Proposition: An Illegal Immigrant Is Entitled To Receive A Life-Saving Organ Transplant That Otherwise Would Go To A U.S. Citizen In Similar Need

There must be something wrong with me, for I don’t think this proposition is ethically obvious at all. In fact, I think it’s probably dead wrong.

Here is the story:

Silvia Lesama-Santos, 46, is a mother of four who has lived illegally here for at least 30 years. The transplant program at the Oregon Health and Science University denied her request to receive a new liver, telling her that she did  “not have documentation of lawful presence or immigration documentation,” which was required for her to be eligible for a transplant.

The ACLU of Oregon took on Lesama-Santos as a cause, and publicized her plight. The Oregon ACLU’s  head, Mat dos Santos, called the hospital’s policy “cruel and inhumane.”

The bad publicity, in turn, quickly forced the hospital to change its policy. “It was brought to our attention this evening that an archaic transplant policy was preventing an undocumented individual from being evaluated at OHSU,” the school said in a statement this week. “Upon learning of the policy, OHSU leaders acted immediately and terminated the policy. We deeply regret the pain this has caused the family. OHSU is committed to serving our entire community — all are welcome at OHSU, and this policy does not reflect our values.”

Flushed with success, the ACLU is planning  “to ask other hospitals to change similar policies,” ask, in this case, meaning “coerce.”

As with so much involving the illegal immigration issue, this appears to be emotion-based reasoning. If we eliminate all obvious disadvantages and negative consequences to living here illegally, which is apparently the pro-illegal immigration activists’ ultimate goal, then we are installing de facto open borders. Illegal immigrants can drive in some states; they won’t  be deported if sanctuary cities can help it. They can hold jobs. In California they can even be lawyers. Now they have a right—isn’t the ACLU’s mission protecting citizen rights?—to take a liver away from a citizen who will die without it. If an illegal immigrant has a right to a liver, she has a right to a heart, or bone marrow.

Citizenship has to mean something.

The ACLU’s argument boils down to “let’s tug on the public’s heartstrings that are unattached to their cerebrums, and extort the hospitals.” It’s a good strategy, since hospital administrators care far more about the bottom line than principles of law or ethics. I agree that an illegal immigrant should not be turned away from receiving medical care as long as no citizens suffer as a result. However, there can be no right to step in front of a law-abiding citizen and take an organ that is needed to safe his life, or make any citizen wait a second longer for a transplant because an illegal immigrant broken into the line.

I think we should give illegal immigrants transplants using all of those surplus livers, kidneys and hearts hanging around when supply outweighs demand.

42 thoughts on “Proposition: An Illegal Immigrant Is Entitled To Receive A Life-Saving Organ Transplant That Otherwise Would Go To A U.S. Citizen In Similar Need

  1. On a related note. I remember reading a story (can’t find it) where an organ donor put some conditions on the recipients for his spare parts. It was not something terrible, but along the lines of “must like dogs” or “stays in touch with family”.
    My guess (i.e. I have no idea) is that legally, once you register for donation (disclaimer: I do) these requests have no weight and it’s up to some medical board to decide who gets your transplant, but I wonder what would be the ethical verdict for such request. How about the request being “must not be a convicted criminal”, or, closer to this story “must be a citizen or legal immigrant”? Interested in discussing where the line should be drawn, and what consideration should be given to such requests.

    • I guess I could only see that happening if your death was anticipated by a disease that targeted one part of the body but left other parts usable. In a case where your average Tim is killed in a car accident, there’s a hurry to harvest the organs and get them in place….no time to go checking on Tim’s desires for his organs and then interviewing people to see if they meet his obscure demands.

      But back to the former “anticipated death”, I think you could select someone to receive your donation, lest you decide not to donate at all. But that’s on you and your “team” to conduct the search and identify the recipient. Seems a bit of a hassle.

  2. There are actually non-citizens who come to the Unites States specifically for the purpose of obtaining a liver transplant. My personal view is that if there is a donor liver available that is not a suitable match for any citizen on the transplant waiting list but is a match for a non-citizen then it should be used rather than wasted.

