Every year in China there are about 300,000 patients who need an organ transplant but only about 10,000 surgeries are performed. That according to Huang Jiefu, former vice-minister of health.

There are a number of reasons for the shortfall. The main one is that Chinese people are much less willing than other populations to donate their organs after death. Huang estimates that six out of 10,000,000 people in China donate, where as in a country like Spain the figure is 370.

In most countries, demand for transplanted organs heavily outstrips supply. But China also faces other barriers. As the current issue of the Lancet reports, "Culturally, the concept of organ donation contradicts the traditional Confucian view that one is born with a complete body, which should end the same way because the body, hair, and skin are gifts from parents."

In 1984 it became legal in China to harvest organs from executed prisoners with their families' consent, a practice that was immediately condemned by international human rights and medical groups. Ethical concerns centered on the possibility of coercion or corruption in the allocation process. A black market developed.

By 2011, Huang reported that 65 percent of the transplants in China used organs from deceased donors and 90 percent of those were executed prisoners.

That same year, Arthur L. Caplan, the Emmanuel and Robert Hart Director of the Center for Bioethics and the Sydney D Caplan Professor of Bioethics at the University of Pennsylvania in Philadelphia, called for a boycott of Chinese science and medicine pertaining to organ transplant in Lancet.

Caplan noted that organ transplantation in China had expanded rapidly in the previous 20 years, but it had "not been accompanied by the development of an ethical system for recovering organs from those who die in hospital while on life support, as is international practice".

Even though there were not enough organs in China for its own people, there remained a brisk traffic of "transplant tourists" to China who were frustrated by the long waits in their own countries and attracted by the "competitive price".

Caplan and his colleagues said that the source for many of these organs was executed prisoners and the international biomedical community "must firmly and boldly challenge the status quo".

The announcement that as of January 1, 2015, China would stop using executed prisoners as a source of organs for transplant came as a relief to many in the medical community, but it also raised some concerns.

In addition to overcoming the barriers presented by Confucian traditions, the Chinese health community has been reluctant to accept - socially or legally - the concept of brain death as a criteria for harvesting, instead sticking with cardiac death as the sole basis for donation. In more than 90 countries, brain death is used as a criterion for declaring death.

China has made important steps toward a more ethical, voluntary organ donation system, the Lancet notes.

In 2007 it issued the Regulation on Human Organ Transplantation, establishing a legal framework for overseeing the system. Three years later 11 provinces and cities across the land initiated pilot programs for organ donations after cardiac death.

And in 2013, a nationwide digital network called the Organ Transplant Response System was set up. Still, as Huang said, "people have concerns about whether the organs will be allocated in a fair, open, and just way".

Huang said the 2007 regulations would be amended and renamed "Donations and transplant of human organs in China", so that voluntary donations would be the only source.

Prisoners will still qualify to donate, but their organs will be registered and put on the national database.

"I believe the situation of organ donations will get better and better in the future," Huang said.

The Lancet editors suggest three key things to help make that happen: a sea change in peoples' attitude toward donations, integrating organ donation into the national health system, and implementing health and wellness strategies to reduce rising rates of end-stage organ diseases that will reduce demand.

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