Hard to Believe · sands of organs transplanted in China is sinister, given thatChinaisthesecond-largestorgantransplanterinthe world and reports low rates of voluntary donation. Gutmann

FILM REVIEW

Hard to Believe

Produced by Ken Stone and Irene Silber, 2015, Swoop Films and Stone SoupProductions (New York, 56 minutes, unrated)

Holly Louise Northam

Received: 12 October 2015 /Accepted: 14 December 2015 /Published online: 30 March 2016# The Author(s) 2016. This article is published with open access at Springerlink.com

Abstract This article presents a review of Hard toBelieve, a compelling documentary reporting the forcedorgan procurement and death of Chinese prisoners ofconscience. The documentary is targeted to ignite polit-ical and public pressure to stop these practices that arethought to be motivated by financial and political gain.Narrated by journalist and author Ethan Gutmann, thedocumentary pricks at the collective conscience, ascredible witnesses provide evidence that point to anabrogation of every ethical principle ascribed to legiti-mate organ procurement.

Keywords Organ trade . Sale . Trafficking . Organdonation . Ethics . China . Human rights . Transplanttourism . Suffering . Consent

The title of this documentary,Hard to Believe, caughtmy attention. I felt impelled to watch, conscious of myprofessional responsibility to be informed, concernedabout the implications. Few would be unaware of ongo-ing protests by Falun Gong practitioners against Chi-nese human rights abuses. Recently, Chinese officialshave acknowledged the use of executed prisoners’ or-gans for transplantation and have promised a moreethical system of organ transplantation, new regulations,and a plan to stop using prisoners’ organs. Despite this,desperation drives some patients to source organs from

illegal market networks, with indisputable evidence thatthis trade results in human misery.

The credentials of the interviewed experts are impec-cable. Narrator Ethan Gutmann, an award-winning hu-man rights investigative journalist and author of TheSlaughter, is supported by internationally recognizedCanadian human rights lawyer David Matas; ProfessorArthur Caplan, director of medical ethics at the Univer-sity of New York; Dr. Enver Tohti, former surgeon fromXinjiang, China; U.S. Republican Congressman DanaRohrabacher; Dr. Jacob Lavee, president of the IsraelSociety of Transplantation; Professor Katrina Bramstedt,ethicist at Bond University and an associate editor of theJournal of Bioethical Inquiry; and others.

Bioethical Inquiry (2016) 13:353–356DOI 10.1007/s11673-016-9717-1

H. L. Northam (*)University of Canberra, Canberra, ACT, AUSTRALIAe-mail: [email protected]

The documentary commences with footage of FalunGong practitioners outside the fourteenth InternationalOrgan Donation Congress in San Francisco. The narra-tor sets the scene, describing how protesters Bfelt theweight of many bodies on their shoulders.^ The narra-tive proceeds to highlight the desperate plight of patientsawaiting transplantation and to systematically outlinethe veracity and magnitude of human rights abusesinvolving forced organ procurement of Chinese minor-ities, including the Falun Gong, Uyghurs, Tibetans, andBHouse^ Christians. Gutmann argues that a lack oftransparency regarding the provenance of tens of thou-sands of organs transplanted in China is sinister, giventhat China is the second-largest organ transplanter in theworld and reports low rates of voluntary donation.Gutmann and others argue that organs from executedprisoners are purchased by foreigners as well as bywealthy, influential Chinese.

In this documentary, David Matas, who investigatesabuse claims by Falun Gong practitioners, reports thatfollowing the Chinese crackdown and detention ofFalun Gong practitioners in 1999, many thousands ofunidentified prisoners of conscience were incarceratedin labour camps and disappeared without trace. Matasand Gutmann describe accounts frommany Falun Gongwho had been detained and imprisoned and who ex-plained that they and others refused to reveal theirnames to authorities because they wished to protect theirfamilies from a similar interrogation and incarceration.