    The American Journal of Transplantation published a paper in Feb 2016 Liver Allocation to Non-U.S. Citizen Non-U.S. Residents: An Ethical Framework for a Last-in-Line Approach.

    The incidence of non-U.S. citizen non-U.S. resident patients coming to the United States specifically for deceased donor liver transplantation raises compelling ethical questions that require careful consideration. The inclusion of these often financially and/or socially privileged patients in the pool of potential candidates for an absolutely scarce and life-saving liver transplant may exacerbate disparities already existing in deceased donor liver allocation. In addition, their inclusion on organ transplant waiting lists conflicts with recognized ethical principles of justice and reciprocity. Moreover, preliminary data suggest that public awareness of this practice could discourage organ donation, thereby worsening an already profound supply–demand gulf. Finally, U.S. organ allocation policies and statutes are out of step with recently promulgated international transplant guidelines, which prioritize self-sufficiency of organ programs. This article analyzes each of these ethical conflicts within the context of deceased donor liver transplantation and recommends policy changes that align the United States with international practices that discourage this scenario.

    • Recommending self-sufficiency kind of implies that citizen should have priority if need is equal, right? I have to wonder if the protestors are even aware of that international consensus? I would tend to prefer the citizen if need is equal, as I would doubt the veracity of someone who’s been pretending they are a good citizen for how long.

      I don’t want ANY people to die for lack of transplants, so register if you can, people. Artificial and grown replacements just aren’t here yet.

  3. Somethings to add to the discussion.

    1. I believe that Doctors are not supposed to look at whether a person is a citizen or not, they are only supposed to provide service to the best of their abilities regardless of where the individual is a legal or illegal immigrant, citizen, or axe murderer.

    2. My understanding is that those in need of transplants are somehow “lined up” on a waiting list based on medical need and the ability to survive the transplant and of course the ability to somehow pay for the transplant; who is in line has got nothing to do with legal status or anything else. I think that the Hippocratic Oath directly implies that medical need trumps things like legal status.

    I understand the citizen vs illegal immigrant argument; however, there are other things to consider.

    Okay, discuss.

    • From a medical perspective (which I’m pretending I have for a moment), I can see where it would make sense to optimize the saving of life regardless of residence. Doctors Without Borders, and all that.

      On the other hand, we don’t want to incentivize (thank you, squiggly red line) people sneaking into the U.S. to get organ transplants assigned to them.

      I’d expect that even if doctors don’t care about legal residence, wouldn’t an illegal immigrant simply be deported once they were identified? Would that not remove them from the recipient list anyway?

  4. While I understand the conundrum,and conflicting interests, I am not sure I want medical providers enforcing national immigration laws. I tried to read John Billingsley’s linked article to get a broader understanding of the issue. I confess that my knowledge here is woefully inadequate to provide any useful commentary.


  5. Wow. Didn’t we all learn this message from countless MASH episodes growing up? Doctors take care of people, even if they are enemy solders. I can’t believe we would have a lesser standard for illegal aliens who are NOT trying to kill us.

    • Was there an illegal Korean immigrant episode? I must of missed that one!

      They have a human right to the care, not the liver, if there’s a citizen ahead of them in line….and any citizen should be.

      • Well, there are episodes on point. Where in triage they put more seriously wounded North Koreans ahead of wounded American soldiers.

          • I’m not doubling down — I’m explaining the reference.

            Obviously, the fact this happened on MASH is of little weight generally, but that episode did immediately leap to mind while reading Jack’s comment.

            Doctors should be above politics. Their job is to treat the most critically wounded, and move on from there. In a hospital emergency room, a person with a broken arm/awesome insurance is still going to have to wait if someone comes in with gunshot wounds/no insurance. The same concept holds true whether or not one is a citizen of another country. I certainly hope that a European doctor would treat me or my family first over citizens if it were deemed that we needed care first. Let doctors do their jobs — save lives. And if there is a close call as to who needs immediate attention, I am going to trust their judgment.

