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Illegal Aliens Are Not Entitled to Federally Funded Organ Transplants

2007; Wolters Kluwer; Volume: 83; Issue: 1 Linguagem: Inglês

10.1097/01.tp.0000247806.81033.fc

1534-6080

Amy L. Friedman, Eli A. Friedman,

Renal Transplantation Outcomes and Treatments

Warren Buffett, the world’s second richest man, recently gifted $31 billion to the Bill & Melinda Gates Foundation, founded by the world’s richest man (1), intending to decrease disparity in health care between developing and industrialized nations. Whether comparing life expectancy (Japan 81.2 years, Botswana 33.9 years in 2005) (2), infant mortality (Angola 191 per 1000, Sweden 2.8 per 1000 in 2005) (2), or literacy (Australia 99.5%, Burkina Faso 12.5% in 2005) (3), the contrast between life quality in affluent versus indigent nations is viscerally distressing. Disparity between have and have not societies was aptly characterized by President George W. Bush: “A world where some live in comfort and plenty, while half of the human race lives on less than $2 a day, is neither just, nor stable” (4). America was built by immigrants seeking the “new” nation’s unique political and socioeconomic freedom that in more recent times was coupled with ready availability of health services. In 2006, the United States, with a population of 300 million, the third most populous nation—after China and India, each with over one billion—is struggling to cope with tens of millions of illegal immigrants seeking escape from hopelessness and a share of what has been termed “the American Dream.” Goldberg, Simmerling, and Frader, elsewhere in this journal (5), argue that “nondocumented residents” deserve access to kidney transplantation as a federal entitlement. At a time when America is being torn asunder by Congressional and media debate as to how, where, and when to handle (admit–expel) illegal (undocumented) aliens, Goldberg, Simmerling, and Frader’s position paper (polemic) well expounds one side of the argument pertaining to distribution of organs. It is fascinating to observe how the authors dance, searching for terms for the group of uremic patients for whom they advocate a right for healthcare funding calling them variously “nondocumented residents, illegal,” or “immigrants” as they maneuver to make their case. Traveling through “Alice’s Looking Glass,” these proponents of American payment for kidney transplants for all who cross our borders state: “An allocation paradigm resting on organs-for-Americans-only raises ethical problems.” On their side lies compassion and all the good things physicians intended to accomplish by deciding to enter medical school. No mentally competent, ethical physician would opt to deny life-sustaining treatment that he or she is enabled to provide. Establishing demographic and other criteria defining which therapies are to be given at governmental expense, however, because it impacts every taxpayer, is a matter properly open to broad debate because even rich nations cannot afford “everything.” Cosmetic surgery, for example, falls outside of entitlements in even the most liberal socialized countries. Clearly, transplantation is a high-end medical product that still depends on some of the most fundamental principals of modern medicine such as control of diet, glucose, and hypertension, medication adherence, and reliable patient behavior for optimal outcomes. Uniquely, initial provision of this technology depends on two scarce resources, the donor organ and a source for financial reimbursement. Yet, even successfully overcoming these initial obstacles does not suffice to assure long-term survival, which must be the ultimate goal of treatment. Proposals for extension of federal coverage to illegal alien residents for the transplant itself cannot be considered independent of the realities of chronic disease treatment within the current American medical context. Fiscal consequences of affording all healthcare services, including organ transplants, to persons illegally in the United States should be explored in detail. How can organ transplantation be spotlighted separately from the clearly troubled American health insurance system? With more than 15% of Americans lacking any form of healthcare insurance, it is no surprise that data demonstrate a strong adverse impact on the quality of medical care these 45 million individuals receive (6). Being uninsured is linked with increased likelihood of an inability to see a physician when needed, deficits in cancer screening and diabetes care (7), higher mortality rates (8), inadequate control of hypertension (9), lower medication adherence (10), and low rate of access to kidney transplantation (11), heart transplantation (12), and liver transplantation (13). There is no longer doubt that uninsured American citizens and legal residents who are legitimate dependents of the flawed health system are in serious medical jeopardy because of the lack of health care when