Matas reveals that the Falun Gong were consistent indescribing their experiences of brutality but, unexpect-edly, also reported organ Bhealth checks^ that involvedthe collection of large samples of blood at three monthlyintervals and unusual eye examinations that did notseem consistent with standard health examinations. Ac-cording to Matas, the most Bchilling thing^ to him wasthat the blood testing and organ and eye exams appearedconfined to detainees who were Falun Gong practi-tioners and that Falun Gong and minority group de-tainees from diverse locations and circumstances inde-pendently reported being involved in similar tests.These incidental findings seem inexplicable to Matasand Gutmann, who do not believe the Bhealth^ exami-nations were motivated by consideration of the detaineeprisoners’ best interests.

Gutmann andMatas form the view that it was possiblethat detainees’ organs were being assessed and used fortransplantation based on the compounding evidence fromthese reports; the significant increase in transplantation

rates in China after the Falun Gong persecution com-menced; and speculation regarding forced organ removalthat arose from detainee witness reports that executedprisoners’ bodies are cremated before their families arenotified of the death or have seen the body of the de-ceased. A breakthrough occurred in Matas andGutmann’s investigations when a doctor confessed hisrole in the removal of organs from an executed prisoner.

Dr. Enver Tohti, a former surgeon from Xinjiang, Chi-na, also is interviewed about his involvement in the re-moval of organs prior to a state-sanctioned death. Hedescribes how he and his surgical team were co-opted bya senior doctor to gather surgical equipment, without ex-planation. They accompanied a supervisor to a site where aplanned execution was under way. Dr. Tohti describes howhe and his team were pressured again to remove the liverand kidneys of a prisoner who had been shot but whoshowed signs of life until the organs were excised.

Gutmann argues that this practice is not isolated andthat Falun Gong practitioners are specifically targetedfor forced organ harvest because their organs are pre-ferred for people purchasing organs. This is becauseFalun Gong are required to maintain healthy lifestylesand do not smoke or consume alcohol. This argument issupported in the documentary by evidence collectedfrom recorded telephone calls to more than 100 Chinesehospitals, during which doctors assure callers thatscheduled transplantation surgery will be conductedusing organs specifically chosen from healthy FalunGong prisoners. The documentary claims that the re-corded discussions are between hospital staff and familymembers of people in need of an organ transplant, whoprior to the transplant surgery seek assurances about thequality of organs they are purchasing. The narratordisputes a statement from Chinese authorities that thecalls are a hoax, arguing that hundreds of witness state-ments support the veracity of the recordings. Evidencethat transplant tourists are offered short waiting times forscheduled organ transplants and receive young, healthyorgans from executed prisoners adds weight to the sus-picions. Gutmann argues that the practice described byDr Tohti of removing organs from dying Bexecuted^prisoners may be motivated by a desire to improve thefunction of the transplant.

Dr. Jacob Lavee, president of Israel’s TransplantationSociety, describes how he was previously complacentwhen patients returned to Israel with a purchased kid-ney, believing the donor benefited from the organ sale.In this documentary, Lavee describes how his attitude

354 Bioethical Inquiry (2016) 13:353–356

changed dramatically when a patient told him he wastravelling to China for a scheduled heart transplant. Thisidea was shocking to Lavee, because the circumstancesof death that allow heart donation cannot be predicted.Lavee was even more distressed when the scheduledheart transplant went ahead as planned and he found thatthe patient had all his medical costs covered by insur-ance. Lavee describes that this information was a Bgamechanger^ for him. It led him to initiate the introductionof a landmark law that has significantly reduced Israelitransplant tourism. The law prohibits medical insurersfrom covering the costs of transplantation for Israeliswho receive illegally procured organs bought outside ofIsrael. Interviewees recount that Spain also has changedits legislation, and although not stated, it is presumablyto follow Israel’s lead. Those in the film strongly rec-ommend that similar laws be introduced to reduce theorgan trade in the United States, Canada, and othercountries with populations known to participate in trans-plant tourism. It is reported in the documentary thatAustralia has intervened to minimize the harm involvedin these practices by ceasing training of Chinese trans-plant surgeons, while Malaysia has sought to limit thetrade by refusing to fund anti-rejection drugs for patientsreturning with an organ from China.

