There is an ongoing discussion in America about how undocumented immigrants both access and use health resources. In a recent article published in the AMA Journal of Ethics, researchers examined the issue through the lens of emergency retransplantation procedures and posttransplant care.
The researchers illustrated the case of Anna, an undocumented immigrant who received a life-saving kidney transplant at the age of 2 through hospital resources for charity transplants, supplemented by Medicaid. At the age of 18, Anna was notified that Medicaid resources would no longer be available to her for transplant-related care. This included immunosuppressive drugs to maintain the transplant and regular appointments with a physician to follow up. Because Anna could not afford to purchase the medication, her transplant failed 2 years later.
In a case like Anna’s, there are a variety of factors that determine what can and should be done for such a patient. Under current legislation, undocumented immigrants are excluded from federally funded public benefits including Medicare and Medicaid. Additionally, undocumented immigrants are denied state and local public benefits, leaving it to each state to individually extend public benefits as they see fit. In most states, only transplant recipients with permanent legal status can receive federal funding for the long-term care that comes with an organ transplant. This raises the question of whether it is ethical to offer undocumented immigrants retransplant when they will likely not have access to appropriate posttransplant care.
Some opponents of retransplantation for undocumented immigrants state that these immigrants do not contribute financially to society at the same level as a citizen, and thus have no claim to resources. They worry that immigrants may take advantage of organ retransplantation only to have the transplant fail because of improper care, leading to an overuse of resources. However, proponents of retransplantation for undocumented immigrants argue that it is a basic human right to have access to care. They say that denying care to undocumented immigrants solely based on that status conflicts with physicians’ ethical responsibility.
Transplant physicians do have a responsibility to treat life-threatening conditions, but for people like Anna who have renal failure, dialysis is an option. Studies show that repeat grafts demonstrate deceased survival rates with each subsequent graft, and physicians must weigh factors like this when determining whether a patient should be listed to receive a retransplant. Particularly for patients who will not be able to receive follow-up care, physicians should consider the risks vs benefits of offering retransplantation. However, it could be argued that by denying retransplantation, a physician is failing in his or her ethical responsibilities. In one study, physicians reported feeling moral distress when faced with deciding who should receive emergency dialysis or retransplantation. Additionally, data show that retransplantation is associated with a 50% reduction in mortality relative to remaining on dialysis after a 1-year post-retransplant period, suggesting that retransplantation is the optimal treatment.
The authors proposed several recommendations for what may be done to treat undocumented patients who require retransplantation. They suggest that policy be created to address follow-up care for patients beyond age 18 years. One option for this would be an extension of resources such as Medicaid or Children’s Health Insurance Program. As an alternative, funding at both a federal and state level could be secured for follow-up care including immunosuppressive medications. These measures would ensure maintenance of transplanted organs for undocumented patients, alleviating the burden from both patients and physicians when treating these cases.
Ackah RL, Sigireddi RR, Murthy BVR. Is organ retransplantation among undocumented immigrants in the United States just? AMA J Ethics. 2019;21(1):E17-E25.