Liver Allocation to Non-U.S. Citizen Non-U.S. Residents: An Ethical Framework for a Last-in-Line Approach

International Travel for Organ Transplantation: Provider and Patient Perspectives

Background

Organ allocation in the United States to non-US citizen, non-US residents who travel for transplant (NC/NRTx) is controversial. Current policies may not be informed by stakeholder opinions, as limited data exist assessing the knowledge or opinions of providers or patients on this issue.

Methods

A cross-sectional, hospital-based pilot survey was distributed to providers and patients from December 2019 to June 2020 at a single large urban transplant institute. Providers were members of the departments of surgery and medicine and included both transplant and nontransplant providers. Surveys included 10 questions on eligibility, prioritization, and limitations for deceased donor transplantation and 12 demographic questions.

Results

A total of 209 providers responded (61% women, median age 40) and 119 patients responded (62% women, median age 54). Awareness of eligibility for transplantation of US citizens, non-US citizens residing in the United States (NC/R), and NC/NRTx was high in both groups, though providers and patients lacked awareness of the eligibility of nonlegal NC/R (those who live in the United States who are not citizens and are not legal residents) to donate and receive organs. Overall, 79.3% of patients stated that NC/NRTx should be eligible for transplant in the United States compared with only 60.7% of providers (P = 0.001). Providers were more likely than patients to prioritize transplant to legal NC/NR over NC/NRTx (58.2% versus 35.1%, P < 000.1) and reported that families should be able to limit donations to NC/NRTx (34.9% versus 23.2%, P = 0.03).

Conclusions

Surveyed patients and providers generally support transplant in non-US citizens; however, the strength of support varied considerably based on the legal status of the patient and the occupation of those surveyed. Larger studies are necessary to develop data-informed policy.

Pediatric kidney transplant in undocumented immigrants: An American perspectives

Kidney transplant in undocumented immigrants remains controversial. While in the United States the National Organ Transplant Act does not prohibit inclusion of these patients as transplant candidates, legislative and financial barriers and ethical concerns remain. The purpose of this article was to review the legal and financial barriers to kidney transplant for children with ESKD who are undocumented immigrants and consider arguments for and against inclusion of these children as kidney transplant candidates. While this discussion is largely restricted to the experience in the United States and its unique healthcare system, the themes and ideas may be more generalizable to the experience in many high-income countries. We conclude that access to kidney transplant is legal, ethically justifiable, and clearly in the best interest of these children. Transplant professionals should continue to advocate for changes in policy and greater resources to support these patients.

Liver Transplantation in Unauthorized Immigrants in the United States

BACKGROUND AND AIMS

Eleven million unauthorized immigrants reside in the United States and may account for 3% of deceased organ donors. Recently introduced federal and state legislation propose to address access to organ transplantation among unauthorized immigrants. The national landscape of liver transplantation (LT) for unauthorized immigrants is unknown.

APPROACH AND RESULTS

We included all US LT recipients between March 2012 and December 2018 who were linked to Pew Center of Research data to estimate the population of unauthorized immigrants in each US state and by country of origin, based on US Census data. We categorized patients as unauthorized immigrants versus US citizens/residents. The main outcome measures were (1) the proportion of LTs performed for unauthorized immigrants compared with the proportion of unauthorized immigrants among total population in each US state and (2) graft failure and death post-LT. Of 43,192 LT recipients, 43,026 (99.6%) were US citizens/residents and 166 (0.4%) were unauthorized immigrants. Among unauthorized immigrants, most LTs were performed in California (47%) and New York (18%). The absolute difference in proportion of LTs performed for unauthorized immigrants compared with the proportion of unauthorized immigrants among the total population differed among states, ranging from +20% in California to -12% in Texas. The most common countries of birth among LT recipients who were unauthorized immigrants were Mexico (52%), Guatemala (7%), China (6%), El Salvador (5%), and India (5%). In competing risk analysis, unauthorized immigration status (vs. US citizens/residents) was associated with a similar risk of graft failure (subdistribution hazard ratio [sHR] 0.74; 95% confidence interval [CI], 0.40-1.34; P = 0.38) and death (sHR 0.68; 95% CI, 0.36-1.29; P = 0.23).

CONCLUSIONS

LT for unauthorized immigrants is rare, and disparities in access to LT by state are present. Patient and graft survival among unauthorized immigrants is comparable with citizens/residents.

Organ Transplantation for Foreign Nationals in Canada: A Survey of Transplant Professionals

Background:

Transplantation for foreign nationals (non-citizens and non-residents) (FNs) in Canada is a complex issue. Currently, there are no Canadian guidelines for the provision of organ transplantation for FNs, and no empirical data on this issue or on transplant professionals’ practices are available.

Objective:

This project aimed to gather empirical data on transplant professionals’ perspectives and practices regarding transplantation for FNs.

Design:

Survey research design.

Setting:

A Web-based survey of members of the Canadian Society of Transplantation (CST).

Participants:

All members of the CST were invited to participate between April and June 2016.

Measurements:

Multiple-choice questions were developed to capture participants’ attitudes toward different fictitious clinical scenarios in which an FN needed a transplant, their experiences with FNs, their attitude toward FNs in need of transplantation, their knowledge about relevant institutional and organ donation organization (ODO) policies, and their perspectives on a quota. There were two questions with a five-point Likert scale to measure respondents’ agreement with statements related to possible policy options and arguments for and against transplantation for FNs. There was one open-ended question about the content of transplant programs’ policies on transplantation for FNs.

Methods:

Descriptive statistical analysis were performed.

Results:

A total of 87 transplant professionals completed the survey. Over the 4-year period from 2012 to 2016, 47.1% of respondents dealt with at least one situation of listing or performing a transplant for an FN. Only 19.5% of respondents reported that their transplant program had a policy about transplantation for FNs and 59.7% did not know if their ODO had such a policy. When asked about policy options, 47.5% disagreed with a policy of no transplantation for FNs and 41.4% agreed with offering transplantation for FNs in some circumstances (including life-saving and non–life-saving organs). Study participants agreed that transplantation should not be offered to FNs traveling to Canada specifically for transplantation, that FNs should not be transplanted with organs not suitable for Canadian citizens and that there should not be a transplantation quota for FNs. Participants also seem to be more inclined to offer transplantation of life-saving organs, particularly for children.

Limitations:

The major limitation of this study is the low response rate of transplant professionals to this survey.

Conclusion:

This is the first study to describe Canadian transplant professionals’ perspectives on transplantation for FNs. The findings of this study will be of interest for future policy development on access to transplantation for FNs. Further studies are needed to gather various key stakeholders’ perspectives on this issue, as well as to analyze the legal and ethical issues and the economics, to develop future policies.

“Focus on Practice”-Clinical Ethics Consultation on an Orthotopic Liver Transplant Case

El artículo presenta un caso clínico, dirigido en el año 2011 por el equipo de servicio de consulta ética clínica del Instituto de Bioética y Humanidades Médicas de la Facultad “Agostino Gemelli” de Medicina de la Universidad Católica del Sacro Cuore en Roma (Italia). El caso clínico se refiere a los dilemas éticos sobre las perspectivas del paciente para recibir un trasplante hepático ortotópico porque no era residente del país y carecía de un cuidador para asistirlo durante el periodo de seguimiento, así como de un lugar para quedarse después de la cirugía.