            One more point. I am signed up to be an organ donor and a bone marrow donor. My body will be donated to science when I die. These are MY organs, so if we are going to split hairs here, shouldn’t that decision rest with the person making the donation? I want to help save lives, and I could care less if my organs go a US citizen, someone here illegally, or even if they put my organs in a cooler and fly it overseas because they found a better match there.

          • My recollection from my military training on the International Law of Armed Conflict is that once an enemy solder is captured or hors de combat the Geneva Convention demands that they receive the same treatment as any other wounded soldier. At that point, what side they were on is immaterial as they are now a noncombatant. Noncombatants must be kept safe and provided appropriate care. The order of treatment is by triage category. An immediate category enemy wounded will go before a delayed or minimal American. If they are both immediate, then it will be a medical decision to decide which looks the worst or it may be the luck of the draw and be whoever the litter bearers brought in first. An enemy soldier no matter how badly wounded who attempts to fight back or escape is still a combatant and may be killed or otherwise incapacitated. It’s basically an application of the Golden Rule, treat them like you would want to be treated if in their place.

    • Patching a bullet wound doesn’t cause the next guy to show up with a wound to go untreated. Did Mash have an episode where the doctors left a U.S. soldier to die while they tended to a N.K.? If so, did they do a show on the court martial?

    • Depends fully on comparing two individuals facing equal medical hazards. If two patients arrive before a doctor bearing generally same life threatening injury/illness with generally the same likelihood of fatality if not treated and there is not enough time to give proper attention to both, then yes, American doctors should prioritize the American before the non-American.

    • What a stupid comparison. The issue isn’t about patching a bullet wound or splinting a leg. Those aren’t limited critical resources. The issue is with life saving organs transplants – an extremely critical and often limited resource. I can guarantee you that we didn’t give those commie pricks any of our supplies of malaria pills, penicillin, or replacement organs when there wasn’t enough to treat our own boys and girls.

      When it comes to limited life-saving resources, the needs of your own citizens, for both practical and ethical reasons, must come before the life-saving needs of those who are not your citizens. Why is that so hard to understand?

  6. Mat dos Santos has called foreign nationals residing unlawfully in Oregon (i.e., illegal aliens) “undocumented Oregonians.” I was pretty sure you couldn’t be an Oregonian without being an American, but apparently the Oregon ACLU thinks otherwise.

    Regarding your proposition, Jack, I agree that the citizen should have priority. In this instance, though, was there a citizen who would have lost out on the liver transplant? It’s not clear from the story.

          • She should’ve been placed on the waiting list, right after the last American there. When there were no Americans left and a liver available, she should’ve received the transplant.

            This seems very simple, very uncomplicated.

            If this isn’t to be the case, then being an American has no meaning when it comes to health care, and hospitals should tell us that a legal presence in the United States has no value when it comes to being a transplant recipient. First come, first serve, no matter who you are and how you got here. We are Americans, after all, and it’s our duty to serve lawbreakers if they get in line first at the expense of our own citizens. Most of us are racist homophobic evil white people, anyway, and it’s the very least we can do.

            That would go over well, I think.

  7. Boy, a lot of near misses here. There seem to be a lot of competing values here, but the dots do not appear to be connected, so, knowing nothing about the topic, there is little to dissuade me from weighing in:

    As some have suggested, the starting point for the medical profession should be to help all in need, without regard to any other consideration, except that you triage patients to do the most good for those most likely to survive.

    Competing with that is the problem, mentioned by some, is that there is a limited supply of organs. While the profession may desire to help all who need it, the law of supply and demand makes that impossible. They can’t help everyone in need. They have to choose.

    How do they do that? Some of the restrictions on choice are imposed by the system (federal or state laws). However, I would presume the medical profession itself would be neutral, preferring only fairness to possible recipients.

    Enter the Saudi Prince: that wealthy individual, sitting in an airplane on a runway in Kansas City, waiting for a liver to become available somewhere between Bangor and San Diego, or Miami and Seattle. He could be on any list, in any metro area, and only a few hours away. He might be the ideal patient.

    But, it seems unfair that a Saudi Prince in Kansas might deprive a homeless person in Portland a liver, when wealth is the only reason the Saudi Prince could even get a transplant in Oregon.

