Transplantation of human organs is today a mature programme in many States, making it possible for people with kidney, liver, heart and lung failure to extend their lives. Heart and lung transplants are expensive and less widely available, compared with kidney and liver procedures. State governments, which have responsibility for health care provision, are expected to ensure that the organs that are altruistically donated by families of brain-dead people are given to recipients ethically, and as mandated by law. Priority for citizens enrolled in the State and national waiting lists over foreign nationals is laid down in the Transplantation of Human Organs and Tissues Rules. When the law is clear, it is extraordinary that seemingly preferential allotment of hearts and lungs has been made to foreign patients in Tamil Nadu — in 2017, foreigners accounted for 25% of heart transplants and 33% of lung transplants. The State is a pioneer in orderly and transparent allocation of deceased-donor organs, and has worked consistently to eliminate commerce in kidneys procured from poor living donors. The Transplant Authority of Tamil Nadu has served as a model for other States that now have their own programmes. Every effort must be made to ensure that it retains this high reputation, and organs go to the most suitable recipients on the rule-based parameters of domicile, citizenship, Indian origin and foreign nationality, in that order.
Organ transplants display a maturity curve over time, with a rise in the number of procedures improving outcomes and reducing costs. Heart and lung transplants are complicated procedures. Few Indian patients are willing to opt for one, compared to kidney and liver. Kidney and liver programmes have reached a high level of maturity, resulting in rising demand. Most of these organs go to citizens. Tamil Nadu offers a subsidy for poor patients for a liver transplant. Any inquiry into the allocation of hearts and lungs to foreigners should, therefore, shed light on the factors that led to the decisions, including whether registered citizens were overlooked. It should cover such issues as the capacity of district-level hospitals to perform transplants, and arrangements to air-lift organs, since domestic patients are unable to afford flight facilities. Such measures will make it possible to utilise more hearts and lungs, and offer them to domestic recipients. Enrolling all domestic patients through State registries should be the priority for the National Organ and Tissue Transplant Organisation, set up by the Centre with that mandate. Nothing should be done to erode the confidence of the kin of brain-dead people who donate organs with no expectation of gain. Hospitals and professionals who engage in commerce or unethical behaviour should have no place in the system.