I spent my career as a pediatric cardiothoracic surgeon, involved for almost all of it in transplantation. Medicine should be a caring profession, seeking the best for patients, doing no harm, and dealing in truth as the basis of trust. Transplantation might be the apotheosis of human generosity, since one human consents to donate an organ to preserve the life of another, usually unknown to them. Sadly, in some settings this ethical basis has been ignored and organs have been removed forcibly and without consent from prisoners of conscience, many times resulting in their death. Clinicians acting on behalf of the state are often involved, and thus complicit in the crime.
In 2016, I was invited to become a member of the China Tribunal, a people’s tribunal tasked with reviewing and passing judgment (published in 2020) on evidence of forced organ harvesting from detainees in Chinese detention camps (especially devotees of Falun Gong, the Chinese spiritual and religious movement founded in 1992). At the time, I was not aware of such evidence and barely aware of the presence of the camps. I was shocked, not just by what I came to hear but by the fact that I did not know; neither media nor governments in the West had successfully exposed this information. Subsequently, more effective media reporting has revealed the oppression of the Uyghur population, a Muslim minority in Xinjiang, China. A second people’s tribunal, the Uyghur Tribunal, was established in 2020 and published its judgment in 2021.
People’s tribunals are independent, peaceful, grassroots movements created by members of civil society to address impunity associated with ongoing or past atrocities. They have been established when citizens feel that governments and international bodies have failed to act but should have done so. They comprise citizens as jurors passing judgment on evidence. In the case of the China and Uyghur tribunals, the standard of proof was “beyond reasonable doubt.” The full evidence submitted to the tribunals, both written and in person, is publicly available. Both tribunals repeatedly invited the Peoples Republic of China (PRC) to submit evidence; it did not.
As the scholars Clive Hamilton and Mareike Ohlberg have explained, conflating the Chinese Communist Party (CCP) with the Chinese nation and people leads to all sorts of misunderstandings. The CCP runs an authoritarian regime, defining appropriate thought and aggressively implementing the party’s beliefs and policies. The CCP rejects, in words or deeds, democracy and the freedoms enshrined in the United Nations’ Universal Declaration of Human Rights: freedom of speech, assembly, religion and belief; freedom from persecution; the right to personal privacy; and equal protection under the law. What the individual Chinese citizen is allowed to know will influence their views. It is important to keep this background in mind when summarizing the findings of the two tribunals.
First, the China Tribunal. Evidence demonstrated that the CCP after 1999 had imprisoned thousands of people in detention camps, especially Falun Gong practitioners, solely because of their beliefs. Jiang Zemin, then president of China, announced the creation of the “610 Office,” a security agency dedicated to eradicating the Falun Gong. Jiang was worried about its size (at 70 million, it had more devotees than the party); its wide appeal, even to the upper echelons of the CCP; and its peaceful values, considered to hark back to a time of Chinese weakness. A complex structure was built to carry out this policy. The Falun Gong— along with Uyghurs, Tibetans, Taiwanese, and democratic activists—formed China’s so-called “five poisons.”
Detention was harsh and brutal, and we concluded it was beyond all reasonable doubt that the PRC had committed crimes against humanity—namely deprivation of liberty, murder, torture, rape, and other sexual violence and persecution based on racial, national, ethnic, cultural, or religious grounds.
From 1984 onward, China had carried out organ transplantation using the organs of executed prisoners. We heard evidence of surgeons being forced to remove organs from a prisoner who had deliberately been only “partially” executed. The prisoner had been shot in the right chest rather than the base of the skull, and the abdominal organs were removed in haste before death. The PRC responded to international pressure thereafter and reduced its enormous rate of execution, and hence the supply of organs for transplant should have fallen. There was no voluntary donation scheme, as in the West. Yet at the turn of the 21st century, it became CCP policy to expand transplantation nationwide to achieve a position of global leadership in the organ trade. Still, there was no voluntary donation scheme. A huge hospital construction program was undertaken, and transplant services expanded rapidly. While the Chinese authorities claimed to be performing 10,000 transplants per year between 2000 and 2010, data obtained by reviewing individual hospital websites, publications, and scientific journals—supported by phone calls between researchers—estimated that between 60,000 and 90,000 transplants were performed annually. The number of executions had fallen from 12,000 to 5,000 per year in the same time frame. This gap between available executed prisoners and transplants performed suggested that there must have been a pool of alternative donors. Could they have been sourced from detainees?
Further support for this possibility came from hospitals and transplant agents in China, which advertised bizarrely short waiting times for organ transplantation. Waiting times for a liver in the West usually exceed six months, and for kidneys one may wait two to three years for a nonrelated donor. Similarly for hearts and lungs. Many people die waiting. Chinese hospitals were advertising waiting times of days—impossible without an available pool of donors.
The China Tribunal heard a great deal of evidence from previous camp inmates not only of torture, but also of “medical tests.” These comprised blood tests, for which consent was not obtained, no purpose given, and no results reported; physical examination; and ultrasound scans, again without obvious rhyme or reason. To perform successful transplantation, the tissues of the donor and recipient must be matched to minimize the chance of rejection. Blood tests are necessary. Ultrasound scans give a good indication of structural integrity and health of an organ. Inmates were understandably very uneasy about these tests. They were never told their purpose, and some of their peers had “disappeared.” They put two and two together. We asked ourselves if there might be another rational explanation to test the inmates (a search for infection, for example, to see if they were “fit” for torture), but none was forthcoming. We concluded that forced organ harvesting had taken place and that the donor pool was likely made up of camp inmates, largely the Falun Gong.
