"Living Death": The Ethics of Emergency-Only Hemodialysis Policies for Undocumented Immigrants with End-Stage Renal Disease

Abstract

End-stage renal disease (ESRD), defined as significant and irreversible loss of renal function, is fatal without dialysis or kidney transplantation. The primary treatment method for undocumented immigrants with ESRD is emergency hemodialysis. Emergency hemodialysis, the emergency-based counterpart of regular, maintenance hemodialysis, is cost-prohibitive and strongly associated with poorer health outcomes. In most states, undocumented patients cannot receive life-sustaining hemodialysis treatment until their condition is deemed emergent. Unlike maintenance treatment, emergency hemodialysis is only administered to those exhibiting life-threatening symptoms. Since hospitals cannot receive federal reimbursement for non-emergency services, undocumented immigrants cannot receive hemodialysis treatment unless they are near death. Those receiving emergency-based hemodialysis exhibit poorer health, since undocumented patients often go several days without treatment. Such hazardous treatment conditions significantly endanger their lives, triggering an endless cycle of debilitation indistinguishable from a state of “living death”. Given the profound disadvantages of emergency-only treatment, several states have implemented alternative care measures for this population. This thesis examines the ethical, clinical, and financial shortcomings of emergency-only hemodialysis policies and evaluates alternative care methods for undocumented ESRD patients.