[Skip to Content]
[Skip to Content Landing]

Is Organ Retransplantation Among Undocumented Immigrants in the United States Just?

Learning Objectives:
At the end of this activity, you will be able to:
1. Explain a new or unfamiliar viewpoint on a topic of ethical or professional conduct;
2. Evaluate the usefulness of this information for health care practice, teaching, or conduct;
3. Decide whether and when to apply the new information to health care practice, teaching, or conduct.
1 Credit CME

Numerous undocumented children in the United States with end-stage renal disease undergo kidney transplantation funded by charitable donation or state-sponsored Medicaid. However, when these funding sources expire by adulthood, most are unable to pay for follow-up appointments and immunosuppressive medications necessary for maintenance of their organ. The organs fail and patients are then left with the options of retransplantation or a lifetime of dialysis. The dilemma of retransplantation introduces many questions regarding justice and fairness. This commentary addresses several ethical concerns about the special case of organ retransplantation for undocumented patients. Clinical guidelines and a clear public policy for best practices are needed to adequately address the challenge of retransplantation and maintenance immunosuppression in this population.


Anna was 2 years old when she was diagnosed with polycystic kidney disease, a life-threatening illness. Her family was told that Anna would need a kidney transplant to live. Although Anna was an undocumented immigrant, the hospital had a pool of funding for charity kidney transplants, and the state would provide Medicaid to cover additional costs. Anna received a kidney transplant at the age of 2½.

At age 18, Anna's family was notified that Medicaid funding would no longer be available to cover her transplant-related medical care. She would now be responsible for purchasing the immunosuppressive drugs required to maintain her kidney transplant as well as costs of regular follow-up appointments. After high school, Anna found work as a waitress making below minimum wage, mostly working double shifts on an unpredictable schedule, with no health insurance. She stopped taking her immunosuppressive medications because she could not afford them and could not follow up with her nephrologist due to her demanding schedule. Two years passed, and Anna now presents to the county hospital emergency department. Her kidney transplant has failed. She needs a new kidney or faces a lifetime of dialysis. In addition to her undocumented status, she has no health insurance. What should be done?


Anna's case highlights an important concern in the health care of undocumented immigrants—organ retransplantation. Based on Organ Procurement and Transplantation Network (OPTN) reports published between 2012 and 2013, approximately 1% of kidney transplant recipients in the United States were noncitizens (including undocumented immigrants, permanent residents with a legal visa, and foreign nationals engaged in medical tourism).1,2

Although organs may be allocated to undocumented persons based on OPTN policy, federal funding for both transplantation and posttransplant care is restricted.3 In the United States, current policy—the Omnibus Budget Reconciliation Act of 1985 and the Personal Responsibility and Work Opportunity Reconciliation Act (PWORA) of 1996—excludes undocumented immigrants from federally financed public benefits including Medicare, Medicaid, the Children's Health Insurance Program, and Affordable Care Act (ACA) insurance subsidies and exchanges.49Quiz Ref IDEnacted in 1986, the Omnibus Budget Reconciliation Act prohibited the use of federal funds for undocumented immigrants except in emergency situations,8 as dictated by the simultaneous enactment of the Emergency Medical Treatment and Active Labor Act (EMTALA). Under EMTALA, all states must provide federally funded emergency medical treatment, including emergent-only hemodialysis, which would be needed for the care of failed kidney transplants.4,6,10 In addition, 11 states and the District of Columbia currently use state funding sources to provide undocumented immigrants with maintenance dialysis.11 Notably, kidney transplantation is not considered an emergency treatment for end-stage renal disease (ESRD) and thus, under this legislation, is not eligible to be federally subsidized for undocumented immigrants.5,8 Ten years after the Omnibus Budget Reconciliation Act was implemented, PRWORA (also known as the “Welfare Act”) explicitly denied undocumented immigrants all state and local public benefits, forcing states desiring to extend public benefits to undocumented immigrants to pass new laws specific to their own state. Thus, under current legislation, only transplant recipients with permanent legal status have opportunities to receive federal funding for long-term maintenance of their transplanted organ in most states.46,8

Transplant patients, unlike other surgical patients, have a lifetime of health care costs associated with their transplant. Quiz Ref IDIn 2017, the total cost of a kidney transplant and a single year of necessary immunosuppressive medications was estimated to be over $400 000.12 Posttransplant care requires numerous postoperative office visits, daily immunosuppressive therapy, and regular tests that monitor the health of the transplant or graft. Without the ability to pay for this care, it is likely that these grafts will fail.

