Organs without Borders? Allocating Transplant Organs, Foreigners, and the Importance of the Nation-State

I INTRODUCTION Most of the discussion of market or nonmarket forms of allocating and procuring organs takes as its unit of analysis the nation-state, or, less commonly, a particular state or province, and asks what should the system look like as to this framework. In this article, the second of two articles that I contribute to this issue of Law and Contemporary Problems, (1) I want to expand the viewfinder and examine an issue that has received peculiarly little attention in the scholarly and policy discourse: the desirability of treating the nation-state (or its subdivisions) as the right level of distribution for organs, whether through market systems or nonmarket allocation systems. I show that when we flirt with using a more global viewfinder, a series of difficult (and thus far largely unexplored) ethical and regulatory questions arise relating the inclusion of "outsiders." In part V of this article I explore what relevance this analysis may have to allocation within the nation-state as well. A large number of questions could be discussed under this title, but for this article I largely limit myself to two related questions. In analyzing both questions I use the United States as the "home country" for rhetorical clarity, but the basic issues are the same for any home country. The first issue is: Should the United States allow "foreigners" to be on the list of those eligible to receive organs in the United States when they become available and, if so, at what level of priority? Second: Should the United States maintain its own organ distribution network that is limited to the nation-state instead of participating in a more globalized system? I should emphasize that my interest here is organs that come to recipients through typical government-run (or at least government-approved) organ-allocation systems rather than through foreigners who come to U.S. centers and bring their own living donor. (2) I first describe the two issues and then offer a normative analysis of each. This cluster of issues applies equally to the current U.S. distribution system, with its hostility to markets, and any of the potential alterations discussed in this issue of Law & Contemporary Problems. That is, even if we introduce market elements of one form or another to the U.S. organ-allocation system--as I discuss in my companion article in this issue and as do other authors in the issue (3)--we still have to answer the two questions that I contemplate in this article: Should non-U.S citizens who are nonresidents be allowed to have access to U.S. organs in the domestic system, and should the United States as a whole join larger inter-country organ-allocation systems? In part V of this article, I make some comments about what this analysis implies as to organ sharing within a nation-state, for example between U.S. states or geographic regions. Let me emphasize a terminological point here. I use the term "foreigner" in a specific sense to refer to someone who is a non-U.S. resident and a non-U.S. citizen. There are several intermediate cases between "foreigner" and citizen-- resident, particularly the non-U.S. citizen who is a U.S. resident (like this author at the present moment!), citizen nonresidents (for example, expatriates), legal versus illegal residents (sometimes referred to as documented versus undocumented aliens) as well as various degrees of residency (visa versus permanent resident versus asylum seeker). A full ethical analysis would pick out each of these possibilities and run the analysis for each, but doing so would require a fuller theory of the importance of citizenship versus residency for benefits and burdens of home-country law and policy than I intend to tackle in this article. (4) Parts of the analysis I offer below suggests resident noncitizens, whether in the United States legally or illegally, should be treated quite differently for this analysis, but those implications (and resident noncitizens more generally) are not my main concern in this article. …