Gutmann reports that these international effortsto limit the illegal organ trade were barely noticedin the United States. He argues that it is possiblybecause the Falun Gong use images that are cul-turally challenging and may alienate American ob-servers. In the documentary, Falun Gong practi-tioners are interviewed about their experience ofbeing tortured as detainees. One, BAnnie,^ speaksof being X-rayed, having her blood tested, andreceiving eye and kidney checks. Footage isshown of Falun Gong engaging in a continuousvigil outside the Chinese embassy in London since2002 in an attempt to raise public awareness ofhuman rights abuses. As Gutmann asks, why issuch evil ignored?

Enquiries by European governments and the WorldHealth Organization (WHO) have confirmed the verac-ity of the claimed human rights abuses. RepublicanCongressman Dana Rohrabacher describes how he suc-cessfully fought to have the issue brought to the atten-tion of the U.S. Congress. The narrator asks: How canour society ignore these horrors? Is it compassion fa-tigue? Is it because of cultural or language dissonance?Is it because the public is unaware of the injustice

suffered by prisoners and/or lack sympathy for theirplight? Awitness in the film recounts that one recipientaccepted without question the information that histransplanted organ had come from a prisoner who hadkilled his family. The documentary moves into discus-sion about the idea that an issue may be so Bdifficult^ asto make it publicly and politically untouchable. This is aproposed explanation of why this evil can be ignored.Rohrabacher suggests the idea that no-one wants toconfront the Chinese on this sensitive topic because itmay impact trade and foreign relations.

Ethicist Arthur Caplan expresses his disbelief thatthese practices are allowed to continue unchallenged,as he unpacks the litany of maleficence involved in thedestruction of the principles that underpin legitimateorgan donation. He specifically counts the absence ofvoluntary informed donor consent, the fact the Bdeaddonor rule^ is irrelevant and substituted with medicalmurder, the obfuscation of the organs’ provenance anddistribution, and the removal of organs from executedprisoners as running counter to current standard of prac-tice and as evidence of crimes against humanity. Heargues that an absence of transparency allows thesecharges to be laid. Caplan asks, BWill we put up withit?^ Gutmann informs us that an American best-sellingbook, Larry’s Kidney, which recounts a patient’s trip topurchase a kidney in China, is being made into a movieand that revealing and legitimizing the organ trade inthis way will effectively advertise that China has organsfor sale.

The film also argues that transparent practice anddata trails can provide proof that organ donation isvoluntary and informed—but evidence of such datatrails for organ recovery, allocation, and transplantationis still lacking from China. The documentary presentsthe view that, to address this problem, China mustdisplay transparent evidence of adhering to the rules oflegitimate organ donation—that donation is informed,voluntary, and transparently managed; that organs canonly be taken after a person has died; that prisoners’organs should never be used; that organs should neverbe taken from executed prisoners. Patients in need of atransplant should be fully informed of the risks of theorgan trade, both to the donor and to themselves. Lawssuch as those initiated in Israel to prohibit patients frombeing covered by medical insurance if they purchaseorgans should be introduced in the United States andother countries where patients travel to purchase anillegal organ.

Bioethical Inquiry (2016) 13:353–356 355

This documentary is extremely important for thoseinvolved in organ donation and transplantation, humanrights, healthcare, ethics, and the law. A failure to ad-dress the needs of vulnerable people erodes humanityand destroys public trust. Politicians, policy–makers,and legislators can contribute to solving this problem.In the first instance, patients considering an organ pur-chase must be educated that their donor will be harmedand may die. Patients requiring transplantation need torealize that, regardless of their desperation, in purchas-ing an organ they are complicit in a crime. Rigorousefforts must be made to ensure each country maximizes

its transplantation rate to meet the needs of its popula-tion using organ transplantation practices that align withWorld Health Organization principles. Please watch thedocumentary and come to your own conclusions.

Open Access This article is distributed under the terms of theCreative Commons Attribution 4.0 International License(http://creativecommons.org/licenses/by/4.0/), which permitsunrestricted use, distribution, and reproduction in any medium,provided you give appropriate credit to the original author(s) andthe source, provide a link to the Creative Commons license, andindicate if changes were made.

356 Bioethical Inquiry (2016) 13:353–356