“Transplant Tourism” in the United States?

Increasingly, as instant communication, easy air travel, and rapid dissemination of technology spreads around the world, advanced medical interventions including transplantation have become global enterprises. There are numerous accounts of patients traveling beyond their country of residence for many different types of medical care, including transplantation. However, with variable regulation, inconsistent quality, and little if any outcome data publicly available in many countries, patients cannot possibly be well informed regarding the risks and benefits of transplantation in these areas. In particular, patients desperate for lifesaving transplants are well aware of the lengthy waiting lists in developed countries and are willing to go to extraordinary lengths to get access to transplants with little regard for the source of the organ or the quality of care they are likely to receive. In addition to the patient-centered issues, there are numerous other forces operating in the international transplant business. Hospitals openly advertise their expertise and, at times, their ability to deliver human organs on demand, either from executed prisoners or from paid living donors. Transplant brokers profit from arranging transplants for patients and hospitals, some even find donors for recipients. Some governments have arranged relationships for payment for transplant for their citizens seeking transplants outside of their country of residence that provides covert or open incentive for their citizens to “shop” for transplants. The total extent of these practices is unknown mostly due to the poor data reporting and record keeping in the underdeveloped areas of the world, but they likely occur to a lesser or greater degree in all nations providing transplant services. The United States arguably has the most extensive, publicly available, and well-organized transplant data collection and analysis system in the world. With this system, it is possible ascertain whether listed candidates or deceased donors are US citizens, and determine the waitlist and posttransplant outcomes. Using this database, Schold and colleagues have done exactly this in this issue of Transplantation (1). In this paper, the authors have assessed deceased donor liver and kidney listing and transplant characteristics for US citizens, resident aliens, and nonresident aliens (NRA) and their outcomes from 1988 through 2005. For kidney candidates, NRAs represented less than 1% of the total number of candidates listed or transplanted during the study period, and NRAs represented 1.5% of the total liver transplant listings and approximately 3% of deceased donor liver transplants. Thus, nonresident aliens comprise an extremely small fraction of the total transplant activity in the United States. Nonetheless, more than 4,000 transplants were performed in the United States for NRAs over this study period. Compared with US citizens, NRA kidney and liver candidates were more likely to be younger, have advanced educational degrees, and were much more likely to be self-paying patients than their US counterparts. Most of the NRA transplant candidates had been in the United States for less than 1 year prior to their registration on US waiting lists. The vast majority of the donor organs given to the NRAs in this study were derived from US citizen donors and there was no difference in the quality of the donor organs given to the NRA compared with the US citizens, although NRAs were half as likely to receive a zero-antigen mismatch kidney. Using multivariate models, these authors also found that NRA kidney candidates did not receive transplants more or less rapidly than US citizens. In contrast, NRA liver candidates obtained liver transplants more rapidly in both the pre–Model for End-state Liver Disease (MELD) and MELD eras compared with the US citizens, even when status 1 patients were excluded. Considering the fact that NRAs were more frequently designated status 1 that the US Citizens, NRAs liver candidates apparently enjoyed considerably shorter times to transplant than the US citizens and the self paying NRAs had the shortest time to liver transplant among the insurance types. This paper also points up important geographic differences in the distribution of the listing and transplantation of NRAs around the country. Region 5 listed 45% of the NRA kidney and 26% of the NRA liver candidates included in this study period. Region 2 was second most active with 13% of kidney and 27% of liver NRA listings recorded. Interestingly, both Asian and Hispanic NRA ethnic groups were overrepresented in the kidney candidate listing group but only Asian NRAs were proportionately higher than US citizens in the liver listing group. What do these data mean? Clearly, there are foreign nationals “buying” transplants in the United States. NRAs are paying for access to the US deceased donor organs, and at least in the case of liver transplantation, they were paying for increased access relative to US citizens. While this represents an extremely small fraction of the total US transplant activity and should comfort some, Schold and colleagues have provided an important set of data that should give those who would condemn other transplant enterprises in other countries cause to reflect inwardly. The advantage that we, in the developed transplant world, have is that we can measure this behavior, report on the magnitude of the activity. and provide outcome results for any candidate or, although Schold et al. did not provide this, posttransplant recipient results. These hard data serve as the basis on which to debate organ transplant policy as well as to inform potential candidates and recipients of all nationalities of the potential for success. What of policy? Should foreign nationals be allowed any access, advantaged or not, to an individual countries’ deceased donor pool? Should policy or international law limit individual patients’ autonomy in seeking transplantation care in any venue, with any degree of informed consent, at any cost? Hopefully, all will condemn the exploitation of humans through financially (or otherwise) coerced living and uninformed deceased donation. The World Health Organization has issued draft guiding principles for human transplantation in 1998 (2) (Table 1) for these purposes but there is no prohibition on patients traveling to areas where transplant services expertise or resources including donors are more readily available.TABLE 1: WHO Guiding Principles for Human Transplantation 1998In 1986, the National Task Force on Transplantation was formed as part of the National Organ Transplant Act to study development of transplantation systems for the distribution of organs and standardizing national practice in the United States (3). This task force stated that deceased donor organs are to be considered a “national resource” in the public trust. However, there was no contemplation at that time of whether donor organs, or the expertise for transplantation practice, should be considered a global resource. Increasingly with other world initiatives to fight hunger and infectious disease in underdeveloped areas, health-related materiel and know-how are considered global assets. The developed world must share these resources wisely and most importantly must constantly promote transparency through ongoing data collection and dissemination as Schold and colleagues have done in this report. Ultimately, transparency, especially where there is so much potential for exploitation of human life, is critical for the global advancement of the transplantation field and for the improvement in care for all those who can receive the benefit from the uniquely human transplant procedure.