Australasian Science Magazine

By Elisabeth Lopez

Stem cell expert Megan Munsie and bioethicist Dominique Martin discuss medical tourism and the hidden transnational trade in transplant organs and stem cells, considering their ethics, legislative implications and what the future might hold.

ELISABETH LOPEZ
Hello. I'm Elisabeth Lopez. Thanks for joining us.

If you're living with kidney failure or bringing up a child with a disabling condition like cystic fibrosis, you'll be thinking a lot about what medical science can offer and maybe banking on a miracle. The bad news is that there is a global industry waiting to fleece people desperate for a cure or even just a little relief from the worst symptoms. Each year thousands of people from wealthy countries travel overseas to receive an organ transplant or to undergo an experimental stem cell treatment.

They won't be told that the procedure on which they may have spent their life savings is likely to be sustaining a clandestine trade worth billions of dollars. Even though they take place in hospitals, these procedures are often poorly regulated. Sometimes they're harmless but ineffective and sometimes they're dangerous or even fatal for the recipients and the donors. At the extreme end, it sounds like the stuff of science fiction and crime novels - slick marketing, desperate poverty, human trafficking, organ donors killed on demand - only it's actually happening.

Today on Up Close we have two guests to talk to us about medical tourism for organ transplants and stem cell treatments.

Dr Dominique Martin is a lecturer in health ethics at the School of Population and Global Health at the University of Melbourne. She's a bioethicist and a former medical practitioner and is co-chair of the Ethics Committee of the International Transplantation Society.

Associate Professor Megan Munsie, also based at the University of Melbourne, is a scientist who heads the Education, Ethics, Law and Community Awareness Unit at Stem Cells Australia. She's also chair of the International Society for Stem Cell Research Task Force, Closer Look at Stem Cells. Welcome to Up Close.

MEGAN MUNSIE
Thank you for having us.

DOMINIQUE MARTIN
Hi Liz.

ELISABETH LOPEZ
I'd like to start with you, Dominique. What do we know about the scale of the global organ transplant industry and where it happens?

DOMINIQUE MARTIN
About seven years ago, the WHO did a literature review and they came to the conclusion that we could estimate that global market at about five to 10 per cent of global activity in organ transplantation and so in kidney transplantation, there are about 77,000 kidneys transplanted across the world each year, and so at that time, that would have been up to almost 8000 kidneys transplanted on the black market.

We now believe that the estimate is probably closer to about five per cent, but really these are figures that are speculative. We don't have a lot of data. It's very difficult to collect data obviously on clandestine activities and there's also some [of] that the market now is operating under cover of legitimate transplant practices. So again, it can be very difficult to estimate the scale of activity.

ELISABETH LOPEZ
And I guess there's no compulsion to or no way to declare it to immigration that this is the purpose of your travel.

DOMINIQUE MARTIN
Exactly, no.

ELISABETH LOPEZ
Why kidneys? Are they easier to trace or is it just that more people get them or sell them?

DOMINIQUE MARTIN
It's easier to do kidney transplants for a couple of reasons. One, because most healthy people can donate one of their kidneys. You've got two kidneys and you can donate one of them and live a full and healthy life. The second reason is that patients with end stage kidney failure - so patients who need a kidney transplant - can be kept alive on dialysis, whereas someone who has end stage severe liver failure or heart failure might not be able to survive long enough to have a transplant. So there's greater availability of the organs for transplantation in the case of kidneys and there's greater demand. There are more people on waiting lists for kidneys.

ELISABETH LOPEZ
Where does the travel tend to take place? Destination countries, source countries?

DOMINIQUE MARTIN
That's evolved over the last 10 years. Ten years ago at the sort of the peak of the market and what we knew was happening, thousands of people going to China for transplants. About 1500 people going to Pakistan every year. Perhaps 600 going to the Philippines. Hundreds going to particular countries. Mostly more developing countries - Southeast Asia, some in Latin America. That has changed in recent years with stronger legislation in countries like Pakistan. China now is not doing transplants or certainly has a law saying that they're not going to offer transplants to foreign patients. The Philippines has also made it a lot more difficult.