Quiz Ref IDAmong undocumented children who live in states like California, where coverage is currently guaranteed by state-sponsored Medicaid until age 18,13 at least 1 in 5 kidney transplants fail by the age of 21 because the patients cannot afford the immunosuppressive drugs without Medicaid or alternative funding.14 In cases where posttransplant care is not possible and the organ fails due to lack of funding, remaining options include retransplantation or return to dialysis. Many centers believe that nonadherence to immunosuppressive medications with an initial graft, even if due to lack of access, is a contraindication to receiving a second graft.5,1519 An inability to obtain follow-up transplant care thus can be used as a justification for avoiding retransplantation in transplant centers.

In sum, while undocumented immigrants may be allowed to receive transplants at a given hospital, there is no guaranteed funding mechanism to ensure that they can receive appropriate posttransplant care to maintain their organ in most states. The question then arises whether it is ethically sound to offer retransplantation given this knowledge.

Free Ridership vs a Right to Care

Opponents of retransplantation for undocumented immigrants argue that illegal immigrants have no claim to the limited transplantation resources in the United States due to their lack of citizenship status and unequal financial contribution to society.10,11 More generally, they argue that persons with no legal claim to reside in a country should not be granted access to the publicly funded benefits of that country.10,11Quiz Ref IDAccordingly, some authors believe that undocumented immigrants are free riders who take advantage of public services without contributing to public funding.10,20 Some of these opponents argue that health care policies that make insurance coverage and treatment more accessible to all populations will encourage undocumented immigrants to overuse services without contributing their fair share to the tax base, ultimately placing an unjust burden on the public.20 In cases like Anna's, in which retransplantation is considered because of graft failure stemming from lack of follow-up care, opponents argue that offering retransplantation would be an “overuse” of resources and is also more expensive than primary grafts, which could potentially place a greater burden on society.21

Proponents of retransplantation for undocumented immigrants argue that access to care is a basic human right regardless of citizenship status.22 Although nonadherence to immunosuppression and follow-up care with an initial graft is still a contraindication to listing on the waitlist,1518 in their view, screening out undocumented immigrants conflicts with physicians' ethical responsibility to care for persons in medical need.10 Additionally, several studies have shown that the cumulative cost of emergent dialysis is greater than that incurred from transplantation.23,24 Thus, transplantation should be considered the better long-term alternative for both the individual (for clinical reasons) and society (for cost reasons). Finally, concerns about inappropriate organ allocation to undocumented persons given their unequal societal contribution must be weighed against the fact that undocumented persons contribute $11 billion to our state and local tax base.25

Physicians' Responsibilities

Opponents contend that transplant physicians do not have an obligation to provide retransplantation due to concerns about organ supply and survival of retransplantation patients.26 Accordingly, the only obligation transplant physicians have is to treat life-threatening conditions, particularly when there are no alternative options. Unlike in the case of heart or liver failure, patients with renal failure have dialysis as an option, albeit a time-limited one.27 In determining eligibility for the waitlist, physicians must consider whether denial of listing could result in more harm than benefit to a patient than if a patient were listed and transplanted. It is important to recognize that some patients are harmed by transplantation and that, for these patients, there might not be benefit to retransplantation.15 Studies have shown that repeat grafts demonstrate decreasing survival rates with each subsequent graft.28,29 Overall, clinical outcomes of retransplanted recipients are less favorable than those of patients who have retained their primary graft.16,17,29,29 Evidence also suggests a significantly higher risk of death for retransplanted patients during the first month posttransplant relative to patients on dialysis.28,30,31

Furthermore, opponents believe that physicians should be parsimonious in their provision of care when operating under circumstances of limited resources and try to minimize unnecessary costs.3235 Thus, physicians must judiciously weigh the considerable risks vs benefits associated with retransplantation. Without access to follow-up care, it is unclear whether the retransplanted graft will persist long enough to provide long-term survival benefit.