The Uyghur Tribunal heard remarkably similar evidence, but on an even larger scale. Under direct orders from President Xi Jinping, hundreds of thousands (perhaps well over a million) Uyghurs had been detained in camps in Xinjiang in appalling conditions of cruelty, depravity, and inhumanity. Many had been tortured in the most brutal ways and over long periods of time. Inmates of both sexes had been raped or subjected to extreme sexual violence by police and by people who were paid to carry out such attacks in the camps. Solitary confinement was commonplace.
Detainees were forced to take drugs that affected reproduction, and pregnant women were forced to have abortions, even in the late stages of pregnancy. Like the Falun Gong, Uyghurs were forced to have blood tests and other medical examinations without explanation. Many people were “disappeared.” While there was no direct evidence of forced organ harvesting, it is suspected.
Pressures have been exerted on the Uyghur community outside the camps, including intensive monitoring and surveillance by facial recognition and other advanced technologies, such as DNA sampling and database compilation. Han Chinese men were assigned as “family friends” to live in Uyghur households for weeks in order to report on them to the authorities. A systematic program of birth control aimed at reducing the Uyghur population was established, and Uyghur women have been coerced into marrying Han Chinese men.
A large-scale transfer-of-labor program has been created not only within Xinjiang but also in “mainland” China. The Muslim faith in particular has been targeted, with emblems of the faith, including thousands of mosques and burial grounds, being desecrated or destroyed. Any overt demonstration of Islam (including wearing veils, wearing beards, and studying religious texts) could result in long prison sentences. Even the use of the Uyghur language has been punished. Land and other assets have been appropriated, and communities, including centuries-old houses, have been physically destroyed. The PRC has imprisoned, sometimes for long periods, relatives of those who have spoken out about life in Xinjiang. The PRC has also compelled countries where it can exert pressure to extradite Uyghur refugees to China to face fates unknown. The Uyghur Tribunal concluded that there was sufficient evidence to describe what has and is happening to the Uyghurs as genocide.
These two people’s tribunals have judged the PRC to be guilty of heinous crimes against large numbers of its people, not only abusing them but also using them as an extractive resource without consent: a resource for labor, a resource for physical gratification, and a resource for organs.
As a medic, I am horrified, but perhaps I should not be surprised. Doctors have been directly involved in the most awful acts of torture since at least the Spanish Inquisition, most notoriously in the Nazi concentration camps, and as described in the 2014 Senate Intelligence Committee report on CIA torture. The tribunals’ evidence implies that in China, skilled people, almost certainly medically trained, took blood samples, analyzed those samples, examined prisoners, and removed and implanted organs without either explicit or implicit consent. I still struggle to understand how they could do this, although some evidence we heard reminded us that many of the doctors themselves had reason to fear personal retribution or threats to their families.
For the unethical officials in the CCP, a large population of imprisoned people offers an extraordinary research resource of potential human subjects. If consent to participate in studies is not necessary and authority is total, then anything is possible. It is common knowledge now that China has created a massive DNA database of the Uyghur population, nominally for security purposes. But what else might it facilitate? Such large-scale genomic analysis is currently beyond the means of Western scientists and pharmaceutical companies, but as the search for more personalized, targeted therapies evolves, it is this DNA data which could provide clues for new agents. Once the drugs have been designed, safety and efficacy trials could easily be carried out on the detained population. Xenotransplantation is also a reality now: Witness the recent pig heart transplant into a human in the United States. But what if gene-modified pigs could be farmed, and you had a large, detained population of humans who could be included in transplant trials at scale?
I do not need to remind readers of this magazine of the horrors of medical experimentation in concentration camps. But the potential for a repeat nightmare at scale exists today in China, and we must be vigilant. As Global Rights Compliance has proposed, it is vital that organizations—academic, medical, and business—that work with equivalent Chinese (or other nations’) institutions do three things: First, establish a human rights commitment to prevent involvement in unethical practice (including transplantation); second, conduct human rights due diligence processes to identify, prevent, mitigate, and account for unethical medical or transplantation risks; and third, disengage from any relationship where such unethical organ transplantation is not preventable, mitigatable, or remediable.
Transplant medicine in the West relies on transparent data sharing between donor and recipient teams, with relevant donor and recipient data being held centrally by a national authority. Prioritization is equitable and waiting lists are managed. Risk stratification is made possible. There is a solid audit trail, meaning that the origin of the donor organ is both clear and confirmed to be ethical. It is important to be able to track such data back to the donor if diseases develop in the recipient. Such auditable transparency is what the international medical research community must demand of China.
Author’s Note: I would like to thank all the members of the China Tribunal, but especially Sir Geoffrey Nice QC and Mr. Hamid Sabi for their valuable support and advice. I also wish to pay tribute to all those brave souls who gave evidence to the tribunal at significant personal and family risk, and, of course, to all those whose lives have been lost or damaged as a result of the detentions and activities described.
Martin Elliott is Emeritus Professor of Paediatric Cardiothoracic Surgery at University College London, Emeritus Professor of Physic at Gresham College London, and Director of the National Service for Severe Tracheal Disease in Children, based at Great Ormond Street Hospital. He was a member of the recently completed China Tribunal considering evidence of forced organ harvesting in Chinese detention camps.