Posted on December 10, 2014 at 11:12 PM
The title of the article in the Journal of Medical Ethics
asks this question. The authors from the University of Montreal consider
this subject while the topic of “illegal aliens” or foreign nationals (FN’s) has
been a hot topic in the United States.
They however attempt to answer the problem from an international
perspective. The FN that we hear about
is usually in the country illegally, but may be in the country as a legal non-citizen,
visitor, non-permeant resident, refuge claimant, resettled refugee and in rare
cases a person detained by the government.
A patient who arrives at the emergency room requiring
hemodialysis would likely rapidly be started on renal replacement therapy. This is an emergency and since this is considered,
an emergency there would likely not be a question about the provision of such therapy.
What then about transplantation of a kidney?
Is renal transplantation an emergency treatment? We usually consider transplantation to be a
more economical form of treatment of the acute renal failure in the end, but the
lack of long term funding for medical care of the FN puts a different spin on
the subject. It is not just the procurement of the organ and the surgery but
also provision of and management of the immunotherapy necessary to prevent
rejection of the kidney and the technology to manage the therapy. A foreign national that returns to their
home country where there is not an infrastructure that can provide the drug
therapy or monitoring will reject the kidney.
There is a national issue of financing the care and the ethical and
national issues of obtaining the organ.
In the Eurotransplant member countries, there is no provision
for a FN obtaining a renal transplant.
In the UK, they can receive a transplant only if the organ is not
allocated to a UK resident. In the US, if
the organ procurement organization (OPO) lists a non-resident they have to
report it to the organ procurement transplant network, UNOS. Canada has no
policy. In France, they can receive a transplant if
there is no transplant available in the home country, the patient is not on any
other waiting list, and the patient can afford the cost of the procedure and
There are two ethical issues, national interests and the
ethical interests and responsibility of health care practitioners. The most
common arguments against FN organ transplantation other than financial are the
organ shortage and the waiting time for those already on the lists. Most argue that citizenship and residency
confers some rights. These people are
not tax payors, but also as a group, they are not part of the potential pool of
donors. One solution to the shortage
would to allow only living donor organs from relatives but the host country
would still have to fund the medical care involved in obtaining and maintaining
the organ. Others have expressed concern
about the respective countries becoming a favored medical care ‘destination for
transplantation.’ Lastly, there is
concern that if the general population knew of the practice of FN receiving
kidney transplants it would reduce the donation rates.
Physicians and other health care professionals have ethical
issues. FN’s can be viewed as a vulnerable
population and physicians are obligated to provide care without
discrimination. Physicians have a duty
to provide continuity of care. If the FN
was forced to go home after a transplant and could not receive the antirejection,
therapy they would have probably have been better served by not having the
transplantation in the first place and causing harm. Physicians have an ethical obligation to
provide non-discriminatory care based on immigration status. So providing
beneficial therapy and avoiding harm could be challenging.
Clearly, this issue is one that society should openly
discuss with a clear understanding of the cost and obligations of renal transplantations. In addition, societies should reconcile the
provision of nonemergency health care to FN’s, but in a manner that respects
the shortage of organs and avoids the possibility that the country is thought
of as a ‘medical destination’ for transplantation.
M-C, Williams-Jones B, (2014) Should we perform kidney transplants on foreign
nationals? Journal of Medical Ethics 40: 821-826
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