Alternatively, it could be argued that by failing to retransplant, the physician has essentially abandoned his or her ethical responsibilities to provide for that patient's medical well-being. Physicians cannot fully take care of their patients in need of retransplantation because the only alternative is emergency dialysis due to undocumented immigrants' lack of proper health care coverage for regular maintenance dialysis in the majority of states. Furthermore, in a qualitative study, physicians who worked in safety-net health care systems where undocumented persons receive emergency dialysis reported that determining when to provide emergency dialysis can cause moral distress.36 Physicians felt that when required to make decisions about who was to receive emergence dialysis, they were forced to weigh social factors, sacrifice quality of care, and even inappropriately report medical status in order for the patient to qualify for emergency dialysis.36 Thus, in addition to the moral distress caused by the unavailability of organ retransplantation for patients with undocumented status, physicians face additional stress in providing a suitable medical alternative. Moreover, retransplantation is associated with a 50% reduction in mortality relative to remaining on dialysis if the patient survives beyond the 1-year postretransplant period.30,31 These data suggest that retransplantation is, medically, the optimal long-term treatment for a failed kidney transplant compared to treatment with emergency dialysis alone.

Supply and Demand of Organ Transplantation

Quiz Ref IDGiven both the inadequate organ supply and the limited public budget for health care, opponents of retransplantation suggest that US citizens and legal residents should be prioritized or exclusively offered deceased donor organs.22,37 They worry that retransplantation might not be worth the potential risk if a patient is subsequently deported or otherwise cut off from good follow-up care in the United States. These recipients would not have good long-term outcomes and the transplant might be seen as a waste. Risks of multiple failed retransplants thus could result in a net loss to the US organ pool.

Most transplant candidates, however, can pursue living donation as an option, which would not impact deceased donation organ availability. In a study of undocumented immigrants with ESRD, approximately 60% of participants had a family member willing to donate a kidney but lacked access to organ transplantation due to lack of insurance coverage for immunosuppressive medication, donor surgery, or both.38 Moreover, it is unfair to deny organ transplantation to this population, as 3.3% of the deceased donor pool is contributed by noncitizens.1 The “net loss” argument thus can be challenged given that undocumented immigrants currently contribute to the organ pool both as deceased organ donors and as living organ donors. However, their ability to contribute as living organ donors may be limited as described above. Moreover, proponents of retransplantation argue that citizenship status should not be a consideration in listing for transplantation.21


We propose the following recommendations:

  1. Policy addressing access to immunosuppression and follow-up care beyond 18 years of age for undocumented immigrants needs to be created. A potential solution would be continuation of previously accessible programs like state-sponsored Medicaid and CHIP, which already exist for patients under the age of 18 in some states.

  2. Funding (both federal and state) for follow-up care and immunosuppressive medications could be secured by (a) extension of the Disproportionate Share Hospital (DSH) Payment Program, (b) state-led efforts like California's Medi-Cal program, or (c) extending access to the ACA marketplace to undocumented immigrants.39,40 This recommendation is further supported by new evidence suggesting that, when insured, nonresident aliens have transplant outcomes similar to insured US citizens.41

In the case of Anna, the United States provided her with a kidney to save her life. The country failed to provide her with the financial means to obtain immunosuppressive therapies needed to maintain her kidney. There is an urgent need to identify potential funding sources for maintenance of transplanted organs. In addition, we call for federal and state-level examination of policies for organ retransplantation and provision of immunosuppressive drugs for undocumented persons.

