It is common knowledge that the supply of cadaveric organs does not meet demand. This shortage is often used as ethical argument against transplantation in Non-Resident Aliens; however, this fact in isolation does not present a comprehensive picture of organ allocation in USA. Even though approximately 153 cadaveric livers, kidneys, and hearts are transplanted into Non-Resident Aliens each year, roughly another 85 livers, kidneys and hearts are recovered as usable for transplantation but are not transplanted due to inability to find a recipient. These organs are also unable to be exported due to logistics or lack of patient matching. Because usable, recovered allografts are discarded on a yearly basis, there is no justification to use "allograft scarcity" as argument against transplantation in Non-Resident Aliens. Further, consistent with other countries, a system of two waiting lists which allocates organs to US Residents with the first right of refusal (with Non-Resident Aliens having access to organs refused by or not matched to US Residents) is ethically appropriate. Justification for this two-list system lies in deconstructing "who" is the transplant community, and who are "guests" of the transplant community.
Keywords: transplant, organ allocation, ethics, justice, discrimination, foreign national
Allograft scarcity across all organ types continues to be documented by the United Network for Organ Sharing (UNOS).1 In general, attempts to increase organ donation have not been very successful, with the number of organ donors increasing by only 3% each year.2 There is concern that the number of organs needed will never meet demand, thus there is an ethical imperative to allocate them fairly to patients with the capacity to benefit from them.3 Currently, UNOS permits Non-Resident Aliens (NRA) to be registered on the transplant waiting list and to receive allografts under the same allocation policies as that of United States (US) Residents.4 UNOS considers NRAs as those individuals "granted permission by the US Government to enter the US on a temporary basis as a non-immigrant alien for purposes which include tourism, business, education, medical care, or temporary employment".4 Residents are those who have the legal right to live permanently in the US.
UNOS allows each transplant center to allocate up to 5% of cadaveric transplants to NRAs.4 Approximately 153 cadaveric livers, kidneys, and hearts (total) are transplanted into NRAs each year.1 Most of these cases never receive media attention; however, when this does happen, the spotlight shines directly on US transplant policy. Emotions range from anger that NRAs "take" organs that "should" go to US Residents, to compassion for these needy individuals who are frequently poor, very sick, and unable to access transplant services in their own country.5,6,7
US Transplant Data
As of 27 May 2005, patients registered on the UNOS transplant waiting lists are in need of 95,618 organs (some patients need more than one type of organ). Sorted by citizenship, there are 88,656 US citizen registrations, 3483 Resident Alien registrations, and 851 NRA registrations. Specifically, NRA registrations comprise 0.89% of all registrations, 0.98% of kidney registrations, 0.91% of liver registrations, and 0.38% of heart registrations (www.unos.org). Between 1996 and 2003, NRAs were the recipients of 661 liver transplants, 399 kidney transplants, and 161 heart transplants. During this same period, US Residents were the recipients of 35,660 liver transplants, 64,479 kidney transplants, and 17,580 heart transplants (Table I).1 Donated livers, kidneys and hearts that were clinically suitable for transplant but were unused during this period totaled 679 (Table 2).1 These organs (approximately 85 per year) may have either been unmatched (no suitable donor found), or matched, but the potential recipient was unable to be contacted to arrange transplantation. …