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Table of Contents
CASE SERIES
Year : 2022  |  Volume : 16  |  Issue : 1  |  Page : 119-126

Deception and deceit in living kidney transplant program


1 Paras Hospital, Gurugram, Haryana, India
2 MOHAN Foundation, Chennai, Tamil Nadu, India
3 Manipal Hospitals, New Delhi, India
4 Fortis Memorial Research Institute, Gurugram, Haryana, India

Date of Submission02-Sep-2020
Date of Acceptance09-Jun-2021
Date of Web Publication31-Mar-2022

Correspondence Address:
Dr. Muneet Kaur Sahi
B 284 F 2nd Floor, Sushant Lok-I, Gurugram - 122 002, Haryana
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/ijot.ijot_113_20

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  Abstract 


In India, the majority of kidney transplants are living donor transplants. The transplant law in India only permits donation from first degree relatives, spouses, grandparents and altruistic donation without any commercial intent. Donation that happens other than first degree relative require to go through the process of authorization by a committee that determines their intent of donation. In spite of the requirements that are clearly laid down in the Act, fake and fraudulent activities have been reported to make donations happen with a commercial intent. This paper is an attempt to inform and empower clinicians and transplant coordinators and give them the requisite skills that would help them to identify fraudulent relationships, detect discrepancies in the documents and help ensure that the hospital and the doctors follow the law of the land and not fall prey to fake documentation that has a commercial intent of donation. Sample cases have been studied based on their coordination and different ways of approaches to detect falsification of documents and tutoring of the donors by the family members or broker. It was seen that with the right approach that included thorough donor-recipient interrogation, close scrutinization of documents and keenly observing the donor-recipient relationship including their body language and attire, various discrepancies could be identified. All transplant teams should include a well-trained Transplant Coordinator who is alert to every case of a living donor recipient pair and makes a thorough assessment of the relationship by observing, interviewing and scrutinizing the documents of relationship to exclude fraud. Some recommendations have also been drawn up to minimize the risk of fraud.

Keywords: Authorization committee, interrogation, kidney deception, kidney donor, relationship fraud, transplant coordinator


How to cite this article:
Mathew TR, Sahi MK, Shroff S, Kumar P, Pokhariyal S, Jain S. Deception and deceit in living kidney transplant program. Indian J Transplant 2022;16:119-26

How to cite this URL:
Mathew TR, Sahi MK, Shroff S, Kumar P, Pokhariyal S, Jain S. Deception and deceit in living kidney transplant program. Indian J Transplant [serial online] 2022 [cited 2022 May 25];16:119-26. Available from: https://www.ijtonline.in/text.asp?2022/16/1/119/342422




  Introduction Top


Renal transplantation is the best therapeutic modality for a patient suffering from end-stage renal disease compared to dialysis as transplants lead to a much better quality of life.[1] In India, the number of patients requiring kidney transplants is increasing with the rising incidence of kidney failure. Deceased Donor Organ Transplantation accounts for 10% of renal transplantation in India.[2] The slow progress of the deceased donor program is one of the reasons that has led to an increasing dependence on living kidney transplants in our country.

In living donor transplants, as per the Transplantation of Human Organs and Tissues Act 1994 1st degree relatives, i.e., parents, spouse, children, siblings including grandparents, and grandchildren >18 years of age are allowed to donate.[3] The first relatives are required to provide proof of their relationship by legal documents, however, if these are not available genetic testing needs to be undertaken. In the event of there being no first relatives, the recipient and donor are required to seek special permission from the government-appointed authorization committee and appear for an interview in front of the committee to prove that the motive of donation is purely out of altruism or affection for the recipient.

The clause in the Transplantation of Human Organs Act, 1994 states, “if any donor authorizes the removal of any of his human organs or tissues or both before his death under sub-section (1) of section 3 for transplantation into the body of such recipient, not being a near relative as is specified by the donor, by reason of affection or attachment toward the recipient or for any other special reasons, such human organ or tissue or both shall not be removed and transplanted without the prior approval of the Authorization Committee.”[4] However, in many cases, it has been found that some of the donors are paid for donating their organs and fake documents are prepared to suit the required relationship that is to be presented to the transplant team and the Authorization Committee or Competent Authority. This then reinforces the need for a meticulous assessment of each case that is brought up for a living donor transplant.

Once the donor and recipient pair present themselves to the clinicians, the assessment starts, and the transplant coordinator (TC) is given the responsibility of getting all the relationship documents in place. After the initial introduction and pleasantries, it is ideal to interrogate the donor and recipient separately before calling them together for a joint meeting. Occasionally in unrelated paid donation, the suspicion can start at this early stage of introduction observing the body language and interpersonal communication.