So even those countries that have prohibitive laws, obviously there are loopholes. Some people do get through, but it's become a lot more difficult. So the market then has shrunk in some regions and perhaps shifted to other locations.

ELISABETH LOPEZ
Megan, I wanted to ask you, stem cell tourism is presumably a much newer market. What does that look like?

MEGAN MUNSIE
It has some similarities. The countries that people are visiting are quite similar to the ones that Dominique just mentioned. In fact one of the early destinations of call was Germany, which sort of surprises a lot of people because they think of German precision, perhaps reliability and yet there was a thriving market for unproven treatments. That was closed down in 2011 and what we're seeing is a lot of people travelling to other countries - to China, to India, to the Bahamas, to Mexico.

ELISABETH LOPEZ
So there's a bit of jurisdiction shopping.

MEGAN MUNSIE
There is and interestingly some of the clinics that operate in one country where regulation is changing such as in China, they're shifting their activities across the border and opening up in Thailand, for example.

ELISABETH LOPEZ
There has been a lot of media coverage about the potential of stem cell treatments. There's a small number of proven treatments. What are they compared to the sort of treatments that people seek when they travel?

MEGAN MUNSIE
The treatments that are proven are very few. They really rely on haematopoietic stem cells. They are the stem cells that reside in your bone marrow and we actually have been using these stem cells in one form or another for the last 40 years. However, what these stem cells are used to treat is pretty limited. It's diseases, malignant diseases of the blood and immune system. So conditions like leukaemia for example. We've been using bone marrow transplantation or more recently, cord blood donation, to correct and to supplement or to replace a faulty bone marrow stem cell and thereby make the correct number of red blood cells, white blood cells and platelets.

What we're seeing however, is sort of an extrapolation of that where people have heard about stem cells and perhaps have a deficit in another organ. Perhaps in the brain for example, perhaps a patient has Parkinson's disease and no longer has the right number of nerves making dopamine. Having heard about stem cells, people are perhaps excited about the possibility that stem cells could replace other cell types, but unfortunately we're not there yet for many conditions. People are travelling really to seek out treatments where there is no justification at this stage.

ELISABETH LOPEZ
Is there any justification for overseas travel if you're from a relatively wealthy country with a good public health system? Are you likely to get whatever advances in science that you need on your home turf?

MEGAN MUNSIE
This is a point that's often raised, that there's a perception that perhaps in Australia, treatments are being denied. I think the reality is that there are some experimental treatments being tested in clinical trials, perhaps in the UK, in the USA, but it's not as though they're a proven treatment yet. They're highly experimental and in fact, it's likely in these first in man trials that there will be more issues raised than solved.

However, of course for someone who is trying to find a solution to their problem, they want to travel. They may not be able to access these clinical trials because they're not a resident in those countries, so what else can they do? They feel as though they have no other choice than to pursue these treatments that are marketed as a treatment now.

ELISABETH LOPEZ
Where do the materials, the biological materials come from when we are talking about these stem cell treatments?

MEGAN MUNSIE
Well it's really very much a range. The stem cell term is used as a catch-all and the source of the stem cells could be from foetal tissue, from human embryos, form the patient themselves, or perhaps from donor cord blood. What I find interesting in our research is that a lot of people don't really mind what the source is. They just want to have access to the treatment, or at least their perception of a treatment.

ELISABETH LOPEZ
Are there any ethical issues involved in using your own biological material?

MEGAN MUNSIE
Well I think there are. I think the assumption is made that because the cells are from you, that they're naturally safe and possibly effective. Of course the evidence just isn't there yet. If you use a patient's own cells, the questions you need to ask and to think about is how the cells have been manipulated and how they're being put back. Perhaps they're being put back at a site that they don't usually reside in.