    To prevent this abuse, the medical profession institutes a residency requirement. While not wanting any organ to go to waste, preference is given to locals. If you are nearby, you are preferable to someone requiring shipment a long distance and (for sake of egalitarianism) someone who can afford to fly into town. (That is not necessarily a bad thing when you are dealing with limited resources.)

    Enter the Illegal Immigrant from Mexico. This is the person who has no greater legal connection to Portland than the Saudi Prince, both are foreigners. But, the medical profession, trying to be fair, tried to enforce residency as a qualification. Now, that requirement pits poor Mexicans against rich Arabs and the medical profession’s failure to control for class distinctions is revealed. So, as good little Marxists at heart, the medical profession has to kow-tow to the leftists who want the rich Saudi Prince to die.

    Okay, that last part was a bit forced. But, I think the medical profession is trying to be fair and help the most people possible. The real world interferes with egalitarianism, unfortunately.

    My verdict: this is a situation where strict adherence to rules is the best for fairness. It may mean a Mexican peasant dies, but the Marxists should be happy that, for every Mexican peasant who dies, several Saudi Princes will die too. In all seriousness, there is no great result. Some will always die. Pick your set of rules and act accordingly. There may be bad results, but there will always be bad ones. But, no one is favored for race or class. That is probably a good thing.


    • I’ve always thought that we’re a bit schizophrenic about organ donation, here in the US. On the one hand, we clearly encourage people to become organ donors (there are ads and nasty looks from the folks at the DMV if you don’t do it)… but we insist that organs and the like can only be given, at least by an individual. Hear a story about someone offering money for one, or expressing a desire to sell one of their own organ? Everyone starts waxing incandescent about the wrongness of it.

      And then there are the people we put in jail for life, who might be eligible for an organ over a productive, non-criminal member of society. Queue the outrage! But if we execute a criminal and talk about re-purposing those organs into someone else, all the sudden everyone gets squicked out, because it’s the liver of a murderer, don’t you know! Never mind that the liver, last time we checked, doesn’t actually control a body… you can’t be putting that sort of a thing inside somebody!

      We could make the issue better, and decrease the waiting lists significantly, in more than one way. We could make organ donation mandatory, for instance… The folks with a religious objection to the process would have to be told to pound sand, but it wouldn’t be difficult at all to justify doing. Dead people don’t need organs, and there are some living who do (and if your god is real, and made the world, then whipping up another kidney when resurrecting you shouldn’t be difficult at all). We could let people sell their organs if they want to; after all, it’s a part of their body, and we’re supposed to prize the autonomy of others. I mean, if it’s acceptable to claim that I can excise lumps of unwanted tissue whenever I want to, why shouldn’t I be able to profit off excising redundant pieces of myself? Obviously, not everyone will be able to afford the prices I want, but that’s no more inherently unfair than me not being able to afford a McClaren F1. If capitalism is good, why won’t we see what the market will bear?

      I suspect the problem is that most of the US has never sought to possess a coherent system of ethics, or even morality about the matter, and have instead relied on a hodgepodge of emotion and sentiment to form their views about the practice. And when that is how we’ve taken to deciding an issue, someone is ALWAYS going to get screwed, in the eyes of everyone else – A child was three spots down the list! Surely they’re more deserving than a 60 year old. Save the Great Man with the awards!

      Faced with a society that is either unwilling, or unable, to rationally explicate what they expect, the medical profession came up with rules and procedures. They serve well enough, because they create the illusion of fairness, by being blind and impartial. Certainly, the procedures can be gamed (Steve Jobs, or the Saudi Princes of Jut’s comment), and all rules have loopholes that those with sufficient will and motivation will find ways to exploit. And sometimes, when rules are adhered to, the outcome leaves us all upset. But these are the inherent aspects of the system – Being callous and yet fully knowable is, in a very real sense, the only way ‘fairness’ can be achieved.

      • You raise a good point. Few people have bothered to develop their perception mindset to the point where they could even discuss abstract concepts like ethics with any coherence, and it results in dysfunctional systems. That’s something I intend to change.