The interview and document verification is a continuous process. If there are discrepancies and the element of suspicion is strong then Deoxyribonucleic Acid (DNA) testing for proof of relationship should be recommended from a laboratory accredited with National Accreditation Board for Laboratories.[5]

After processing of all the documents and the results of the DNA test, the recipient and the donor are then recommended for transplant to the Authorization Committee. The approval from the Authorization Committee/Competent Authority is essential before proceeding with an organ transplant.

Separate sessions with donor and recipient should be undertaken. All assessment needs to start with the motive for donation and what triggered the decision. Understanding the educational and financial status of the donor and the recipient should be followed by a casual and friendly interrogation should covering the following areas-

  1. Details and names of other family members and their relationship
  2. The house in which all of them stay-living together or separately
  3. Details of servants, drivers or others they employ
  4. What do they enjoy the most-hobbies, sports or food they like
  5. Which school did they study? Grades in school/college?
  6. What was their desired profession?
  7. Who is their favorite star, politician or sportsmen?


This list should have at least 20 questions out of which a select 5–10 should be asked and it should be different for each pair [Annexure 1], [Annexure 2], [Annexure 3].

The TC must take special care to corroborate and cross-verify the details as given by the donor, the recipient and other family members, to understand if the details match from each of their version. This will provide an understanding whether the donation is between authentic valid pairs (donor-recipient) or is there a commercial intent to the donation. After the session, documents that should be verified include KYC or “Know Your Customer” documents that normally are used by banks to obtain information about the identity and address of the customers and this process helps to ensure that banks' services are not misused when a person opens an account with them–

  1. Voted ID card
  2. Aadhaar Card
  3. Ration card
  4. Marriage certificate, if applicable
  5. PAN card
  6. Passport
  7. Driving License
  8. Or any water bill or electricity bill (not older than 3 months) or latest bank statements signed by the bank or Property Tax/Corporation/Municipal Corporation receipt.


If the TC is not satisfied with the documents provided, then the patient and the donor are asked to produce more details. Some other documents that can be used further to probe any suspicion can be crucial in detecting any fraud are:-

  1. Photo album–photographs with the donor and the recipient. Try to look at the background of the photograph and ask the recipient and donor to identify the members in the photograph and assess whether any editing has been done or not
  2. Birth certificates of the family members-Birth certificates of the children when the donation is between husband and wife, the quality of the paper that the certificate is printed on, check for the authorized signatory of the document and the place and date of the certificate
  3. Bank statements– In cases where there is a joint account in the name of the husband and wife, then the date of opening of the account and transactions done. In the case of other than near relative, the TC verifies the details of the income of the previous three financial years
  4. Marriage certificate-Date and place of marriage and issuance of the certificate
  5. Verification letter from the MLA/Panchayat Sarpanch/Tehsildar/Municipal Councilor to prove the marital status in addition to the marriage certificate especially in cases where spouse is the prospective donor.


After scrutinizing the above-mentioned documents, the TC then correlates the information provided by these documents with the details provided at the time of interrogation.

During such interviews, all potential donors need to be also told about the surgical process of kidney donation and possible short-and long-term risks of donation as per the THO law. The law says, “no registered medical practitioner shall undertake the removal or transplantation of any human organ or tissue or both unless he has explained, in such manner as may by prescribed, all possible effects, complications, and hazards connected with the removal and transplantation to the donor and the recipient, respectively.” Only after this, the case is then referred for medical and legal workup [Figure 1].
Figure 1: Living organ donation work-up process

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The article highlights the methods to detect the fraudulent relationship between living organ donors and recipients by discussing a few illustrative examples and the methods to be used to detect the discrepancies to assess the authenticity of each case. Vigilance needs to be even higher in spousal donation where the wife is likely to be a potential donor [Figure 1].

Annexures sample

Questionnaire for interrogation session with donor/recipient

A few random questions are to be selected from the list given below for the interview with the donor and recipient.


  Methods Top


Case 1

Mrs. X, age 30-year came to the outpatient department with chronic kidney disease accompanied by Mr. Y age 33-year who was presented as the potential kidney donor. Both were accompanied by three men; one was introduced as her brother-in-law and the others as Mr. Y's friends. On being questioned about the absence of other close family members during the interrogation session Mrs. X shared that as theirs' was a love marriage, none of the family members were on good terms with them.