ELISABETH LOPEZ

How does a person with no scientific or medical training have any hope of countering very persuasive PR or a physician themselves may be selling them a cure that has not been proven?

MEGAN MUNSIE
Also when coupled with the use of Dr Google, it becomes a very, very hard road to navigate. What we advise and what my colleagues through the International Society for Stem Cell Research advise, is that people have to do their research. There are some resources, some checklists that can help people perhaps ask the right questions, but we really want people to go back, gather their information and go back and talk to their primary health care physician. Someone who's not trying to sell them something about what their options really are.

ELISABETH LOPEZ
Dominique, tell me a bit about what is happening in developing countries in terms of the economy that's risen around organs.

DOMINIQUE MARTIN
So it's obviously a phenomenon of poverty in developing countries such as the Philippines, Sri Lanka, Pakistan, India, even parts of China, Vietnam, more recently, where you have people who don't have viable employment prospects or people who are perhaps working in really low paying jobs below the poverty line. There, when a kidney broker comes to town and either starts to call in debts perhaps or offers the opportunity to get rich quickly, to suddenly have a lump sum payment of $2000 or even $5000 that would be the equivalent of a fortune, many years of income to those individuals, to those families, that's really what drives those people then to sell their organs.

The unfortunate reality is that many of them then don't receive the money that they've been promised. They wind up in the long term worse off financially as well as health wise and socially. So the consequences, the outcomes for those people who make a decision to sell are usually very negative.

ELISABETH LOPEZ
Tell me a bit more about the after care of these people, the medical after care.

DOMINIQUE MARTIN
There is no medical after care for people who sell their kidneys on the black market. In some of these countries, in many of them there isn't an effective public health system so if you were to donate your kidney in Australia or in the United States, you would have reasonably good access to follow up care as a donor, but if you sell your kidney on the black market, then you don't have perhaps the finances to access health care and you certainly don't have anyone trying to follow you up.

ELISABETH LOPEZ
When you're talking about health care, it's not necessarily fancy stuff. It can mean simple things like access to testing for blood pressure.

DOMINIQUE MARTIN
There's not an extensive or elaborate program that's really needed to follow up kidney donors, but it is important to have regular health checks to make sure that they continue to be well and also particularly if something does go wrong, if they injure their remaining kidney or suffer some kind of urological or kidney problem, then having only one kidney becomes a very serious situation for them. If they lack access to care then - for example they can't afford dialysis if they were themselves to require dialysis, and that's a really serious situation.

ELISABETH LOPEZ
A lot of the reportage of this issue has understandably involved urban myths, like the person who wakes up in a bath of ice one day with stitches across their abdomen. I suppose for a time what was happening in China could have been interpreted as an urban myth because of government denials. What was taking place there?

DOMINIQUE MARTIN
For many years, China has had a program of executing prisoners. They have a capital punishment system as do other countries, but they would remove organs from executed prisoners and a large proportion of those organs were then sold as transplant packages to wealthy foreign patients and of course, domestic patients. That has fortunately changed…

ELISABETH LOPEZ
2015…

DOMINIQUE MARTIN
Yes, 2015, end of 2014, the government really took a strong stance on ending that policy and to the best of our knowledge, that has now ceased in China and they've really been working hard at developing new more ethical programs of deceased organ donation.

ELISABETH LOPEZ
You're listening to Up Close and we're talking about medical travel with two guests from the University of Melbourne - Dr Dominique Martin who researches the global trade in organ transplants and Associate Professor Megan Munsie who's interested in travel for stem cell treatments. Dominique, are there any legal markets in the world for - commercial markets that is - for organs?

DOMINIQUE MARTIN
Yes. Iran has had for some time now over a decade a so-called regulated market in organs, particularly in kidneys. Saudi Arabia also has what is not described as a market but is in effect a market - they pay the families who consent to donate the organs of their relative after death and Kuwait also provides payments to deceased donor families. So those are legal programs in which incentives, financial incentives, are offered in return for organs.