Sign in to take quiz and track your certificates

The AMA Journal of Ethics exists to help medical students, physicians and all health care professionals navigate ethical decisions in service to patients and society. The journal publishes cases and expert commentary, medical education articles, policy discussions, peer-reviewed articles for journal-based, video CME, audio CME, visuals, and more. Learn more

Article Information

AMA Journal of Ethics

AMA J Ethics. 2019;21(1):E17-25.

AMA CME Accreditation Information

The American Medical Association designates this journal-based CME activity for a maximum of 1.00 AMA PRA Category 1 Credit™. Physicians should claim only the credit commensurate with the extent of their participation in the activity.

Acknowledgements: The authors would like to acknowledge Courtenay R. Bruce, JD, MA and Jennifer Blumenthal-Barby, PhD for their contribution to the revision of this manuscript.

Conflict of Interest Disclosure: The author(s) had no conflicts of interest to disclose.

Disclaimer: The people and events in this case are fictional. Resemblance to real events or to names of people, living or dead, is entirely coincidental. The viewpoints expressed in this article are those of the author(s) and do not necessarily reflect the views and policies of the AMA.

Description: Undocumented immigrants are not eligible for organ transplantation in most US states, although this population contributes to the pool of deceased and living organs as well as to the tax base.

Author Information:

  • Ruth L. Ackah, MD is a general surgery resident at the Ohio State University Wexner Medical Center in Columbus, Ohio. Formerly, she was a student in the Ethics Research Track and a research affiliate of the Michael E. DeBakey Department of Surgery in the Division of Abdominal Transplantation at Baylor College of Medicine, where she began her work in transplant and surgical ethics. She received her undergraduate degrees in biochemistry and chemistry from the University of Texas at Austin. Her professional interests include cardiothoracic and abdominal transplant surgery as well as medical ethics and health policy; Rohini R. Sigireddi is a third-year medical student at Baylor College of Medicine in Houston, where she is also a research affiliate of the Michael E. DeBakey Department of Surgery in the Division of Abdominal Transplantation. She received her undergraduate degree in chemistry, policy studies, and anthropology from Rice University. Her professional interests include abdominal transplant surgery and organ allocation policies; Bhamidipati V. R. Murthy, MD is an associate professor in the Division of Abdominal Transplantation and the Section of Nephrology at Baylor College of Medicine in Houston. He received an MD from Delhi University's Maulana Azad Medical College and specialty training at the New England Medical Center Hospitals and Cleveland Clinic Foundation. His professional interests include all aspects of transplant nephrology.

Disclosure Statement: Unless noted, all individuals in control of content reported no relevant financial relationships.