Mrs. X was then advised to undergo dialysis in the transplant center till the time her paperwork was processed, and the date of the surgery decided. They were also asked to produce documents such as the voter ID card, marriage certificate, marriage album, ration card, and bank account passbook so that the process of verification of documents could begin.

Case 2

A 25-year-old Mr. A came to the hospital for his renal transplant with his father Mr. B and stepmother Mrs. B. Mrs. B was the proposed donor and she was 47-year-old.

Case 3

Mrs. A, age 40-year-old was an international patient who approached the hospital for a renal transplant with her cousin brother as the donor (mother's sister's son). The cousin's brother was 21-year-old.

The husband and the facilitator (a person who brings and guides an international patient) accompanied the patient for the first visit to the hospital. They informed the doctor that the donor did not come as he was resting in the guest house. TC then requested the family to bring the donor next time so that she could start the interrogation process.

Next day, facilitator and the donor came to the hospital, but the patient did not come. TC was informed that she was tired and resting in the guest house.

In subsequent visits, the TC asked for legal documents and interrogated the donor and the patient separately. During the processing of the documents, it came to light that the husband had the same blood group as his wife, but he gave some unreasonable excuse for not wanting to donate to her. The patient was carrying a human leucocyte antigen (HLA) report of the potential donor and the recipient, which reported a 100% match.

Case 4

Mr. K, a 56-year-old patient was advised renal transplant at a local hospital where the transplantation facility was not available. Mr. K was then referred to a renal transplantation hospital.

Mr. K accompanied by his daughter met the TC in the renal transplantation hospital. He told her that his son-in-law was the potential donor and he was 25-year-old. The TC requested Mr. K to bring the son-in-law in the next visit so that she could start the interrogation process.

In the next session, TC questioned Mr. K as to why the daughter, an immediate relative can't donate. She was informed that the daughter cannot donate her husband (potential donor) was not allowing her to donate. The reason citied being that their marriage was just 2 years old and he did not want to jeopardize her health.

Case 5

Mr. M, a 47-year-old international patient came to the hospital for a renal transplant with the facilitator and his son-in-law age 21 years old, as the donor. Initial work-up of the case had been done by a junior staff and it was referred to the TC for detailed work-up.

During the first interrogation session, the TC found out that the patient and the donor were not accompanied by their wives. When questioned about their absence, the facilitator told her that the wife of the patient had undergone a spinal surgery and the daughter of the patient was pregnant. They were carrying a positive urine pregnancy report of the daughter.

Patient consent

The patient consent has been taken for participation in the study and for publication of clinical details and images. Patients understand that the names and initials would not be published, and all standard protocols will be followed to conceal their identity.

Ethics statement

MOHAN Foundation Ethics Committee (EC/NEW/INST/2020/542 submitted to NECRBHR, DHR.


  Results Top


Case 1

In case of Mrs. X and Mr. Y interpersonal relationship, family photographs and proper interview helped expose the false marriage certificate.

  • Suspicion 1–Interpersonal Relationship-It was noticed that the patient was always accompanied by one particular person for her dialysis session and their relationship looked too close to be that of a friend of her husband
  • Suspicion 2-Family Photograph-The wedding album photographs had the same set of 4 people with the same background in all the pictures. In all the photographs, the patient was wearing full sleeve except in one where the TC noticed an Arteriovenous fistula.


Oninterrogation with the set of questions [See Annexure 1], the bluff was easily exposed. The TC asked the recipient (wife) when was the fistula made, she replied 6 months back. Then she asked how long they have been married and the recipient blurted out 10 years. Immediately the bluff was called out by the TC. She said that themarriage album which was supposedly made 10 years back was a fake and it was made recently for the sole purpose of undergoing a transplant. The real husband of the patient (the person who accompanied the patient during her dialysis session) then confessed to his relationship with the patient He also confessed to the fake marriage of his wife with the donor and that the documents were prepared for the sole purpose of undergoing kidney transplantation.

Case 2

The TC's methodological approach helped expose the fake relationship documents between Mrs. and Mr. B.

  • Suspicion 1-Dress and body language-The outfit and body language of the stepmother gave a strong impression that she could be a paid donor
  • Suspicion 2–Interview-The stepmother was not able to answer any of the questions that were asked about her husband, his siblings, or his parents
  • Suspicion 3– Document scrutiny-The verification of the documents on the information they had provided showed disparity between the date of issuance of the donor's Aadhaar card and the date of marriage. The Aadhaar card clearly mentioned the name of the donor's husband and that it was issued a year before the date of marriage mentioned in the marriage certificate.