ELISABETH LOPEZ
Do we know much about what happens in these markets in terms of impacts on donors and the impact of financial incentives?

DOMINIQUE MARTIN
Well the Iranian example is often cited as an example of success. In the United States, a number of health professionals and philosophers have recommended that they introduce incentives for donation in order to replicate that success, but when you look at the reality of Iran's programs, their organ transplant rates are certainly not the best in the world. They're nowhere near as high as the United States and although there's an oft-repeated claim that Iran eradicated their waiting list for transplants, they didn't in fact have what we would recognise as a waiting list and a recent report by Iranian nephrologists show that they have indeed quite a significant waiting list with about 17,000 people waiting for kidney transplants alone.

So the market hasn't solved the organ shortage problem and the other impact that it has had means that there is almost no living related donation in Iran. If you can afford to obtain a kidney transplant, you don't donate to your loved one. You will purchase an organ. The other thing is that the regulations that are supposedly in place to protect people have not proven to be effective. In fact what you see in the Iranian market is very similar to what happens in the black markets. There isn't follow up of people who sell their kidneys. The people who sell are often in desperate financial circumstances. There are poor outcomes certainly for those organ sellers economically, socially and health wise.

It's not a good example of something that I think anyone ought to be trying to replicate.

ELISABETH LOPEZ
Megan, what sort of market forces do we see in terms of the materials needed for stem cell treatments?

MEGAN MUNSIE
Well again, it's a little opaque. In fact it's unclear whether stem cells are actually being put back for many of these patients. The similarities I suppose are really again the strong marketing and the business model that these groups have set up. So the assumption is that the treatments work and that they are safe. They rely heavily on patient testimonials. If you do search online and look for a stem cell treatment, you'll be presented with a very slick website or a series of slick websites and again, back to what you mentioned earlier, it's very hard for the person who's seeking a solution to work out what's legitimate and what's illegitimate, what's real and what's not.

Particularly if you have a patient who maybe suffers from the same condition interviewed, talking to you on screen, it becomes very compelling.

ELISABETH LOPEZ
Are a lot of people in the market for stem cell treatment really worried about the science if they have a chronic, debilitating or even terminal condition and feel they have nothing to lose?

MEGAN MUNSIE
I think that they see this as a solution, as a treatment that's a real option, particularly if they've perhaps heard from another patient or if they've spoken to the provider at the clinic. I find it really interesting that the patient will often speak to another patient through a chatroom and that will be enough of an endorsement to pursue this treatment. They also rely strongly on the intermediary at the clinic who might speak the same language, who may be able to speak English. That sort of mediator who can help them on their journey.

ELISABETH LOPEZ
You've done some sociological studies of the people who seek out these treatments and you've found some interesting things about who's prepared to talk about their experiences and who isn't. Can you go into that a little bit?

MEGAN MUNSIE
We've interviewed a lot of Australians who have travelled abroad and they've travelled to Germany, they've travelled to China and India, predominantly. What's really been fascinating is although we've put out broad, sort of, recruitment calls to get people to share their stories, it's very much an anonymous research project, so no one is named, and yet it's very hard to get people to speak to us who haven't had the experience that they expected. So those perhaps who are disappointed.

Now I've often spoken to people who are very dissatisfied with their treatment but they will not come forward and participate in our research project. So one of the reasons they may not want to share their story is that they've relied heavily on family and friends to fund their trip. So these trips aren't cheap. They're usually in the order of $10,000, $50,000 or even more to travel. That's a lot of fundraising to get them there and I think that they're often just so pleased to have had the opportunity, they don't want to look foolish for making the decision and they certainly don't want to be disrespectful for those who have tried to help them.

Just to highlight that, I had met a gentleman who had travelled to India on multiple occasions and spent hundreds of thousands of dollars that his community had fundraised for him. He was very upset that he had in his eyes wasted that money, been foolish. Yet when I have heard him speak in a public forum, he mentioned that he sort of thought it was great that he'd had the chance. So quite a different way of presenting his journey in a different forum.