        As far as fairness goes, I tracked down an old rant I made deconstructing the concept, which I think matches the point you’re making about it. (The comments under it are also excellent reading.)

        • Thanks EC. I don’t remember that from when it was fresh – I must have missed it at the time (I might have been taking a day or two to avoid the internet in the lead up to the election – I remember needing some of those breathers). You’re right, it definitely matches where I was going with things, though I don’t know, looking back, if I got there (definitely not explicitly; I blame the meds I’d taken before writing). So, to clarify:

          When judgments about how things work out are going to be based on sentiment and emotion instead of reason (as is the case with Organ Transplants), there is always going to be someone screaming that the result was “unfair”, by which they really mean “It wasn’t the result that matches MY expectations.” Especially when the consequences are as high as they are with organ transplants.

          Because we can never match the expectations of everyone, we are left seeking a solution that doesn’t seem entirely arbitrary, and can be used to shut down every critic. That solution is policy – a knowable set of rules and regulations which are made beforehand, and followed in all situations, without regard to who will be helped or hurt. This grants the illusion of fairness to everyone involved – regardless of whether the process works for or fails a specific person, if it was applied in an equal and consistent manner, we can say that the outcome was fair. It’s a lackluster solution, but until we’re (meaning society as a whole) ready to have a coherent conversation about finding actual solutions, and agreeing on our expectations, it’s the only viable solution that we’ve identified, as the alternatives all lead to societies tearing themselves apart when the various expectations and personal interests collide.

          Part of what makes those policies functional and fair-seeming is that everyone can know what they are, and that they are fixed and applied equally. When a place like OSHU bows to sentiment and changes those policies suddenly because of an outside force, they have forgotten why the policies were needed in the first place: they have forgotten that the public is fickle and emotionally charged and incoherent. They have forgotten that changing those policies to the immediate benefit of one person inherently means the policies are no longer being applied with impartial equality to everyone. And they have forgotten that it was from that impartiality that the policies became “fair”.

          • Yeah, the Left seems to be trying to impose compassion (voluntary benevolence) as a new brand of honor (rules we create for the good of society). The idea of impartial decisions is a manifestation of honor. When people try to change the entire set of rules because an individual is particularly pitiful, things get messy.

            Though they often conflict, compassion and honor are both very important. However, trying to create a form of honor based on compassion completely misses the point of the distinction between the two, and will not end well.

    • Excellent comment Jut.
      “My verdict: this is a situation where strict adherence to rules is the best for fairness.”

      One of the problems right now is that there is significant disagreement about what the rules should be to ensure “fairness.” For example, there has been significant debate over the conditions under which people who suffer liver failure due to drinking should be considered for transplant. Some people think it fair that drinking history shouldn’t even be considered. Some think it fair that if someone has destroyed their liver by their own actions they don’t deserve any chance at a transplant. Some are in the middle and think some period of sobriety should make the person eligible. There is the same range of opinions regarding residency and many other factors. I think these for the most part are societal decisions and not primarily medical decisions.

      The medical decision making is to determine factors such as who is sick enough to need a transplant, are they likely to survive the surgery, what is the risk of rejection, is the available organ the right size, who is likely to die the soonest without a transplant, and other such questions. There are also factors such as how long an organ will survive (liver less than 12 hours) and how far the recipient is from the hospital which will affect who will be available to receive a given organ. These are all pretty objective measures and I don’t think there are any tough ethical questions involved.

      The societal factors are the ones where the hard questions lie. Should a drinker get a new liver? Under what circumstances? Should illegal aliens be eligible? Should ability to pay be a factor? What about age–should a 20-year-old be ahead of a 40-year-old? Should a heavy smoker showing no inclination to quit be eligible for a heart? While there should be medical input into some of these questions, the medical team these days ultimately must submit to what society decides is the “fair” thing to do in winnowing down the many potential recipients for the few available organs. The transplant team would like the recipient with the best chance to survive and thrive to be selected but once someone has been selected they are going to provide the best care they can no matter who it is.

