“Be careful when you travel, or you might wake up in a bathtub missing a kidney!” Many of us have heard some variation of this warning, either in jest or earnest depending on the paranoia of one’s parents or friends. The not-so-subtle implications of this urban legend are that healthy organs are in short supply, and that American travelers are used as an unwitting source. While the former is certainly accurate, the latter is actually the opposite of the truth. In fact, the scarcity of donor organs, as well as the cost associated with post-transplant medical care, has contributed to profound inequities in organ transplantation that disadvantage and exploit immigrants in the United States. More specifically, undocumented immigrants experience significant disparities in access to organ transplantation, despite being asked (and agreeing) to be deceased organ donors at rates similar to the rest of the U.S. population. This represents a significant injustice within our organ transplant allocation system that, if left unremedied, makes continued requests for organ donation from undocumented immigrants unethical. 

A 2022 report from the National Academies of Science, Engineering, and Medicine noted that roughly 3% of deceased organ donations – organs donated after a patient has died – are provided by undocumented immigrants. While this may not seem like a significant percentage, it is proportionate to the number of undocumented immigrants living in the US: about 10.7 million people as of 2016, or 3% of the U.S. population. Despite contributing proportionately to the United States’ supply of life-saving organ donations, undocumented immigrants are not treated as equal partners in our organ transplant allocation system. For example, only 0.4 % of deceased donor liver transplants go to undocumented immigrants – this represents a stark disparity between what our organ donation system asks of undocumented immigrants, and what it offers to them.

The Barrier of Post-Transplant Care

According to the official policy of the Organ Procurement and Transplantation Network, citizenship and residency status cannot factor into decisions on whether to allocate an organ to a specific patient. In other words, the decision not to grant an organ to a patient cannot be based on their status as an undocumented person. However, organ allocation decisions can and do consider a potential recipient’s ability to remain compliant with post-transplant care; given the significant cost of immunosuppressive medications and other post-transplant care, this requirement essentially rules out many uninsured patients, including undocumented persons. As a result, a patient with end-stage renal disease who is undocumented may be denied a kidney transplant based on the belief that a lack of access to post-transplant care will lead to a worse prognosis – this same patient, however, may be asked to agree to donate their liver, lungs, or corneas when they die. This discrepancy plainly violates the important bioethical principles of justice and reciprocity: our current system of organ allocation asks far more of undocumented persons than it is willing to offer them. 

Facilitating Transplants for Undocumented Immigrants Is Possible

To remedy this issue, we recommend nation-wide eligibility for funding of post-transplant care for undocumented patients who are otherwise eligible for transplant. Importantly, there is precedent for such a change. In California, for example, pediatric patients who require transplant are eligible for Medicaid funding for post-transplant care up to the age of 18. Moreover, federal and state governments have demonstrated their willingness and ability to cover the cost of long-term post-transplant care for adults: starting this year, patients who receive kidney transplants “qualify for lifetime Medicare coverage of their immunosuppressive drugs, regardless of age”. Based on these existing policies, one possible mechanism for achieving a more just allocation of organ donations would be to expand California’s model of Medicaid coverage for post-transplant care to undocumented children nation-wide, as well as beyond the age of 18. A second possibility would be to include undocumented persons in the aforementioned recent Medicare coverage expansion (although this would only address the current inequity as it pertains to kidney transplants).

Facing the Challenges Ahead

While we have offered possible solutions to help remedy disparities in organ transplantation among the undocumented population, we acknowledge that these solutions will not be without their challenges. Some common objections include expense, difficult political messaging, and the potential of increased immigration to the U.S. for medical care. 

As to criticisms regarding the potential expense of these solutions, we respond by pointing to the relatively small proportion of the US population made up of undocumented immigrants. Including undocumented persons in the policies mentioned above is unlikely to pose a significant cost increase to Medicare. Representing only 3% of the U.S. population, undocumented immigrants accounted for just 0.2% of Medicaid expenditures and 0.03% of total national health expenditures in 2016. 

Another likely objection is the difficult political messaging associated with our proposed policies. Providing federal and state funded healthcare to undocumented immigrants has been a contentious political issue in the U.S. for decades, with many associated misconceptions – one common myth being that undocumented individuals do not contribute to paying taxes that cover state and federal health programs like Medicaid and Medicare. In reality, many undocumented persons working in the U.S. have taxes withheld by their employers. In 2018, for example, undocumented immigrants contributed approximately $20.1 billion in federal taxes and $11.8 billion in state and local taxes in 2018 – these funds are vital for sustaining Medicare and Medicaid. Similarly, without the generosity and selflessness of undocumented deceased organ donors, there would be significantly fewer organs available for transplant in the United States.

Another concern raised by opponents to funding post-transplant care for undocumented immigrants is that this might incentivize individuals to travel from their home countries to obtain organ transplant in the U.S. However, current law requires that individuals reside in the U.S. for at least 5 years before qualifying for Medicaid; this requirement can be extended to undocumented persons requiring organ transplantation. Additionally, health benefits are among the least common reasons for immigration, the most common ones being economic opportunity, dire climate, and security. 

Our Duty to Pursue Equity in Transplant Care

While there will be challenges to expanding these policies to cover undocumented immigrants, these obstacles do not change the fact that it is our moral obligation to do so. We have a duty to make sure that we do not exploit the altruism of an already disadvantaged population, and to pursue justice, transparency, and reciprocity in the organ transplant allocation system. If we want to make certain that our system of organ allocation does not exploit undocumented immigrants, we have two choices: we can either ensure that undocumented persons are treated as equal partners in this system, or we must cease asking these patients to become deceased organ donors.

Daniel Harwood, MD, MBE (@Dan_Z_Harwood) is a graduate of the Perelman School of Medicine at the University of Pennsylvania

Hilary Bediako, MD, MBE (@hilarybediako) is a graduate of the Perelman School of Medicine at the University of Pennsylvania