ELISABETH LOPEZ
It is very difficult to counter such a powerful force as hope.

MEGAN MUNSIE
Exactly and I think even just the act of pursuing something may make the experience satisfactory.

ELISABETH LOPEZ
Do we have an issue here with the sort of narratives that we construct around diseases like cancer, about it being a battle? That it really takes a big personal effort of will, that you've got to be in there fighting the condition, you can't just be passive.

MEGAN MUNSIE
I think in the stem cell space, because it's an emerging technology and, you know, I think one day there will be some fantastic cellular based treatments from stem cells, but for many, many conditions, we're not there yet and a lot of people who are pursuing this treatment see themselves very much as pioneers. Out there exploring all their options, leaving no stone unturned. I think it does play into a war against their condition or the sense that they must battle it because no one else is prepared to do something for them.

ELISABETH LOPEZ
It's interesting seeing headlines in even quite reputable journals, things like stem cell treatments coming soon to a body near you. It's a catchy headline, but what sort of perceptions are being created, even by responsible or accurate media reporting?

MEGAN MUNSIE
The last couple of years we've seen a huge change in how we can harness the potential of stem cells in the lab. For many years we've been able to take a stem cell and force it to grow into a particular cell type. So for example, a pluripotent stem cell like those obtained from human embryos can be made to grow into particular type of nerves and we can make a [beating heart] in a dish and we can make cartilage in a dish. What we have been able to do a little better in the last couple of years is to be able to start to put together different cell types to make the basic building block of an organ.

So we can make mini-kidneys, we can make mini-brains, we can make mini-guts. Now those organs or mini-organs are a long way from a mature, functioning kidney. In no way are they at the stage of being able to address the organ shortage, but from the community's perspective, of course the implication is that the science is just that one step away from solving this problem and in fact of course it's going to be 20 years or more before we can produce something that is tested, proven and reliable.

ELISABETH LOPEZ
On Up Close we're discussing the global trade in medical products of human origin - organs and stem cells. Our guests are Dr Dominique Martin, a lecturer in health ethics at the School of Population and Global Health at the University of Melbourne and Associate Professor Megan Munsie from Stem Cells Australia, an Australian Research Council initiative. I want to ask you both about regulation. Obviously as we've spoken before, there's a bit of jurisdiction shopping, different countries have different regulations. What sort of regulatory frameworks do we need to try and stem unethical practices? Dominique.

DOMINIQUE MARTIN
I think regulation really begins at home and that applies for both stem cell tourism, transplant tourism, the issues associated with these markets and with other markets in health care. If countries at the national level, perhaps larger countries at the state level as well, don't take responsibility for addressing the domestic problems, then we're never going to be able to address effectively the transnational problems. So with organ transplantation that means really working on strengthening donation and transplantation programs within a country and having strong regulation that prevents trade in organs within that country and unethical practices and then taking it beyond that, because of course with the globalisation of health care now, we have so many millions of patients travelling across the world each year to access particular health care services, we do need to look at how to regulate and how to support ethical practice in - and responsible practice - in the transnational setting.

With organs in 2014, the Council of Europe established a new convention on organ trafficking which is now open for signatures from all countries across the world. I think there's currently 12 countries that have signed that convention and that really is a step towards prohibiting and addressing organ trade that occurs across borders.

ELISABETH LOPEZ
At a domestic level, a lot of health insurance or a few health insurance companies are getting in on the medical travel game by offering dentistry and cosmetic procedures overseas. Is there a bit of a halo effect happening where people think okay, well I can get my teeth fixed, I can get my thighs shaped, well why not stem cell treatment or a new kidney?

MEGAN MUNSIE
As you said, a halo effect is real and in many ways it normalises and promotes these treatments. It legitimises them. You mentioned before about medical insurers and I think that's really interesting. We are seeing outsourcing and different countries around the world where basically the policy is to enable the patient to travel and to seek out treatment abroad. In Australia, we're seeing that to some extent in some medical procedures. It's not extending to support stem cell travel at the moment, but of course it's a great concern of ours.

