Three years ago, Dr. Thomas Diflo's moral nightmare walked into his examination room: a patient freshly implanted with a kidney bought from China's death row, where prisoners are killed—sometimes for minor offenses—and their organs harvested.

Since then, Dr. Diflo, director of the renal transplant program at the New York University Medical Center, has seen half a dozen such people, typically young Chinese American women. The surgeon says his patients weren't distressed about snatching organs from the condemned, but he was overwhelmed by the implications.

Unable to shoulder the burden alone, on January 11, Diflo took his "horror at a real ethical quagmire" to the medical center's Ethics Committee.

Diflo is the first American doctor to talk publicly about this experience, and he did so only after being drawn out by the Voice. The gruesome practice has been documented among ethnic Chinese communities throughout Asia, but so far every attempt to prove that people were leaving U.S. soil to buy organs from China's massive death row has failed.

"To tell you the truth, the original rationale for bringing this situation to the Ethics Committee was my own discomfort in taking care of these patients. I was outraged at the way in which they obtained their organs, and I had a great deal of difficulty separating that fact from the care of the patient," Diflo told the Voice.

"Several patients were very up-front and candid about it, that they bought an organ taken from an executed convict for about $10,000," Diflo recalls. "Most of the patients are ecstatic to be off of dialysis, and none has seemed particularly perturbed regarding the source of the organs."

There's no telling how many kidney buyers returning to the U.S. have gone for follow-up care at a less elite institution or stayed within secretive medical channels recommended by their brokers. Diflo gets his patients on referral from recognized hospitals. "Patients sort of arrive on their doorstep and they don't know what to do. Not everybody who's had a transplant is cared for by a transplant specialist. I tend to see the more complicated ones," Diflo says.

Of all medical disciplines, organ transplantation is perhaps the most bittersweet. Transplants are gifts that coax life from death, that close the door for one person while opening the future for another. But the outright sale of organs is abhorrent to nearly all surgeons in the field. Selling organs is a felony under a 1984 federal law that was spearheaded by then senator Al Gore, and is punishable by up to five years in prison and a fine of up to $50,000. Live or executed prisoners in the U.S. are forbidden to donate an organ, even for free, except to family members under special circumstances.

In China, human rights groups say, citizens have been executed for nonviolent offenses like taking bribes, credit card theft, small-scale tax evasion, and stealing truckloads of vegetables. Political dissidents have also been sentenced to death. Chinese embassy officials did not respond to requests for comment, but in the past the government has denied promoting the for-profit organ trade.

Diflo says he and his colleagues wrestled with the issue in a debate that was "quite lively and revealing, but the bottom line was that we take care of patients who come to us, regardless of their situation—moral, ethical, financial, or social. Although I might find what they had done reprehensible, I was still nonetheless obligated to care for them in the best way that I knew how, and that is what I do."

But Diflo refuses to let it end at that. "Because it is not really appropriate for me to take my outrage out on the patients who come to me, I began to think that I would be better off addressing the root problem, the pilfering of organs from prisoners in China. That is what pushed me to pursue this further," he says. And so he's going public.

America-based human rights activists have sought this break for years.

The trafficking of human organs from Chinese executions to American residents is "something we've always known was going on but something we've never been able to document," says an American investigator working for the Laogai Research Foundation, a group founded by renowned human rights crusader Harry Wu and named for the gulags of China.

The Federal Bureau of Investigation partnered with Wu in 1998 in a sting operation aimed at netting two suspected organ brokers who resided in Queens. Wu posed as a board member of a renal clinic in Aruba and got the men, Wang Cheng Yong and Fu Xingqi, to not only arrange for patients to fly to China for kidneys but to also smuggle corneas, which can keep for weeks when frozen, for sale abroad. The case was dismissed when a key witness fled the U.S. and refused to return to testify. The Laogai Research Foundation also discovered a doctor advertising himself as an organ broker in a Chinese-language newspaper published in the U.S. but no physical evidence was ever uncovered. In 1998, the FBI raided the Los Angeles offices of a man the feds said had presented himself as an organ broker, but it's unclear whether the scheme led to any transplants.

Even in a normal year China executes more inmates than in all other nations combined, reports Amnesty International. In 1999, the confirmed toll reached 1263, according to the organization, which gathers its statistics from tallies published, for propaganda purposes, in government-run newspapers.

Executions often come in floods, usually around the holidays, according to the investigator. This week, with the Labor Day celebrations that started May 1, is viewed by Chinese doctors as a particularly good time to get an organ, but there's no better time than the Lunar New Year, she added. Most—perhaps 70 percent—of the hospitals performing the procedures are run by the military, which has the best connections to the penal system and can be present at executions, she explains. Money from patients purchasing organs is dispersed among those who provide access to the prisoner's body. Hospitals even pay judges to tip them off when they sentence a suitable donor to death. "The money goes to officials all of the way up the line," she says. "It goes to the courts, the people in charge of the prisons. It goes to the doctors, the hospitals, everything."

