Antonio Russo is a sweet-eyed, spindly-legged, 8-year-old Italian stoic, the veteran of several complicated kidney operations, including an unsuccessful attempt to replace his own failed kidneys with one from his father.
Antonio needs a new kidney, and he and his mother have come to the United States to wait for one. His reasoning is simple. "In Italy it takes a long, long time to get a kidney," he says. "If I wait there for a kidney, I die. So I come here."
His doctors at Georgetown University Hospital have put his name on the appropriate waiting lists. In the meantime, every third hour of every day, in a bare apartment in Northern Virginia, he lies patiently on his bed and lets his mother administer the system-cleansing dialysis he needs to stay alive.
Antonio is one of a growing number of foreign patients who arrive in Washington and other American cities each year to receive American kidneys. They come largely from less-developed or Moslem countries, where technological impediments or religious custom prevent the gathering of transplant kidneys, and they pay tens of thousands of dollars for the privilege.
Their growing presence has created an ethical problem for the doctors and hospitals who treat them, and raised questions of how foreign kidney patients fit into a system already hampered by a shortage of donor kidneys. That shortage, as well as that of other transplant organs, is expected to become more acute by the end of the decade, when new drugs are expected to make transplants much less debilitating.
The problem of surgical priorities is reminiscent of the questions raised by battlefield medicine: whom do you save? "To me the issues raised here are similar to lifeboat ethics," says Warren Reich, professor of bioethics at Georgetown University School of Medicine. "Here you have the United States, an island with lots of technology and resources in a world where many countries do not have them. We consider surgery routine, other countries do not. People in other parts of the world have no machines but they have ambitions to live."
In the Washington area in last three years, the number of transplants performed has increased each year, but it is the transplants to foreign patients that have more than tripled, while the number of Americans receiving kidneys has remained constant, according to statistics kept by the federal kidney disease network. According to Rep. Albert Gore Jr. (D-Tenn.), whose subcommitte began investigating the number of transplants to foreign patients two months ago after nurses and surgeons reported concern, the figures echo those for other American cities.
About one quarter of the some 125 kidney transplants performed in Washington last year involved foreign recipients, a percentage greater than in most other metropolitan areas, according to federal statistics.
Do the numbers mean that Americans are waiting longer for kidneys? "It would be absolutely ludicrous to think anything else," says one local surgeon.
Gore agrees: "The present system is inequitable and unfair and can result in organs that could save the life of an American patient going to foreign patients instead." Last month Gore proposed legislation to establish a national kidney allocation network to augment or replace the current, loosely connected, regional system.
Because most hospitals require that foreign patients pay for their transplant operations ahead of time, and because they typically pay as much $50,000 or $60,000--about double the average U.S. federal government transplant reimbursement--Gore and others say the hospitals have a financial incentive to find kidneys for foreign patients.
Not all local transplant surgeons, however, are convinced a problem exists. "There is heated discussion on this subject all the time," says Dr. Jose Salcido, a surgeon at Children's Hospital and a member of a local medical group studying the matter. Doctors point out that foreign patients enlarge the pool of available recipients, which means kidneys are less likely to be wasted for lack of a recipient. They also say that foreign patients, far from home and paying dearly to wait, are often willing to accept donor kidneys that they say American patients or their surgeons can afford to reject as several hours too old or not the best possible tissue match.
There are currently about 10,000 Americans waiting for kidney transplants around the country, according to the National Kidney Foundation. Last year there were just over 3,500 transplants of kidneys taken from cadavers nationwide, in short, not enough to go around.Nevertheless, approximately 15 to 20 percent of all kidneys removed from donor cadavers each year are discarded or sent overseas, some for lack of suitable recipients, or because American doctors believe the kidney not fresh enough to be transplanted.
At present, Georgetown University Hospital is the only one of Washington's transplant hospitals with a stated policy giving its American patients, as well as Americans on waiting lists at other hospitals, preference, and its own surgeons say that the policy is not always strictly adhered to. Other area transplant surgeons and specialists say they find repugnant the idea of discriminating among patients on basis of nationality.
"This country is supposed to be a haven of medical care for people of the world, whether they are from Timbuktu, the moon or here," says Dr. Said Karmi, surgeon and co-director of the transplant unit at George Washington University Hospital. "I think it is not right to give second-class care or second-class treatment." Karmi and others point out that foreign patients pay their way. "They pay double for it, so the hospitals make a lot of money on them," Karmi says. "Everybody knows that. They pay their way 100 percent."
When most Americans think about waiting lists for kidneys, they picture a highly efficient, highly centralized system capable of routing available kidneys around the country to the best possible recipients. Instead, the system that has evolved is a loosely organized patchwork of 110 regional kidney gathering and transplant systems, formed largely at the initiatve of individual groups of transplant surgeons.
The systems vary tremendously in size as well as the degree to which they communicate and cooperate among each other, and within those systems physicians have tremendous leeway in how they place a kidney. (Washington hospitals are members of the Southeastern Organ Procurement Foundation in Richmond, whose list includes 41 transplant centers in 17 states.) If a surgeon's own patient is dying, or otherwise in desperate need for a kidney, the doctor may decide to keep the kidney for his or her own patient despite the fact that the regional list indicates there is another patient with a much better tissue match, in, say, Atlanta.
The surgeon also may keep the kidney because it is too old to be flown to Atlanta and still be used. Another consideration is the crossmatch, the last test that must be done before the kidney is transplanted. The crossmatch mixes serum from the transplant patient and the cells of the waiting kidney to test their compatibility--how the patient's system will react to a strange, new organ.
There is no way to predict the outcome of the crossmatch, and it cannot be done until the kidney has arrived at the hospital where the recipient is waiting. But if the cells are found incompatible, the transplant cannot take place, leaving the surgeon with one kidney and no takers. Which is why doctors say they like to have a pool of at least three or four potential recipients in same city as a backup. "By accepting the kidney, I assume financial and ethical responsibility to be sure that it is used," says Dr. Anne Thompson, head of nephrology department at George Washington University. "In general, the larger the pool of patients, the easier it is to bring in a kidney." Transplant doctors and others say they would like to see the problem resolved as quickly as possible, fearing that adverse public reaction could undermine the great changes in public attitude toward organ donation in this country. Some have suggested creation of some sort of clearinghouse of kidneys for international patients. Rep. Gore says he is unsure about the ethics of organ-sharings with Moslem countries "that allow acceptance of kidneys but forbid donation."
As Antonio's pediatrician, and one who saw him through months of painful surgery, Dr. Robert Fildes at Georgetown is well aware of the dilemma. As his doctor, he has enormous ethical as well as personal loyalty to Antonio. During the long months in and out of surgery Antonio remained game, his doctors say, learning English, perfecting ruthless imitations of the staff in the renal ward, and becoming so knowledgeable about his condition that he was known as the walking medical dictionary. The months of hospital care have exhausted the Russo family's life savings. Fildes sounds relieved when he says that Georgetown's stated Americans-first policy will likely be little handicap as the policy is seldom applied strictly in the case of children.
On the other hand, he wonders if each country doesn't have an obligation to take care of its own first. "These kidneys are gifts," he says. "This isn't like a car, or a television, it's not a commodity in some free enterprise system. It's not something for sale. It's a gift of life."