Glazier  AK, Danovitch  GM, Delmonico  FL.  Organ transplantation for nonresidents of the United States: a policy for transparency.  Am J Transplant. 2014;14(8):1740–1743.Google ScholarCrossref
Organ Procurement and Transplantation Network Ad Hoc International Relations Committee.  2014 Report of Non-US Resident Transplant Activity. https://optn.transplant.hrsa.gov/media/1854/IRC_Annual_Report.pdf. Accessed November 12, 2018.
Organ Procurement and Transplantation Network.  Policy 5.4.A Nondiscrimination in organ allocation.  Policies. https://optn.transplant.hrsa.gov/media/1200/optn_policies.pdf. Effective September1 , 2018. Accessed October 31, 2018.Google Scholar
Raghavan  R.  Caring for undocumented immigrants with kidney disease.  Am J Kidney Dis. 2018;71(4):488–494.Google ScholarCrossref
Linden  EA, Cano  J, Coritsidis  GN.  Kidney transplantation in undocumented immigrants with ESRD: a policy whose time has come?  Am J Kidney Dis. 2012;60(3):354–359.Google ScholarCrossref
Sommers  BD.  Stuck between health and immigration reform—care for undocumented immigrants.  N Engl J Med. 2013;369(7):593–595.Google ScholarCrossref
Kullgren  JT.  Restrictions on undocumented immigrants' access to health services: the public health implications of welfare reform.  Am J Public Health. 2003;93(10):1630–1633.Google ScholarCrossref
Omnibus Budget Reconciliation Act of 1985, Pub L No. 99-272, 100 Stat 82.
Personal Responsibility and Work Opportunity Reconciliation Act of 1996, Pub L No. 104-193, 110 Stat 2105.
Dwyer  J.  Illegal immigrants, health care, and social responsibility.  Hastings Cent Rep. 2004;34(1):34–41.Google ScholarCrossref
Cervantes  L, Fischer  S, Berlinger  N,  et al.  The illness experience of undocumented immigrants with end-stage renal disease.  JAMA Intern Med. 2017;177(4):529–535.Google ScholarCrossref
Bentley  TS, Phillips  S.  2017 US organ and tissue transplant cost estimates and discussion.  Milliman. http://www.milliman.com/uploadedFiles/insight/2017/2017-Transplant-Report.pdf. Published August2017. Accessed October 31, 2018.Google Scholar
California Healthline.  New law will expand Medi-Cal to 170K undocumented children. https://californiahealthline.org/morning-breakout/new-law-will-expand-medical-to-170k-undocumented-children/. Published October13 , 2015. Accessed September 26, 2018.
McEnhill  ME, Brennan  JL, Winnicki  E,  et al.  Effect of immigration status on outcomes in pediatric kidney transplant recipients.  Am J Transplant. 2016;16(6):1827–1833.Google ScholarCrossref
Kiberd  BA, AlBugami  MM, Panek  R, Tennankore  K.  Contraindications to kidney transplantation: uneven grounds?  Transplant Res. 2015;4(1):2.Google ScholarCrossref
Graves  RC, Fine  RN.  Kidney retransplantation in children following rejection and recurrent disease.  Pediatr Nephrol. 2016;31(12):2235–2247.Google ScholarCrossref
Dobbels  F, Hames  A, Aujoulat  I, Heaton  N, Samyn  M.  Should we retransplant a patient who is non-adherent? A literature review and critical reflection.  Pediatr Transplant. 2012;16(1):4–11.Google ScholarCrossref
Gill  JS, Tonelli  M.  Penny wise, pound foolish? Coverage limits on immunosuppression after kidney transplantation.  N Engl J Med. 2012;366(7):586–589.Google ScholarCrossref
Evans  RW, Applegate  WH, Briscoe  DM,  et al.  Cost-related immunosuppressive medication nonadherence among kidney transplant recipients.  Clin J Am Soc Nephrol. 2010;5(12):2323–2328.Google ScholarCrossref
Ziv  TA, Lo  B.  Denial of care to illegal immigrants. Proposition 187 in California.  N Engl J Med. 1995;332(16):1095–1098.Google ScholarCrossref
Fortin  MC, Williams-Jones  B.  Should we perform kidney transplants on foreign nationals?  J Med Ethics. 2014;40(12):821–826.Google ScholarCrossref
Evans  RW.  A cost-outcome analysis of retransplantation: the need for accountability.  Transplant Rev. 1993;7(4):163–175.Google ScholarCrossref
Abouna  GM.  Organ shortage crisis: problems and possible solutions.  Transplant Proc. 2008;40(1):34–38.Google ScholarCrossref
Abouna  GM.  The humanitarian aspects of organ transplantation.  Transpl Int. 2001;14(2):117–123.Google Scholar
Gee  LC, Gardner  M, Hill  ME, Wiehe  M.  Undocumented immigrants' state and local tax contributions.  Washington, DC: Institute on Taxation and Economic Policy; 2017. https://itep.org/wp-content/uploads/ITEP-2017-Undocumented-Immigrants-State-and-Local-Contributions.pdf. Accessed September 25, 2018.