needed. Goldberg, Simmerling, and Frader argue not that funded transplantation for nonresidents is more important or appropriate than providing health coverage for legitimate residents, but that it would save millions of federal dollars because this therapy for end-stage renal disease is less expensive over the long term when compared with dialysis. Although this simplistic view may be accurate for some illegal aliens, organ transplantation for foreigners is likely to prove much more risky and expensive on average than for a legal resident/citizen because of the need to diagnose/treat untreated comorbid infirmities and indolent infectious diseases, such as tuberculosis, now at an all time low in American citizens, although endemic elsewhere. There are other inordinate, unreimbursed, and untracked expenses generated by the care of illegal recipients, including “fundraising” by the hospital and the costs for federally mandated translators. For example, when President William J. Clinton signed Executive Order 13166 into law on August 11, 2000 (14), the federal government officially required that private physicians, clinics, and hospitals that accept Medicare and Medicaid must, at their own expense, provide translators for any language spoken by any patient. The U.S. Office of Management and Budget reported that the increase in healthcare costs would total $267.6 million. The American Medical Association estimated that the cost of an interpreter can exceed the reimbursement of a Medicare or Medicaid visit by 13 times. The Department of Health and Human Services insists that providers subject to the order who do not provide, without charge, to (limited English-proficient) patients, on request, translation services into any language are guilty of discriminating on the basis of national origin in violation of the Civil Rights Act of 1964 (15). Furthermore, it is reasonable to project that illegal aliens with functioning organ allografts will decide to have family members join them in America where allograft-sustaining teams and medicines unavailable in their home countries are dispensed (without cost to the patient) as a taxpayer-funded entitlement. Thus, hidden costs surrounding organ transplants in illegal aliens would likely eradicate any benefit to American taxpayers generated by their manual or intellectual productivity. The economic balance sheet yields a negative sum. Beyond the funding for the transplant itself is a question overlooked by Goldberg, Simmerling, and Frader, of whether nondocumented residents are likely to prove responsible guardians of an allograft. Why should an individual whose very presence in the United States represents a determination to disregard regulations (often despite a risk of serious adverse consequences) be expected to adhere to a complex medication regimen, keep patient appointments, and generally cooperate with authority figures, even those who ostensibly seek to help? In fact, insured but undocumented patients were more likely to miss physician and emergency room visits than insured nonimmigrants in California (16). It may be inappropriately risky to initiate a state of immunosuppression, with the consequent risks and requirements for close monitoring, in an individual who is unlikely to behave responsibly or in a patient who cannot manage the medication costs that are not covered by Medicare. In mid-Summer 2006, with only 80% of immunosuppressants funded for the first three years after kidney transplantation, and varying coverage for the other medications, many low-income patients are confronting increasing obstacles to adhering to their pharmacologic regimens and require exorbitant support to avoid treatment gaps (17). Illegal aliens do not qualify for the pharmaceutical assistance programs that often prove to be the safety net for citizens and legal residents. Until success in extending coverage to the life of a kidney transplant is achieved, placing any indigent patient without alternate resources in a circumstance requiring ongoing unaffordable medication may be unreasonable. The costs and risks of funding kidney transplantation for nonresidents may well prove to be prohibitive, even if an organ is available from a living donor. However, for those individuals lacking a designated donor, an additional pragmatic reality is that every illegal person given the scarce resource of a dead donor kidney denies that kidney to a waiting list that has a median time of more than 5 years; in some areas, such as New York City, it is often 10 years. On July 1, 2006, the Organ Procurement and Transplantation Network of The United Network for Organ Sharing listed 70,552 patients waiting for a kidney transplant of whom 7,484 had been waiting for five or more years. Goldberg, Simmerling, and Frader’s comparison of facilitating illegal aliens’ access for a kidney transplant with their relatively ubiquitous access to dialysis under emergency Medicaid fails because putting A on dialysis does not deny dialysis