    • There is no payer. It is uncompensated care meaning nobody involved in providing the care receives anything. Hospitals do this all the time although usually not for things that cost over $500,000 (liver transplant) each. A hospital will receive Medicaid money for delivering a baby for an illegal alien that shows up in the emergency room in labor. That is funded through Medicaid and I think is the only circumstance where care for illegal aliens is funded. Medicaid spends about $2 billion a year on that.

  8. On one hand there is the Hippocratic Oath that directly implies that medical need trumps things like legal status, so in that regard the policy change is a direct reflection of the core of the Hippocratic Oath and it can be said that they changed their policy to reflect the ethical core of the Hippocratic Oath and present that argument to the public and their actions on the surface can be regarded as ethical. (Yes it’s a run-on sentence)

    On the other hand there is the fact that illegal immigrants are literally taking advantage of a near “border-less” country and existing systems in place across the United States that ignore their legal status will allow them to do whatever they want regardless of the fact that they are in the United States illegally and some existing systems in place that actually help them do anything they want because they’re illegal immigrants. The United States has been, and still is, enabling illegal immigrants and this policy change is another system changed that enables illegal immigration.

    This leads me directly to a topic that we’ve talked about on Ethics Alarms in the past: is the perception of an action what makes the action ethical, or is it the motives behind the action that makes the action ethical, or does it take both? If I remember correctly, I think the general consensus was that it’s the perception of the action that makes it ethical.

    The perception of this action is two fold; first ethically complying with the intent of the Hippocratic Oath and second it’s another policy change enabling illegal immigration.

    Using the Hippocratic Oath argument to change a policy is a very strong argument under certain circumstances, however this change was not done in a “vacuum”. If this policy change had been done in what I called a “vacuum”, meaning a full review of policies was done without outside influence and the policy was changed solely to better conform to the Hippocratic Oath, no one would have bated an eye at the change and it’s not likely that we’d be discussing it at all. In the vacuum both the motives of the action and the action itself could easily be considered ethical; this is not what happened.

    This policy change was not in a vacuum, this policy change was done due to social justice warriors “attacking” the institution to publicly shame the the institution into changing their policy to advance one particular group of people beyond the reasonable expectations that were in put in place with the previous policy. I can easily look at this policy change and say that the motives behind the action far outweigh any perceived ethical value of the action. In this case, kowtowing to the outside pressure of illogical social justice warriors enable both social justice warriors and illegal immigration, the Hippocratic Oath argument in this particular case is nothing but a rationalization.

    For what it’s worth; I am really angry that the United States federal government has turned a blind eye to illegal immigration for many years through many administrations and allowed this problem to get worse. Sure administrations and campaigns have mouth the words for years that something needs to be done about the illegal immigration but they’ve done nothing to actually solve the problem and the result is that the problem persists and has gotten worse over the years. Now we are in a hyper politically charged political environment inflamed by ignorant social justice warriors (SJW) that are completely blind to any logic outside their emotionally charged arguments and it doesn’t matter one bit what anyone does to fix the illegal immigration problem, the solution will be smeared by illogical SJW’s. This is the direct result of the deliberate dumbing down of America

    EC wrote above, “I’d expect that even if doctors don’t care about legal residence, wouldn’t an illegal immigrant simply be deported once they were identified? Would that not remove them from the recipient list anyway?”

    Therein lies just one of the real problems in the United States, this is not being done. If this were to be an active policy then illegal immigrants would catch wind that they will be deported when they’re identified and that will slow illegal immigration to a crawl and as illegals are deported it will start reversing the negative effects on our society due to illegal immigration.

    If you are a reader who is an illegal immigrant, I have absolutely no sympathy for you, so stop your whining. You are the problem not the law(s) that you refuse to comply with. Take the legal steps to become a United States citizen or voluntarily get out of our country or be deported when you’re identified as being illegally here. The choices are yours not ours, comply with the law or suffer the consequences.

    • “Knowing” the people that comment on Ethics Alarms, it actually surprised me when I came back to this thread today and found that no one had replied to this comment. I’m a little baffled.

      I’ve seen a lot of topics I would have like to comment on but no time to do so, so I’ve had to let them go. I can finally see the light at the end of the tunnel for participating a little more at EA again, project is nearing the foreseeable “end”.

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