DOMINIQUE MARTIN
There were very few health insurers that actually provided reimbursement of costs for people who went overseas to obtain an organ on the black market, but there were some examples in particular from Israel which has quite a reputation for Israelis going overseas to purchase organs on the black market. All over the world, the Philippines, India, Pakistan, South America and Qatar, like many other Gulf states, also provided coverage for patients who went to China and to other countries and certainly Qatar and Israel are two fantastic examples where the government has taken a strong stance against the organ trade and has made it now illegal for health insurers to provide coverage for anyone who goes overseas for a transplant unless it's been pre-approved and ethically endorsed and is all legal as per Israeli, Qatari law.

ELISABETH LOPEZ
Dominique, you referred a bit earlier to the need to shore up domestic schemes for things like organ donation. Megan, I imagine you'd probably say the same for umbilical cord donations. Going to organs first, Dominique, you're able to tell us a bit about how the different schemes work according to whether they're an opt-in, opt-out scheme?

DOMINIQUE MARTIN
There's a lot of talk in the Australian media in 2015 about the potential impact of having presumed consent or an opt-out system. In Australia we currently have an opt-in system. If we actually look at international data on this, it shows that it's not so much what the law is in terms of consent, it's actually about the broader infrastructure of organ procurement. The world's leading countries in deceased organ donation - Croatia and Spain - they do have presumed consent opt-out systems, however in practice they still consult the families every time there is a potential donor and those families do have the opportunity to refuse.

They do have higher consent rates than we do have in Australia, but really the bottom line is that presumed consent can be helpful if it certainly conveys a message or reflects the position of a society that donation is the norm. However in practice, that will be completely meaningless and there are countries with presumed consent systems that have absolutely appalling rates of donation. It's really about the broader healthcare system and getting both health professionals and the community on board with donation.

ELISABETH LOPEZ
Megan what, in your opinion, are the sort of regulations we need to see in national jurisdictions about stem cell treatment? Because the issue in terms of treatments that don't work is not necessarily restricted to going to developing countries, is it?

MEGAN MUNSIE
Well I think it's simply we need evidence and we need a mechanism to obtain that evidence. So really we need to have clinical trials that are well funded in order to capture, to monitor, to follow up, to have a long-term understanding about whether these treatments are safe and are also beneficial.

ELISABETH LOPEZ
So is it the case that you can still be seeking out a stem cell treatment in your own country and it's not necessarily going to be a proven treatment?

MEGAN MUNSIE
I would have said a few years ago that that wasn't the case. I would have said that most people were travelling abroad, but in 2011 the laws changed in Australia. We had a new framework introduced around biologicals and when the framework was introduced, there was an exclusion around the use of the patient's own cells by a registered medical practitioner for that individual patient for a single use.

Now what that enabled was of course the use of veins from the patient in surgery and some legitimate practices that were happening already, it meant that those practices didn't have to go through the same rigorous assessment by our Therapeutic Goods Administration. However, it also allowed a window for doctors here in Australia to start selling unproven stem cell treatments provided they use the patient's own cells.

ELISABETH LOPEZ
So would you go as far as to say this a loophole? That if it's your own cells then a lot of the ethical regulations just don't apply?

MEGAN MUNSIE
Well of course that's how it's marketed, but I think that that shouldn't be the consideration. I think the fact that the cells that are being used are from the patient certainly means that there are some issues around safety are not as complex. However, it doesn't necessarily mean that they are safe. You need to be able to do the analysis - how are the cells being manipulated? How are they being prepared? How are they being put back?

When we were first looking at this activity overseas, some of the hallmarks concerning practice was when a clinic was offering to treat multiple conditions, diverse conditions, ranging perhaps from autism to Parkinson's disease to heart disease with the same stem cell treatment. Now that is exactly what we're seeing happening in Australia, where through injecting the cells, often ill-defined, we don't know how they're prepared, back into the vein of a patient. They're being offered for a myriad of conditions and they're not just being offered as a sort of an innovative treatment. They're being sold. It's a business and I agree with you. I think these businesses are exploiting what we think is a loophole in the regulations here.

