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Official UNOS Response On Transplants for Non U.S. Citizens

Posted Feb 05 2013 5:29pm

As our readers know, I published a blog a while back questioning U.S policy on providing organ transplants to some non-U.S. citizens.  That blog raised even more questions and comments from our readers so I sent the following note to Anne Paschke one of the communications executives at the United Network for Organ Sharing, (UNOS) in Richmond, Virginia.  Below is my note to Anne followed by the official UNOS response.

Email to Anne Paschke

Hi Anne:

Some time ago I published a blog on foreign nationals getting transplants in the United States from American Donors.  I have only a passing familiarity with the issue and I”m hoping you can offer some clarification.  What is our official policy on non-U.S. Citizens getting transplants from American donors?  Does this policy only include foreign nationals with a passport or visa to visit the U.S. or does it also cover illegal immigrants?

My second question deals with the lost Angeles Times story of about five years ago where it was reported that the University of California, Los Angeles Medical Center transplanted four Japanese gangsters http://articles.latimes.com/2008/may/30/local/me-ucla30 .  Did that happen and if so how did it slip through the “Blind” system.

When I receive your answer I will likely publish it but without editing.  All I really want to be able to do here is to offer my readers the UNOS point of view on these issues.

Here is UNOS’ response:

 Before addressing more specific issues, it’s important to note a few facts and principles that guide how the Organ Procurement and Transplantation Network (OPTN) addresses transplantation of foreign nationals.  United Network for Organ Sharing (UNOS) operates the OPTN under federal contract.

  • An individual transplant hospital makes the decision to accept and list any transplant candidate according to its own evaluation process and its own medical judgment.  The OPTN has no authority to approve or deny an individual candidate’s listing or influence a listing decision made by a transplant center.
  • Federal law and regulation that guides the OPTN directs that allocation policy be based only on medical criteria and, to the greatest extent possible, utilize objective medical evidence.  The OPTN cannot develop allocation policy that addresses what may be considered “social worth” factors about any candidate.  The OPTN does not have authority to enforce laws regarding any individual’s citizenship or residency.
  • As the United States is a world leader in many forms of medical treatment, historically we have not denied access to transplantation for non-residents.  In some instances, people who have sought transplantation in the U.S. would have no chance to receive a transplant of the needed organ in their home country.
  • Transplant recipients who are U.S. citizens or residents occasionally benefit from organs donated by citizens or permanent residents of other countries.  This may be in the form of organs imported from other nations (chiefly but not exclusively Canada) or from non-residents who become donors in the United States.  Also, although there are some exceptions, most countries that perform transplants do not limit their services to their citizens only.  The principle of reciprocity is important to maintaining goodwill and trust in organ donation.

Given these facts and principles, the OPTN has developed policies to accomplish certain objectives:

  • To allow non-residents or non-citizens access to transplant services in the United States, while generally ensuring that the great majority of recipients are U.S. citizens or foreign nationals
  • To ensure that no individual transplant candidate gets more or less consideration for available organs based on non-medical factors, including citizenship or residency
  • (In recent times) to study patterns of donation and transplantation from non-residents to guide the development of future policy and keep the U.S. transplant system consistent with international guidelines and recommendations.

Recent changes to OPTN policy have made it differ somewhat from the policy that existed in the early years of the OPTN.  We’ll outline what has been in place and then discuss the current requirements and initiatives.  We’ll also discuss the most recent national trends.

Prior requirements and policies

The early history of OPTN policy was based on guidance from an advisory task force convened after the 1984 National Organ Transplant Act was passed.  The task force debated the principles outlined above and recommended that allocation policy generally allow limited access for non-residents to be considered for transplants, with no difference in how the individual candidate gets priority for a transplant.  The task force recommended that the OPTN strive for a ratio of no more than ten percent of transplant recipients as non-resident foreign nationals.

The OPTN does not control the listing of individual transplant candidates and could not set an up-front listing limitation.  Instead, it established a process to review the number of transplants performed each year at each transplant program.  Initially, if more than ten percent of the people transplanted at the program were non-resident foreign nationals, the OPTN would send the program an audit letter.  The program would be asked to provide more information about the non-resident recipients transplanted and any reasons why the program exceeded the threshold. Exceeding the audit threshold was not in itself a violation of OPTN policy.  However, if the audit revealed a persistent and intentional pattern of transplanting a high number of non-residents, the OPTN could consider further review or action against the member.

In practice, even though some transplant programs exceeded the review threshold, none ever did so by a very high margin.  Generally the programs had sufficient reasoning for the number of transplants they performed for non-residents.  Many have been in areas serving large non-resident patient populations, and often their local area has a similar proportion of non-resident organ donors.  (Among non-resident recipients of living donor transplants, it’s fairly common for the living donor to be a relative or acquaintance from their home country and who travels to the United States to donate, thus not affecting the ratio of access for U.S. citizens or residents.)

In 1995, the OPTN reevaluated the threshold policy, in part because very few transplant programs met or exceeded the ten percent audit threshold.  The review threshold was lowered to five percent of recipients and remained so until last year.