The Laogai Research Foundation reports that sometimes tens of operations are done at the same hospital on the same day for patients who are essentially walk-ins. China says it has performed about 25,000 transplants in 20 years, but makes no distinction between organs culled from executions and those garnered through accidents and live donors.

Forced labor from China's laogai has always been a source of cash for the country's rapidly advancing economy. And punishment doesn't necessarily end at the point of death, usually a single shot to the back of the head. Families are often forced to pay for the bullet used. But the laogai turned into Execution, Inc. less than 20 years ago after the introduction of Cyclosporine, an immunosuppressant drug that prevents rejection of organs by the recipient's body.

Wei Jingsheng, an agitator at Columbia University's Human Rights Center, testified before the International Relations Committee and Government Reform & Oversight Committee of the U.S. House of Representatives on June 4, 1998, that while he was on death row a guard confided that often organ removal is the means of execution in and of itself. Wei, who now heads his own foundation in Washington, D.C., stated that the guard told him, "There are almost no exceptions. They first are given anesthesia. Just the same as killing a pig. . . . We use cloth to wrap them up and bring them to the execution ground. No one cares if they are alive or dead."

After a long stretch of silence, Zhang sent the message. "My first feeling was of satisfaction, knowing that this evidence finally proved this practice. But this feeling was quickly replaced by another," Wei told the congressional committees. "My second feeling was of heaviness, knowing that this young man used his life to record an unbelievable crime. If I did not have the opportunity to tell others of this evil, if I did not have the opportunity to try and stop this evil from continuing, then I would have to apologize to this young man. All this time, I have deeply felt this responsibility. We must stop this practice."

Harry Wu spent 19 years in the laogai, and has also testified before Congress. His Laogai Research Foundation claims that when bullets are used, the target reflects the market: a shot to the head when a liver's wanted, a shot to the chest when corneas are in demand. Amnesty International also reports that a form of lethal injection gaining acceptance in China can be used to kill without damaging crucial organs, and can blur the line between life and death.

Long before the U.S. and China clashed in the spy plane incident, the West was wary of the emerging superpower. Wei and Wu have edged the organ trade into the human rights spotlight on China, an arena already crowded with accusations of prison and child labor, coerced abortions, and suppression of religious minorities and Tibetan national aspirations. The nation's trade surplus with America, chilling of freedoms in Hong Kong, and occasional saber rattling at Taiwan have done little to soften sentiments in Washington. Business interests striving to engage China as a strategic ally, rather than competitor—through most-favored-nation trade status, membership in the World Trade Organization, and support for its bid to host the Olympics—may have a tougher row to hoe now that Diflo is delivering the goods on an explosive Chinese crime that touches on American soil.

Suddenly, what had existed largely as a kind of urban legend, a science-fiction horror story from a distant world, has become very, very real, right here on the streets of New York. Activists say that if it's happening here, it's likely happening in other large cities of North America, from Boston and San Francisco to Vancouver and Los Angeles.

The Chinese government published regulations in 1990—"On the Use of Dead Bodies or Organs From Condemned Criminals"—stating that for a prisoner to be a donor, prior consent must be given by that person or remaining family, unless the body is unclaimed. Human rights activists scoff at that statement, noting that since prisoners are often kept from communicating with family members, there is no one to claim the body, which is harvested and cremated almost immediately. The government also requires that medical teams involved in the procurement of organs act stealthily: "Surgical vans must not display hospital logos; surgeons must not wear hospital uniforms when at the execution site; guards must be present until the organ is removed; and the corpses should be promptly cremated following the removal of the organs."

Human rights groups seeking to determine the source of organs might try matching the dates of operations to dates of executions in the same city, but the method isn't reliable, especially since the government has taken to selectively publicizing its tallies. The Laogai Research Foundation says doctors speaking for the Chinese government claim regulations against contacting the family of a donor prevent them from revealing to patients where the organs come from.

The harvesting enrages physicians like Dr. Diflo. "I think it's a gross violation of human rights and very much at odds with what the transplant community tries to promulgate as the way to go about things. This does not involve appropriate consent. I don't think prisoners are given the option of donating or not donating. It's not done from an altruistic point of view," Diflo says. Even putting aside his reservations about the death penalty, Diflo says, "The central issue is the nonconsensual taking of organs and making human body parts a commodity."

The Laogai investigator agrees. "It's very obviously profit-motivated because if the person can pay extra then they might be able to move up an execution date, or have it arranged for later," she says. "And those who pay more get better treatment." She cites a case where an ethnic Chinese patient from Malaysia was allowed to die without anti-rejection medications when his money ran out.

The economics of human organtrafficking are powerful. Patients can live active lives on dialysis—thanks to this technology, most don't need a kidney to survive—but the inconvenience and discomfort are considerable. Diflo says his patients were "obviously much more troubled by being on dialysis than by getting organs this way."

For patients, the cost of a transplant is far cheaper than a lifetime of dialysis, says Dr. André-Jacques Neusy, head of the dialysis unit at Bellevue and director of the NYU School of Medicine Center for Global Health. Both Bellevue and NYU Medical Center work with Gouverneur hospital in Chinatown.

