Undocumented, Not Undeserving

By Steven Duncan

“Somebody has to pick and choose. And then they have to go home and sleep at night. It’s like trying to play God.” In 1962, these words appeared in LIFE magazine at the advent of the hemodialysis machine.¹ In Seattle, a committee of ordinary citizens was assembled to choose which patients would be granted access to this priceless resource or be sentenced to die without it.² Each committee member, steeped in their own bias and value system, was tasked with determining the worth of patients they had never met.

Ethical questions arising from this era continue to pose challenges whenever critically ill patients outnumber the system’s supply of available treatments.³ Today in the U.S., there is a national shortage of available organs, and the demand for transplants is rapidly increasing.^4-5 Incredible advances in the field of nephrology have allowed nearly a quarter million Americans living with a kidney allograft to work and raise their families without dependence on hemodialysis.⁶ However, the allocation of organ transplants has never been fair, especially to resident noncitizens.

Thousands of organs are donated every year by undocumented immigrants who would be denied a transplant if roles were reversed.⁷ Around 3 percent of organ donations in the U.S. come from undocumented immigrants, while only about 0.5 percent of transplants go to undocumented recipients (usually donated by their own families).^8-10 An estimated 6,500 undocumented immigrants suffer from end-stage renal disease, and as a rule, they will die ineligible for the waitlist.¹¹

After being denied a life-saving transplant, in a cruel twist, families have been approached by organ procurement boards to request their loved one’s remaining organs.¹² Any system that encourages donation to a pool of resources but denies individuals access to that same pool is inherently flawed.¹³ While the law does not explicitly prohibit offering transplants to undocumented immigrants per se, a lack of health insurance coverage effectively does.⁷ As a result, it is rare for an undocumented immigrant to receive a transplant. Despite the present inequality, immigrant communities remain generous in their desire to contribute to organ and tissue banks. One study found that 74 percent of sampled immigrant respondents indicated a willingness to donate, even after being provided information about the low likelihood of reciprocity.¹⁴

Extending transplants to immigrants is frequently seen as a liability, since every graft that fails due to medication nonadherence represents someone on the waitlist who could have lived.¹⁵ Legitimate concerns have been raised surrounding the belief that organs tend to fail among undocumented immigrants due to poor follow-up and lapses in immunosuppression.¹⁶ More recent studies have challenged this assumption and found that resident non-citizens have comparable graft and overall survival rates when controlling for medical tourists (individuals who visit the U.S. solely to obtain healthcare).¹⁷ Undocumented immigrants on dialysis are typically younger and likely to be productive members of society with a kidney transplant.¹⁸

Even still, funding and insurance are major roadblocks. Pediatric transplant patients run into trouble when Medicaid expires; one in five transplants fail in such patients after they reach adulthood.¹⁹ Volatile immigration policy has also been cited as a reason for denying life-saving transplants to immigrants since sudden deportation would prevent secure and adequate follow-up.²⁰

Little has been done from a national policy standpoint to address this issue, and new federal legislation has even been proposed to codify preferential organ allocation to lawful citizens.^15,21 In light of organ shortages, patients with citizenship may feel cheated if undocumented patients get a kidney before them. Some opponents argue that transplantation is expensive and immigrants do not contribute enough financially to be considered candidates. However, most unauthorized immigrants pay state and federal taxes which amounts to billions of dollars in contributions without the benefits of citizenship.^22-23

Ultimately, uninsured patients with renal failure who cannot get a transplant will get sicker and require repeated emergent dialysis, which is extremely expensive ($300,000-400,000 per person per year); this life-saving care is already being funded by taxpayers and must be provided by law.²⁴ Research shows that transplants are the better option for patients and more affordable than even scheduled dialysis.⁴ In order to curb costs, the state of Illinois has already pioneered a program to fund transplants for undocumented immigrants. In addition to being more equitable, this is more cost effective in the long run: a kidney pays for itself in 18 months.⁸ Hopefully other states and governing bodies will soon take notice.

It is time for transplants to be more equally available to all permanent residents of the U.S. regardless of citizenship status. Ethically, therapeutically, and financially, this goal makes the most sense. Undocumented immigrants are donating organs disproportionately to a system that essentially turns its back on them. Just as in the early days of ethics committees in Seattle, individuals who are otherwise excellent candidates for transplant are being rejected because of factors beyond their control. Despite a growing national organ shortage, solutions can be found in expanding organ procurement initiatives, securing funds, and adjusting public policy to be more even-handed.²⁵ Until systemic changes are made to address the needs of everyone, the cost of inequality is far too great.

1. Alexander S. They Decide Who Lives, Who Dies. LIFE Magazine. November 9, 1962:102-125.

2. Jonsen AR. The god squad and the origins of transplantation ethics and policy. J Law Med Ethics. 2007;35(2):238-240. doi:10.1111/j.1748-720X.2007.00131.x

3. Goldberg M. Here Come the Death Panels. The New York Times. https://www.nytimes.com/2020/03/23/opinion/coronavirus-hospital-shortage.html. Published March 24, 2020. Accessed January 24, 2021.

