Conceptions of Reciprocity: The Navarro transplant case, organ allocation and undocumented immigrants
The following piece was prepared for the blog AccessDenied: A Conversation on Unauthorized Im/migration and Health and is cross-posted here with permission.
Organ donors give the gift of life, but the sheer volume of patients hoping for transplants far outstrips donor generosity. How should we make decisions to ensure the equitable distribution of a limited supply of organs? In a system that depends on the goodwill of donors and public trust, this question becomes further complicated when undocumented immigrants seek transplants – especially in the United States, where undocumented immigrants consent to donate organs more often than they receive them. In light of this fact, should citizenship be a substantial consideration? Or should allocation decisions be made according to a claim of reciprocity – i.e., that individuals or groups who are willing to donate are more entitled to receive organs than others?
In the recent case of Jesus Navarro, assertions of reciprocity became a key factor in driving public awareness. Navarro, a 35-year-old father from Oakland, California, became the focus of media attention when it was reported that he might not receive a needed kidney transplant because of his immigration status. This prompted a public campaign on Navarro’s behalf led by Donald Kagan, who himself received a transplant from an immigrant donor. The campaign thereby accentuated a key dilemma: how can an allocation system justify a policy of readily accepting organs irrespective of immigration status, but deny transplants based on the same criterion?
In responding to these public advocacy efforts, Chief Medical Officer Dr. Josh Adler at the University of California San Francisco (UCSF), the hospital handling Navarro’s case, issued a joint press release with Navarro that differentiated between Navarro’s comprehension of the situation and the hospital’s official policy:
[Navarro's] undocumented immigration status … was a concern for UCSF because it increases the risk that Mr. Navarro will not … receive the follow-up care and medication needed to stay healthy after a transplant …
Mr. Navarro has told UCSF that, to him, this meant he would not get a transplant until he resolved his immigration status; this was not what UCSF was trying to convey. Instead, UCSF was following its policy to make sure Mr. Navarro would continue to have the health insurance necessary to receive proper post-transplant follow up.
UCSF historically has performed transplants on undocumented immigrants, and it claims not to discriminate on the basis of immigration status. At present, the hospital is keeping Navarro’s position on the waitlist. His case did, however, prompt UCSF to publicly acknowledge the precarious position of undocumented immigrants and the difficulties they face in financing follow-up care.
Navarro’s predicament is not new, nor was it handled in an abnormally unjust way. As Danielle Ofri, a physician at New York’s Bellevue Hospital, has noted in recounting the story of one of her patients, Julie B., who is undocumented and who needs a heart transplant,
It is unlikely that she’ll ever get it, because she lacks papers. I’m well aware that there’s not a lot of public sympathy for someone who came to America illegally.
But when illegal immigrants die in America, their families often graciously bequeath their organs for donation. Many Americans are alive because of the generously [sic] of undocumented immigrants.
Yet this argument for reciprocity does not satisfy those who support the competing notion of allocation based on citizenship. Many Americans want to determine transplant accessibility based on a logic of accepting citizens and rejecting foreigners, as public comments responding to media coverage of the Navarro case in the Huffington Post and ABC News attest.
At present, ad hoc negotiations of equity persist. The current U.S. system for allocating organs does not distinguish between undocumented recipients or donors on the basis of citizenship status,although it does keep track using the broad category “foreign nationals.” There have been reviews of policy, and these issues remain on the table. Still, ultimate decisions are devolved to transplant centers.
As Jesus Navarro’s and Julia B.’s cases highlight, distribution criteria that some perceive as systematically non-discriminatory constitute injustice to others. Distribution decisions based solely on what is most clinically prudent can still hide inherently unjust inequities. Many, including Ofri, advocate for a system in which transplant priority is given to recipients who are registered as donors. Proponents argue that this will prompt more people to register as donors, thereby boosting the organ supply. This would also force individuals and communities to confront the unfair disjuncture that arises when patients are unwilling to donate themselves, especially for religious or cultural reasons, but willing to receive organs from others.
Yet adopting a policy of reciprocity based on willingness to donate has its own complications. Because transplant matching depends in part on genetic factors linked to ethnicity, minority patients are unduly affected when low numbers of individuals from ethnic minority communities register as donors. Although these numbers may seem to reflect reciprocity and fair allocation on a demographic level, they actually conceal health outreach inequities and the disproportionate amount of minority patients who suffer from diseases that necessitate transplants. Debates about how donation can be incentivized without disproportionately affecting marginalized populations invoke concerns about donor commodification. Such debates also demonstrate the need for marginalized communities to participate in determining donor recruitment practices and organ allocation policies. The blog TransplantInformers, where I serve as Managing Editor, is one source that extensively covers ethnic underrpresentation on donor registries and advocates for the interests of marginalized communities in donor outreach and education.
The Navarro case, and dilemmas of undocumented migration and transplantation more broadly, provide an opportunity for us to challenge denials of transplant access. However, given the discrete supply of organs, we must still make difficult choices about how we weigh the criteria in deciding who receives the gift of life.