Faced with a poor prognosis without transplantation, desperate patients with end-stage liver disease often reach for any means to prolong their lives. These patients, who resort to transplant tourism, are an especially vulnerable population who may be unaware of the substantial risks associated with organ transplantation practices in many areas of the world. I read with great interest the recently published article by Fan et al.1 documenting the dramatically higher hepatocellular cancer recurrence rates and markedly reduced posttransplant survival rates of recipients who traveled to mainland China for liver transplantation in comparison with those who stayed in Hong Kong. This is valuable evidence of the recipient outcomes of liver transplantation in mainland China and should be proactively shared with patients who are considering transplant tourism. Fan et al.1 reported a recipient survival rate after liver transplantation at their center (Queen Mary Hospital, Hong Kong) that compares favorably with the rates at leading centers worldwide. The authors' efforts to accurately quantitate outcomes at other centers in mainland China are commendable. Recipient selection and donor characteristics are likely influential drivers of the reported outcomes. In their article, organ donors are described as “probably more akin to uncontrolled non–heart-beating donors” for the mainland China cohort. Although the authors are circumspect regarding whether the donors were actually executed prisoners, it seems likely that this was the donor population.2 Although leading destination countries for transplant tourism include China, India, the Philippines, and Pakistan, transplant tourism to mainland China has been isolated as particularly controversial.3-6 Organ procurement from executed prisoners in China has been reported by nongovernmental investigative reports and in the medical literature.2-4 These reports indicate that as many as 95% of organ donors in China are prisoners. Indeed, Dr. Jiefu Huang, Vice Minister of Health in China, reported that “apart from a small portion of traffic victims, most of the cadaveric organs come from executed prisoners.”2 Both live and deceased donor organ procurement from prisoners violates US and international professional guidelines and international standards ratified by the World Medical Association in its statement on human organ donation and transplantation.7-9 These international ethical guidelines exist to ensure that the donation of organs is voluntary, both in life and after death. Because not all countries adhere to these ethical guidelines, when traveling to another country for organ transplant surgery, patients risk using an organ obtained in an unsafe or unethical manner.10, 11 Full disclosure, in scientific reports and at the bedside, is an imperative for our transplant community.5, 12, 13 Laudable efforts aimed at broadening the use of live donor organ donation and donation after brain death in China have the potential to mitigate China's dependence on executed prisoners as the dominant donor pool.14 Transplant physicians are obliged to inform patients considering transplant tourism about both the personal risks of inferior transplant outcomes and the potential for contributing to the demand for practices that may violate human rights.10 Yet, action by international regulatory and credentialing bodies, such as the Joint Commission International, may be required to ensure patient safety and the adherence to internationally accepted ethical standards in organ transplantation.10, 12 Scott W. Biggins M.D., M.A.S.*, * Gastroenterology Health Outcomes, Policy and Economics Program, Division of Gastroenterology and Hepatology, University of California, San Francisco, San Francisco, CA.