Bellevue is a public hospital, so it takes all comers. Many of the city's sick immigrants end up here. "We call it the 'Bellevue Express,' " because patients head there directly from the airport, remarks Neusy. In addition to being the designated facility for the president and visiting dignitaries, the hospital offers extensive translation services.

Affiliated with the NYU Medical Center, Bellevue is Dr. Diflo's chief source of referral patients who have Chinese prisoners' organs. People who receive a transplant must remain under a doctor's care for an extended period. Thus, patients who buy a kidney from China's death row end up seeking treatment in American hospitals, where the cost can be supported by public funding. Diflo says his patients pay for their anti-rejection drugs with Medicaid and Medicare.

Though no patient would be denied treatment at Bellevue when arriving with an organ of mysterious origin, candidates for domestic transplants must be legal American residents. Even for those eligible candidates the wait for an organ can be extraordinary. There are now more than 75,000 people on waiting lists for organs in the U.S., according to the United Network for Organ Sharing, which maintains the national Organ Procurement and Transplantation Network under contract with the U.S. Department of Health and Human Services.

Fewer than a third of those people are likely to get their organs this year, the group said in March. Immigrants, both legal and illegal, will sometimes visit home rather than relocate, naturalize, or wait, Neusy says. "We've had patients disappear from the dialysis unit and reappear with a kidney," he notes. He was unaware of any who'd gone specifically for kidneys from executed prisoners in China. "It's disturbing to think we have professional colleagues on the other side that would condone this kind of thing," he says.

Dr. Nathan Thompson, also of Bellevue, concurs. "We have had patients who have gone against our advice and come back with transplants. Where they've gotten them I have no idea," Thompson says.

Another Bellevue physician, Dr. Gerald Villanueva, sent Diflo a Chinese American woman who had appeared at the hospital, implanted with a death row kidney. Suffering from hepatitis, the patient became one of the complicated cases referred to NYU. Only after talking to Diflo did Villanueva realize the source of her transplant. "I guess we've all heard about things like this, but it kind of gets you when, for the first time, you see it," he says. "There are things we read about, but when you see it, it's still surprising. I guess it shouldn't be, huh?"

Diflo says that doctors seeing scores of patients daily simply don't have time to probe more deeply into their patients' histories, especially when language is a barrier. And they're not paid to argue with their charges. "I don't really see that confronting them about the ethics involved will really serve any useful function. In addition, we see them during our office hours, in which we can see as many as 50 patients in three hours—not really time for prolonged ethical discussions," he says.

Most doctors interviewed for this article agreed that the majority of those organs aren't coming from China. There's a thriving black market in organs sold by live, willing donors in poorer nations with medical know-how, like India. "I believe that both are morally and ethically reprehensible," Diflo says. "If there are degrees of reprehensibility, however, China wins hands down" because the organs are coming from the executed, who are deprived the right of refusal, for profits. Unlike with desperately poor live donors, that's cash that neither the victims nor their survivors will ever see.

Nearly every country touched by the organ trade has laws barring the business; India and Japan are among those who've enacted them only in the past decade as the tide of the organ trade rose. In the United States, the practice of flying to China for organs becomes a crime if arrangements were made for a fee on American soil. But as with the war on drugs, many experts argue that the only real solution to fighting the organ trade is by addressing the demand. People need organs quickly, through humane means. Doctors interviewed floated several ideas.

The most ready cure is for more people to make provisions that their organs be donated at the time of death. Belgium achieves this by presuming organ donation, requiring that people opt out. The doctors noted that while organ donor cards (like those on drivers' licenses) might help tip the balance in discussions with family, the form isn't a binding agreement. Families can still have the final say. And even with that acceptance, families—parents—must be willing to say goodbye at times when they might falsely believe there's a shred of hope.

"Brain death is a hard concept to get across. Japan only recently accepted it as a legal definition," explains Dr. Dale Distant of the SUNY Downstate Medical Center. "How does a person take this action when their loved one is warm, his heart's going, a machine is making his lungs go up and down; when for all the world he's just in a coma?" In many corners of the world, including part of Asia, people hold strong, entrenched taboos against violating the body after death.

On the furthest fringe, some scientists are hoping to master techniques that might allow newborns in future generations to be equipped with a genetic repair kit—stem cells or other tissue frozen at birth or even later for eventual cloning into needed organs. Enterprises like the longevity company YouthCell have been founded on this premise. Scientists are also trying to perfect transplants from livestock into humans.

But social and technological change takes time. Meanwhile, no one expects Chinese bureaucrats to readily forsake an easy source of income like selling organs from the laogai. "If you have a government more or less imposed on the people, you can do that, so in China it's not a problem," says Distant.

Diflo, for his part, says he came forward not to seek attention for himself but in hopes of kicking off public discussion and scrutiny of the issue. "I don't see myself going on a world speaking tour," he says. "The whole reason I spoke up about this is that I was having a difficult time taking care of these patients because of my own repugnance at what had gone on and how things had happened. It really comes from a more personal place. It comes from my own outrage."