treatment to B, but giving a scarce dead donor kidney to an illegal alien de facto removes that kidney from use in American citizens. We concur that access to placement on the waiting list should not be proportionately linked to the rate of donation among a patient’s own demographic cohort, particularly because United Network for Organ Sharing does not track the types of demographics noted (such as religious demographics). Nevertheless, the type of check and balance system on which America is based is appropriately used to ensure at the individual transplant center level that the lists are not flooded by nonresidents. The individual nonresident placed on the list still enjoys equal representation in the allocation system by the nondenominational and unbiased computer. Just as there are liberal and conservative positions on sealing American borders to illegal transgressors, so are there polarized positions advocating or rejecting allocation of (paying for) federally subsidized kidney transplants for persons illegally residing within the United States. Other industrialized countries faced the issue by resoundingly rejecting the concept that any person within a country is entitled to the social and medical benefits bestowed on its citizens. Mexico, for example, although vehement in protesting intensified American border security, has a single, streamlined law (18) that ensures that foreign visitors and immigrants are: in the country legally, are able to sustain themselves economically, are of good character and have no criminal record. On entering Mexico from the United States, border guards create a record for each foreign visitor and require that they not violate their visa status or interfere in the country’s internal politics. Foreign visitors who enter under false pretenses are imprisoned or deported, whereas those who aid in illegal immigration are sent to prison. France recently approved a firm immigration law that will permit foreigners to enter the country only if they are able to earn an income, replacing regulations that previously allowed illegal immigrants to obtain French documents after 10 years. The French government, which estimates that as many as 400,000 illegal immigrants now reside in France, is planning 26,000 deportations this year (19). Illegal aliens in France do not have a presumed entitlement for government-funded kidney transplants. Is it ethically defensible to restrict benefits for American patients as a result of imposition of requirements that costs for illegal aliens be drawn from the same budget allocation? Ultimately, every dollar/organ for illegal recipients must be taken away from legitimate recipients. Until reasonable means of allocating resources are developed, support of a consistently expanding cohort of illegal recipients poses a dilemma analogous to that provoked by the request to initiate dialysis support for obviously futile geriatric intensive care unit patients with multiorgan failure. In both circumstances, confronting the enormous fiscal burden blurs and diverts attention from weighing otherwise evident ethical implications. The issues under examination can be sharply focused: Do nations have the right to restrict entry to individuals with advanced illness who are unable to obtain needed life-sustaining therapy, meaning near-term death is probable? Are individuals who entered a nation illegally, or overstayed the terms of a legal visa, entitled to government-funded health care, including organ transplants? Once discovered to be illegally residing in a nation, does that nation have the right to deport an individual, even should the person have a serious illness? Do children of illegal immigrants, born outside of the United States, have a right (entitlement) to health care, meaning that their parents or guardians are then permitted to continue residence? Rather than protract a nonproductive series of arguments and rebuttals, however, Goldberg, Simmerling, and Frader should be credited for introducing a truly sensitive subject to a proper venue for its analysis. Every transplantation team delivering uremia therapy has had to cope with restrictions on organ distribution imposed by current regulations. An avid intellectual debate will be both informative and appropriate while perhaps promoting resolution to current intense stresses on transplant teams wanting to provide replacement organs to all who might benefit. We challenge the wisdom of redistributing limited financial resources to fund kidney transplants that are relatively high risk and disproportionately expensive for illegal aliens whose ability to responsibly serve as a secure host for a precious organ is unproven. Our perspective is that opting to cover a single kidney transplant for an illegal resident in lieu of providing fundamental health care to multiple legal citizens and residents who will otherwise be untreated is not the most compassionate manner of allocating care for all served by a system in need of repair.