For purposes of the policy, the OPTN only applied the review threshold to non-resident foreign nationals; resident foreign nationals were considered on the same basis as U.S. citizens.  There was no definitional separation of legal non-resident status (such as a medical or student visa, work permit, etc.) from an illegal status.

The OPTN has never had authority or resources to verify legal residency status among candidate listings.  Anecdotally, however, it appears that the majority of non-residents as defined by the policy have had legal non-resident status.

Recent policy

In September 2012, the OPTN adopted a substantial revision to policy regarding transplantation of non-resident foreign nationals.  The changes were approved in part to address what the OPTN is most able to enforce within its authority.  They were also intended to gather more information to study potential future policies that may be developed, as well as to reflect consensus guidance from recent international transplant conferences.  You can read the policy in its entirety on the OPTN website: http://optn.transplant.hrsa.gov/PoliciesandBylaws2/policies/pdfs/policy_18.pdf .

The new policy eliminates the threshold for a transplant program to receive an audit letter if it transplants a certain percentage of non-resident transplant recipients.  In its place, the OPTN will gather data on all citizenship information supplied by member transplant programs and develop a public report on listing and transplantation of non-U.S. citizens and non-U.S. residents at U.S. transplant hospitals.  This report has yet to be prepared but should be completed sometime this year.

The OPTN is also asking members to report more specific information about listing and transplantation of non-U.S. residents, including their country of residence and whether they traveled to the United States specifically for a transplant listing.  This information will be included in the annual report and will help identify any specific patterns or trends in groups of non-residents listed and transplanted.

We wouldn’t be able to answer any detailed questions about individual non-resident candidates or recipients listed or transplanted at a U.S. program.  This is due largely to the fact, noted above, that the OPTN is not involved in any hospital’s individual decision to list or transplant any candidate.  In addition, medical confidentiality statutes limit public disclosure of patient-specific information unless the person(s) involved provide their consent, or unless the information may be publicly accessible for some other reason.

Data and trends

Non-resident aliens account for roughly one percent of both transplant recipients and donors nationwide.  The rate (not the number) of non-resident recipients in the United States is roughly the same as the rate of non-resident donors.  The vast majority of both recipients and donors are U.S. citizens, with resident aliens accounting for another three to four percent.

In 2011 (the latest year with complete data available), more than 95 percent of transplant recipients in the United States were U.S. citizens (27,180 out of 28,537).  Resident U.S. aliens accounted for an additional 3.7 percent of recipients (1,071 out of 28,537).  The remaining one percent (286 recipients) were reported in some other category, most as non-resident aliens or non-citizens residing in the U.S.  (Some of the data are being reported differently now to conform to the new definitions mentioned above.)

Similar proportions exist for deceased donors in the United States.  In 2011, more than 95 percent were U.S. citizens (21,424 out of 22,518); another 3.9 percent were resident aliens (880 out of 22,518); and approximately one percent were reported in some other way, mostly as non-resident aliens (214 out of 22,518).

Similar proportions also exist among living donors.  In 2011, more than 95 percent were U.S. citizens (5,756 out of 6019); 3.2 percent were resident aliens (193 out of 6019); and 1.1 percent were reported in some other category, primarily non-resident aliens (70 out of 6019).

These ratios of transplants by reported citizenship have remained largely the same since 1988, the first full year of national data collection by the OPTN.  However, there were a substantial number of “not reported” fields in the early years of OPTN data collection; today the number of recipients with unreported citizenship/residency is virtually zero.  We would be happy to supply the entire table of data by citizenship by year upon request.

Among candidates currently listed for a transplant in the United States, the ratios are much the same (although citizenship is not currently reported for about 2.8 percent of candidates, possibly because they have only recently been added and the citizenship field is not yet filled in).  Of the candidates where citizenship is reported, about 93 percent are U.S. citizens, roughly 4.5 percent are resident aliens, and about two percent are listed in some other category.

Bob Aronson of Bob’s Newheart is a 2007 heart transplant recipient, the founder of Facebook’s nearly 2,500 member Organ Transplant Initiative and the author of most of these donation/transplantation blogs.

You may comment in the space provided or email your thoughts to me at bob@baronson.org. And – please spread the word about the immediate need for more organ donors. There is nothing you can do that is of greater importance. If you convince one person to be an organ and tissue donor you may save or positively affect over 60 lives. Some of those lives may be people you know and love.

Please view our video “Thank You From the Bottom of my Donor’s heart” on http://www.organti.org This video was produced to promote organ donation so it is free and no permission is needed for its use.

If you want to spread the word personally about organ donation, we have another PowerPoint slide show for your use free and without permission. Just go to http://www.organti.org and click on “Life Pass It On” on the left side of the screen and then just follow the directions. This is NOT a stand-alone show; it needs a presenter but is professionally produced and factually sound. If you decide to use the show I will send you a free copy of my e-book, “How to Get a Standing “O” that will help you with presentation skills. Just write to bob@baronson.org and usually you will get a copy the same day.

Also…there is more information on this blog site about other donation/transplantation issues. Additionally we would love to have you join our Facebook group, Organ Transplant Initiative The more members we get the greater our clout with decision makers.


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