On being questioned about this discrepancy, the husband explained that his wife did not have any relatives so the Aadhaar card was made with the details provided at the time of issuance.

To prove that the husband was not telling the truth the TC asked for the family photographs. On closer inspection of the photographs, it was found that the head of the father was disproportionally bigger than the body which clearly indicated that the head had been photoshopped in the photograph.

Case 3

Relationship between Mrs. A and the cousin was proved through a DNA test.

Suspicion-the HLA report rarely shows a 100% match with a cousin.

The donor and the patient answered all the questions very confidently and gave similar responses. The information given in the documents matched with the details given by the patient and the donor. The documents looked authentic with due attestation by the Embassy.

In the subsequent visits, the behavior of the patient and the donor was studied very carefully. The TC also sought the help of the transplant team members to observe them. It was felt that the pair had been extremely well tutored as to how to behave, what to say, what not to say and there was little one could do except ask for a DNA test of the potential donor and the recipient. The test was performed as a last resort, the results of which validated that their claim was false.

This case illustrates how DNA can be used to prove fraud where interview does not help in a well-tutored case.

Case 4

The donor owned up to be a paid donor.

Suspicion 1-Appearance-it was observed that the appearance of the son-in-law was in total contrast to that of the patient and his daughter. The donor looked to be from a lower socioeconomic status.

Both the patient and his daughter claimed that it was a love marriage and since the donor's parents were against their relationship, he was staying with them and taking care of the patient's business. The TC then asked the reason for the daughter not donating to her father, the donor shared that he does not want her to donate.

Suspicion 2-Agitated Behavior-On being questioned to show the marriage certificate and other legal documents proving the validity of the marriage, the father became very agitated and threatened the TC that he can produce any document that may be required to prove the relationship as he was police personnel.

Taking the donor into confidence-The TCintensified her efforts to get to the truth and tried a different approach. She explained the surgical process of kidney donation and the possible short-and long-term risks of donation. The donor had not been explained anything previously and was relieved to understand the procedure. He then opened up to the coordinator and came out with the truth that he was a “third party paid donor” and not a relative.

Case–5-The facilitator “gave the truth” away

TC was given the case after complete workup that was done by a junior colleague with all the necessary documentation in place including a No Objection Certificate (NOC) from the Embassy.

The TC requested for an interrogation session with the donor and the patient.

Suspicion 1-Body language-Doubts pertaining to the claimed kinship between the donor and recipient arose initially itself upon closely observing their body language and dialogue.

The donor seemed neither comfortable nor confident during the entire course of the interrogation.

Suspicion 2-False report-The urine pregnancy report of his wife (patient's daughter) produced by the donor seemed fake upon closely studying it and therefore as a follow-on the donor was asked to furnish an Ultrasound Sonography film. This request from the TC enraged the facilitator and caused him to act in inappropriate ways to the extent that he even offered to refer 7 more transplant patients in return for clean chit on this transplant.

The interpreter then left the hospital with the patient and the donor and never came back.


  Discussion Top


The work of a well-trained TC goes beyond the routine of merely organizing transplant surgery and coordinating with various teams in the hospitals. Living donor transplant coordination is entirely different from deceased donor transplantation and has its own set of requirements. One important element of this also is to ensure that the ethical and legal principles of the THO law are upheld and not compromised. The clause in the act where “affection and attachment” provides an opportunity for unrelated altruistic donors to donate to their loved ones, it also provides possible abuse of this clause and many pairs use this clause to slip in paid donors into the program. In most instances, these paid donors can be identified by the medical staff over a period of time by their disparity in appearance, on smart questioning, and through diligent observation of the documents produced by them. Many do get tutored by the middlemen and with foreigners, this becomes even more difficult as they come with the certification of the embassy.

In India, there have been multiple exposure of many such pairs and even in the best of the hospitals, the management has been caught unaware.[6],[7] These expose are not in the best interest for the eco-system of the program in the country as it widens the trust deficit in the healthcare and more in the already maligned living organ donation.

A thorough donor-recipient interrogation is the most important aspect of living donor coordination for a transplant. As was evident in from above five case reports that suspicion can start at the very beginning of the evaluation. The importance of observing the donor and recipients, the body language, the interpersonal relationship and the attire is important. Next comes the close scrutinization of every document as the most authentic-looking document can be forged, and the photographs can be photoshopped. To identify these discrepancies, a TC has to be vigilant and armed with a sound knowledge of all the government documents and identity proofs to be able to spot falsification of the documents. DNA should be the last resort in case of doubt, and this is like fingerprinting and never lies.