4. Abouna GM. Organ shortage crisis: problems and possible solutions. Transplant Proc. 2008 Jan-Feb;40(1):34-8. doi: 10.1016/j.transproceed.2007.11.067. PMID: 18261540.

5. United States Renal Data System. 2018 USRDS annual data report: Epidemiology of kidney disease in the United States. National Institutes of Health, National Institute of Diabetes and Digestive and Kidney Diseases, Bethesda, MD, 2018.

6. Hart A, Smith JM, Skeans MA, et al. OPTN/SRTR 2017 Annual Data Report: Kidney. Am J Transplant. 2019;19 Suppl 2:19-123. doi:10.1111/ajt.15274

7. Gupta C. Immigrants and organ sharing: A one‐way street. AMA J Ethics 2008; 4: 229– 234.

8. O'Neill E. Transplants A Cheaper, Better Option For Undocumented Immigrants With Kidney Failure. NPR. https://www.npr.org/2019/05/12/721800514/transplants-a-cheaper-better-option-for-undocumented-immigrants-with-kidney-fail. Published May 12, 2019. Accessed January 24, 2021.

9. Maier S. Undocumented Immigrants' Transplant Survival Rates on Par with U.S. Citizens'. UC San Francisco. https://www.ucsf.edu/news/2019/09/415451/undocumented-immigrants-transplant-survival-rates-par-us-citizens. Published January 8, 2021. Accessed January 24, 2021.

10. Glazier AK, Danovitch GM, Delmonico FL. Organ transplantation for nonresidents of the United States: a policy for transparency. Am J Transplant. 2014;14(8):1740-1743. doi:10.1111/ajt.12770 immigrants: an assessment of knowledge and attitudes. J Clin Ethics. 2013;24(4):364-372.

11. Raghavan R. New Opportunities for Funding Dialysis-Dependent Undocumented Individuals. Clin J Am Soc Nephrol. 2017;12(2):370-375. doi:10.2215/CJN.03680316

12. Baru J. Organ Donation Among Undocumented, Hispanic Immigrants: Assessment of Knowledge and Attitudes. [Youtube]. Cook County Hospital, Chicago IL, United States: MacLean Center. Published February 6, 2014. Accessed January 24, 2021.

13. King LP, Siminoff LA, Meyer DM, et al. Health insurance and cardiac transplantation: a call for reform. J Am Coll Cardiol. 2005;45(9):1388-1391. doi:10.1016/j.jacc.2005.01.032

14. Baru JS, Lucas BR, Martinez C, Brauner D. Organ donation among undocumented hispanic immigrants: an assessment of knowledge and attitudes. J Clin Ethics. 2013;24(4):364-372.

15. Grubbs V. Undocumented immigrants and kidney transplant: costs and controversy. Health Aff (Millwood). 2014;33(2):332-335. doi:10.1377/hlthaff.2013.0462

16. Ackah RL, Sigireddi RR, Murthy BVR. Is Organ Retransplantation Among Undocumented Immigrants in the United States Just? AMA journal of ethics. 2019;21(1):E17-E25. doi:10.1001/amajethics.2019.17

17. Lee BP, Terrault NA. Liver Transplantation in Unauthorized Immigrants in the United States. Hepatology (Baltimore, Md). 2020;71(5):1802-1812. doi:10.1002/hep.30926

18. Linden EA, Cano J, Coritsidis GN. Kidney transplantation in undocumented immigrants with ESRD: a policy whose time has come?. Am J Kidney Dis. 2012;60(3):354-359. doi:10.1053/j.ajkd.2012.05.016

19. McEnhill ME, Brennan JL, Winnicki E, et al. Effect of Immigration Status on Outcomes in Pediatric Kidney Transplant Recipients. Am J Transplant. 2016;16(6):1827-1833. doi:10.1111/ajt.13683

20. Segal B. Undocumented Organ Transplants. Bill of Health. https://blog.petrieflom.law.harvard.edu/2017/03/06/undocumented-organ-transplants/. Published March 6, 2017. Accessed January 24, 2021.

21. To Amend the Public Health Service Act to Establish a Preference, in the Allocation of Donated Organs, for Individuals who Are Lawfully Present in the United States, and for Other Purposes. HR 5518, 115th Cong (2018).

22. Merrell, M., 2007. The impact of unauthorized immigrants on the budgets of state and local governments. Congress of the United States, Congressional Budget Office.2

23. Shoichet CE. Undocumented immigrants are paying their taxes today, too. CNN. https://www.cnn.com/2019/04/15/us/taxes-undocumented-immigrants/index.html. Published April 15, 2019. Accessed January 24, 2021.

24. Rizzolo K, Novick TK, Cervantes L. Dialysis Care for Undocumented Immigrants With Kidney Failure in the COVID-19 Era: Public Health Implications and Policy Recommendations. Am J Kidney Dis. 2020;76(2):255-257. doi:10.1053/j.ajkd.2020.05.001

25. Maggiore U, Oberbauer R, Pascual J, et al. Strategies to increase the donor pool and access to kidney transplantation: an international perspective. Nephrol Dial Transplant. 2015;30(2):217-222. doi:10.1093/ndt/gfu212