Doherty  NM.  Cardiac retransplantation: determining limits.  Heart Lung. 1994;23(2):180.Google Scholar
Dobbins  M, Robeson  P, Ciliska  D,  et al.  A description of a knowledge broker role implemented as part of a randomized controlled trial evaluating three knowledge translation strategies.  Implement Sci. 2009;4(1):23.Google ScholarCrossref
Ng  V, Anand  R, Martz  K, Fecteau  A.  Liver retransplantation in children: a SPLIT database analysis of outcome and predictive factors for survival.  Am J Transplant. 2008;8(2):386–395.Google ScholarCrossref
Miura  K, Sakamoto  S, Shimata  K,  et al.  The outcomes of pediatric liver retransplantation from a living donor: a 17-year single-center experience.  Surg Today. 2017;47(11):1405–1414.Google ScholarCrossref
Rao  PS, Schaubel  DE, Wei  G, Fenton  SSA.  Evaluating the survival benefit of kidney retransplantation.  Transplantation. 2006;82(5):669–674.Google ScholarCrossref
Wolfe  RA, Ashby  VB, Milford  EL,  et al.  Comparison of mortality in all patients on dialysis, patients on dialysis awaiting transplantation, and recipients of a first cadaveric transplant.  N Engl J Med. 1999;341(23):1725–1730.Google ScholarCrossref
Tilburt  JC, Cassel  CK.  Why the ethics of parsimonious medicine is not the ethics of rationing.  JAMA. 2013;309(8):773–774.Google ScholarCrossref
Fleming  DA, Snyder Sulmasy  L.  Ethics of parsimonious medicine.  JAMA. 2013;309(21):2209–2210.Google ScholarCrossref
Fleck  LM.  Choosing wisely.  Camb Q Healthc Ethics. 2016;25(3):366–376.Google ScholarCrossref
Brett  AS, McCullough  LB.  Addressing requests by patients for nonbeneficial interventions.  JAMA. 2012;307(2):149–150.Google ScholarCrossref
Cervantes  L, Richardson  S, Raghavan  R,  et al.  Clinicians' perspectives on providing emergency-only hemodialysis to undocumented immigrants: a qualitative study.  Ann Intern Med. 2018;169(2):78–86.Google ScholarCrossref
Prottas  JM, Jonasson  O, Kleinig  JI.  In organ transplants, Americans first?  Hastings Cent Rep. 1986;16(5):23–25.Google ScholarCrossref
Baru  JS, Lucas  BR, Martinez  C, Brauner  D.  Organ donation among undocumented Hispanic immigrants: an assessment of knowledge and attitudes.  J Clin Ethics. 2013;24(4):364–372.Google Scholar
Centers for Medicare and Medicaid Services.  Medicaid disproportionate share hospital (DSH) payments. https://www.medicaid.gov/medicaid/finance/dsh/index.html. Accessed May 11, 2018.
Fabi  R, Saloner  B.  Covering undocumented immigrants—state innovation in California.  N Engl J Med. 2016;375(20):1913–1915.Google ScholarCrossref
Shen  JI, Hercz  D, Barba  LM,  et al.  Association of citizenship status with kidney transplantation in Medicaid patients.  Am J Kidney Dis. 2018;71(2):182–190.Google ScholarCrossref
AMA CME Accreditation Information

Credit Designation Statement: The American Medical Association designates this Journal-based CME activity activity for a maximum of 1.00  AMA PRA Category 1 Credit(s)™. Physicians should claim only the credit commensurate with the extent of their participation in the activity.

Successful completion of this CME activity, which includes participation in the evaluation component, enables the participant to earn up to:

  • 1.00 Medical Knowledge MOC points in the American Board of Internal Medicine's (ABIM) Maintenance of Certification (MOC) program;;
  • 1.00 Self-Assessment points in the American Board of Otolaryngology – Head and Neck Surgery’s (ABOHNS) Continuing Certification program;
  • 1.00 MOC points in the American Board of Pediatrics’ (ABP) Maintenance of Certification (MOC) program;
  • 1.00 Lifelong Learning points in the American Board of Pathology’s (ABPath) Continuing Certification program; and
  • 1.00 credit toward the CME [and Self-Assessment requirements] of the American Board of Surgery’s Continuous Certification program

It is the CME activity provider's responsibility to submit participant completion information to ACCME for the purpose of granting MOC credit.


Name Your Search

Save Search

Lookup An Activity


My Saved Searches

You currently have no searches saved.


My Saved Courses

You currently have no courses saved.