Following are our recommendations to the transplant units, TC s and the administration of the hospitals conducting transplants to follow in case of donor-recipient evaluation to minimize the risk of fraud:-

  • It is of utmost importance that TC should be familiar with all the regulatory norms and guidelines related to transplantation as well as the updates issued by the authorities from time to time
  • The recipient should be interviewed exhaustively about his/her medical history which should include the duration and period of the disease, the doctors consulted, the treatment advised, date of initiation of dialysis, date of creation of the fistula, hospitals visited and any other relevant information related to the patient's condition
  • To closely observe the body language of the patient and the potential donor in order to gauge their relationship and emotional connect as these are useful in coming to a clearer understanding of the motives and the intention behind the donation
  • It is important to interview the patient and the donor separately to clearly establish the financial and social background of the two. This will help in ruling out any financial pressure and motivation behind the donation
  • The transplant team should assess the awareness of the donor on risks associated with donation and transplantation
  • In case of the slightest doubt, the TC should not hesitate in requesting for additional documents apart from the standard documents. These could include marriage album, old E-mails, school transfer certificate, or any other material that will help in alleviating the doubts and establishing the relationship
  • It is imperative that each document like the voter identity card and Aadhaar card should be verified, and cross-checked with respect to, date of issue, registration, names mentioned (h/o, w/o, s/o, etc.). In case of a marriage certificate and birth certificate, the quality and the issuing authority of the certificate has to be assessed and verified
  • In case of an international patient, there is a need to cross verify the NOC issued from the embassy by communicating with them directly by E-mail to assess its authenticity
  • If the patient who was earlier undergoing treatment at another hospital, it is advisable for the TC to discuss his/her reasons for discontinuing the treatment and/or options of transplant at that hospital
  • Even when all the documentation has been procured and yet the TC harbors certain doubts, it would be prudent to bring those doubts to the notice of the Authorization Committee to ascertain the authenticity of the relationship or the documentation.


The interrogative job of a good TC is nothing less than that of a sleuth. As Sir Arthur Conan Doyle quoted in his famous detective series, “My name is Sherlock Holmes, it is my business to know what other people do not know.”


  Conclusion Top


A good team should include a well-trained person like TC to be able to assess all the living donor-recipient pair and use a set method to observe, interview and scrutinize the documents of relationship to detect fraud. In India, the law is very stringent, and living donors are not easily available. Standard process of assessment should be followed as laid out to detect paid commercial donors. Training may be required on how to scrutinize the documents.

Ignoring the verification of documents can lead to legal complications for the transplant team, the hospital authorities, and the committee members. In view of the above, each center conducting organ transplants will have to set up a clear process protocol for medical and legal work-up.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.


  Annexure Tables Top










 
  References Top

1.
Abecassis M, Bartlett ST, Collins AJ, Davis CL, Delmonico FL, Friedewald JJ, et al. Kidney transplantation as primary therapy for end-stage renal disease: A National Kidney Foundation/Kidney Disease Outcomes Quality Initiative (NKF/KDOQI™) conference. Clin J Am Soc Nephrol 2008;3:471-80.  Back to cited text no. 1
    
2.
Shroff S. Current trends in kidney transplantation in India. Indian J Urol 2016;32:173-4.  Back to cited text no. 2
[PUBMED]  [Full text]  
3.
Shah SB, Shah BV. Legal Aspects of transplantation in India. Indian J Transplant 2018;12:169-73.  Back to cited text no. 3
  [Full text]  
4.
Government of India. Transplantation of Human Organs Act, 1994. Central Act 42; 1994. Available from: http://legislative.gov.in/sites/default/files/A1994-42.pdf. [Last accessed on 2020 Aug 24].  Back to cited text no. 4
    
5.
Sahay M. Transplantation of human organs and Tissues Act-”Simplified”. Indian J Transplant 2018;12:84-9.  Back to cited text no. 5
  [Full text]  
6.
After Top Doctor's Arrests, More Trouble for Mumbai's Hirnandani Hospital. NDTV; 2016 August 10. Available from: https://www.ndtv.com/mumbai-news/after-top-doctors-arrests-more-trouble-for-mumbais-hiranandani-hospital-1442528. [Last accessed on 2020 Aug 24].  Back to cited text no. 6
    
7.
Kidney Racket Busted in Delhi's Apollo Hospital, 5 Persons Arrested. NDTV. 2016 June 04. Available from: https://www.ndtv.com/delhi-news/kidney-racket-busted-in-delhis-apollo-hospital-5-persons-arrested-1415359. [Last accessed on 2020 Aug 24].  Back to cited text no. 7
    


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