world's lowest rates of voluntary donations. This in turn has contributed to a reliance on organs from executed criminals, a practice that has been widely criticized in China and abroad as unethical, given that the consent of the condemned is not considered entirely voluntary under the circumstances. The system also raised suspicions that prisoners were executed to meet the demand for transplant organs. One Chinese doctor even testified to a U.S. Congressional hearing in 2001 about removing skin from a prisoner who had been shot in the head but was not yet dead.
In recent years China has begun taking steps to reform its troubled transplant system. In 2009 the Ministry of Health established a pilot program, which is being expanded nationwide, to match donated organs with patients in need, to reduce the chances of wealthy, connected patients jumping to the head of the line. The government has reduced the number of hospitals permitted to perform transplants in order to check the secretive black market organ trade. And state-run news media have begun promoting voluntary donations, with donors and their families given extensive, heroic coverage.
Health officials say their target is to end the use of organs from executed prisoners next year. China does not disclose the number of executions or organs harvested from prisoners, but in 2009 the state-run newspaper China Daily reported that more than 65 percent of organ donations came from executed prisoners. Human rights groups have called China the world's leading executioner, putting to death as many as 8,000 people in 2006. But that number appears to have declined with the reduction of crimes carrying the death penalty and the requirement, starting in 2007, that the Supreme People's Court review death sentences. Dui Hua, a San Francisco-based human rights group, estimated in 2011 that the annual number of executions had dropped to about 4,000.
The decline in executions is reducing an already inadequate supply of transplant organs.
''Relying on prisoners for organs is a dead end,'' Huang Jiefu, a transplant surgeon tasked with fixing China's donation system, said at a conference in December. The estimated 10,000 transplants carried out annually are dwarfed by the 1.5 million Chinese who are awaiting organ donations, according to health officials.
Efforts to encourage voluntary donations have had a slow start. In the previous three years, health officials said in August, 1,006 people donated 2,742 organs under a pilot donation program.
The resistance to donation has often been attributed to Chinese cultural traditions about leaving corpses intact. But surveys have indicated strong public support for organ donations. In a 2012 survey by the Canton Public Opinion Research Center in the southern city of Guangzhou, 78 percent of respondents called posthumous donation ''noble'' and 79 percent rejected the statement that harvesting organs was disrespectful to the deceased. But an overwhelming four out of five said they worried their organs would end up being sold for profit.
Despite a 2007 ban, the sale of human organs remains a problem in China. Last May, a trial of nine people accused of trafficking kidneys in the eastern city of Hangzhou revealed that donors in their 20s would be paid as little as 15,000 renminbi, or $2,450 for a healthy organ, which could then be sold to patients for 200,000 renminbi, more than $32,000. A 2012 case of a student in the central province of Hunan who sold a kidney for 22,000 renminbi, about $3,000, to buy an iPad perversely increased interest among young people in selling their own kidneys, People's Court Daily, the official newspaper of the Chinese Supreme People's Court, reported in May.
Another source of public skepticism about organ donation stems from the agency the Chinese government has recruited to promote the national donation system: the Red Cross Society of China. The organization, which has close government ties, has been the target of widespread doubts about its integrity. Many Chinese accused the organization of misusing donated funds following the devastating 2008 earthquake in Sichuan. In 2011 a young woman named Guo Meimei, who claimed to be affiliated with the Red Cross Society of China and posted photos of her lavish lifestyle, further damaged the agency's reputation.
Now some are asking whether such a tarnished institution is the best vehicle for building public confidence in organ donations.
''I don't trust this institution, and when scandals happen I only see its surly silence, not a public reply, let alone an apology and correction,'' wrote Pan Caifu, an online columnist, on his doubts about organ donation. ''I've never given the Red Cross a penny, and now you tell me an institution that's exhausted its trustworthiness should 'co-ordinate' my organs? That's a bridge I can't cross.''
Zhang Yidong, a friend of Mr. Xu, who witnessed the rival organizations argue over the cancer patient's corneas, said he holds the Chinese Red Cross responsible for the debacle.
''They made a mess of this situation,'' Mr. Zhang said. ''To put it plainly, they wanted to sell his organs. I can use one phrase to describe the Red Cross and the health officials: They are thieves.''
The Anhui Red Cross denied any wrongdoing, announcing that its investigation of the incident found no evidence of an argument. Its representative told CCTV, the state-run broadcaster, that he wouldn't change a thing about his bedside behavior. But even CCTV, which has enthusiastically promoted organ donation, acknowledged the damage caused by the incident, saying the public was calling the Red Cross worker ''cold, pitiless and bureaucratic.''
Red Cross Society of China officials have attributed the public's suspicion of their work in organ donations, disaster relief and other fields to poor public understanding and say that building trust will take time.
''These crises of confidence promote the reform of the Chinese Red Cross and urge us to unceasingly improve.'' Zhao Baige, executive vice president of the Red Cross Society of China, told reporters in March. ''I believe that as society becomes more open, the public will become more rational.''
Foreign experts recruited to advise China on organ donations say the government is highly motivated to reform the system, and expect it will eventually end the questionable practice of prisoner donations.
''One day, I don't know how many years it will take, but the traditional way will disappear because the government want it to stop,'' says Dr. Martí Manyalich, a transplant coordinator in Barcelona, Spain, who visited China in May to advise on improving the country's donation system. Spain has the world's highest rate of organ donations, but that system took years to develop, Dr. Manyalich said. China will also take a long period to wean itself of executed prisoners, but the official will to reform the system exists, he said.
''They are working for the long term,'' he said. ''It will not be solved in one day, but it will be solved.''
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