ELISABETH LOPEZ
What are some of the differing perspectives of medical practitioners on the ethics of these treatments or transplants?

DOMINIQUE MARTIN
I think it's an interesting question with regards to travel for organ transplantation. At the heart of this industry obviously have been health professionals, the destination countries, but also in the countries from which patients have travelled. The famous Israeli South Africa organ trafficking case involved Israeli health professionals who were facilitating that travel to South Africa to obtain organs that were in fact taken from poor Brazilian young men who were trafficked to South Africa for that purpose, the Netcare case.

So health professionals have actually played a role in it for profit, as I guess we find also in the stem cell industry, but if you talk to a transplant professional on the street or in a conference, you get a divergence of perspectives. I think the majority certainly believe that the illicit market is harmful and unethical but there is a very strong division between those who believe that the solution lies in developing new and enhancing current methods of altruistic donation and those who believe that introducing regulated markets would be a solution.

ELISABETH LOPEZ
Is self-regulation an answer?

DOMINIQUE MARTIN
The nature of organ transplantation and donation is such that you really do need a healthcare system, you do need to have some oversight and I think few would be proposing that it would be self-regulated in the sense of just health professionals regulating it. I guess in practice that probably amounts to the same thing. So if a market were to be introduced into countries such as Australia or the United States or the UK where we currently don't have a market for organs for transplantation, it would require extensive regulation that would be at the level of government, not so much health professionals.

But obviously the health professionals who have been lobbying for the introduction of such markets would be playing a lead role, perhaps in the design of such a market and to date really, I don't think there's been any serious work on that which I think is very sensible because I think in practice it would be unfeasible and probably ethically unjustifiable.

MEGAN MUNSIE
In the stem cell space, self-regulation's certainly being mooted as a solution, as sort of a gap or a bridge between the scientists who are concerned about premature adoption of the technology and the clinicians who are already out there doing it. It's seen - it's being presented as a reasonable pragmatic measure. What concerns my colleagues and I is that at the core of a self-regulation model should be independent oversight as well as evidence and at the moment, the way it's being proposed is very broad and we think it will actually just allow the businesses really to operate as they currently are, with very little oversight or question or restriction in practice.

ELISABETH LOPEZ
Do you think it will ever be possible to develop an ethical, commercial marketplace?

DOMINIQUE MARTIN
I think in the case of transplants, I personally am unconvinced that that would be practically possible, but more to the point, even if it were practically possible, I think there are superior options. I think that there are far more ethically acceptable alternatives to having a regulated market system. So I think rather than being defeatist about it and thinking we have to turn to the market to fix our current inadequacies of the current systems, I think we need to look beyond what we're doing currently and see how can we do better. There's certainly a lot of information out there about how we could do that.

ELISABETH LOPEZ
Megan.

MEGAN MUNSIE
I'd say in the stem cell space it's different. I think that there is room for an ethical marketplace and I think we're already seeing that and will continue to see that, but it needs to be condition specific. It needs to be tailored to take the technology, to harness the potential of the stem cells, to take the technology and deliver a product that has been reviewed and approved and tried and tested for a particular condition and move away from this magic bullet approach.

ELISABETH LOPEZ
Dominique, Megan, thanks very much for being our guests on Up Close.

DOMINIQUE MARTIN
Thank you.

MEGAN MUNSIE
Thank you.

ELISABETH LOPEZ
We've been talking about medical travel for human organs and stem cells with Dr Dominique Martin and Associate Professor Megan Munsie of the University of Melbourne. Dominique Martin is a member of the custodian group of the Declaration of Istanbul on Organ Trafficking and Transplant Tourism, and Megan heads the Education, Ethics, Law and Community Awareness Unit at Stem Cells Australia.