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General Considerations in Assessment for Transplant Candidacy

General Considerations in Assessment for Transplant Candidacy

This white paper is provided by the OPTN Ethics Committee for informational purposes to the OPTN Board of Directors and are intended for the operations of the OPTN. It has not been adopted as OPTN policy and does not carry the monitoring or enforcement implications of policy.

Revised in 2021

Transplant centers are encouraged to develop their own guidelines for transplant consideration. Each potential transplant candidate should be examined individually and all guidelines should be applied without of bias. 

Preamble

Transplant programs in the United States evaluate the suitability of potential transplant candidates using listing criteria developed by the transplant programs. The criteria are both medical and non-medical in nature. The use of non-medical criteria in evaluating patients for transplantation can affect the decision to list a potential transplant candidate for transplantation. This white paper offers an analysis of ethical considerations associated with non-medical criteria commonly used by transplant programs in listing decisions. It addresses use of life expectancy, potentially injurious behaviors, adherence, repeat transplantation, incarceration status, immigration status, and social support as transplant evaluation criteria. It also incorporates a section devoted to pediatric, adolescent, and young adult candidates for transplantation as these groups warrant separate and special consideration. This list is neither exhaustive nor immutable. Some factors the transplantation community has identified as important, such as intellectual disability and financial considerations, are not addressed in this white paper. Intellectual disability considerations are under review at the federal level, and thus not addressed here.[1] The OPTN continues to monitor this progress and may consider additional analysis in the future. Additionally, ethical considerations associated with the use of financial requirements for transplantation may also be considered for additional analysis in the future.

 

Non-medical factors relevant to transplant evaluations and listing decisions often include, but may not be limited to, psychosocial factors (e.g., social support, patient adherence).[2] Use of non-medical transplant evaluation criteria remains an area of concern to many in the transplant community.[3],[4]Non-medical criteria are thought, by some, to uphold the principle of utility by selecting candidates who can medically benefit from transplant. Their use is often supported as an effort to ensure optimal stewardship of a scarce resource. Yet, ethical concerns with using non-medical criteria to evaluate potential transplant candidates involve equity and justice.[5],[6],[7],[8]

 

The elements of non-medical transplant candidate evaluation should reflect the most current evidence available and their use should reflect a balance of ethical principles of utility, justice, and respect for persons. Importantly, these factors should be consistently applied to all potential transplant candidates, while ensuring the evaluation process is transparent, evidence-based (where available), and revisable.

 

This analysis relies on the three ethical principles identified in the Ethical Principles in the Allocation of Human Organs, which include utility, justice, and respect for persons.[9] As described in the Ethical Principles…, utility refers to the maximization of net benefit to the community and justice refers to the fair pattern of distribution of benefits. The principle of respect for persons primarily conveys the importance of the concept of autonomy. Transplant evaluations should balance justice requirements and respect for persons with utility considerations, including efforts to avoid futility.[10] The OPTN recognizes that listing decisions are complex and that transplant clinicians try to work with patients to identify and mitigate risk factors for negative outcomes and foster positive ones. The OPTN recognizes that, to support centers in reducing reliance on non-medical criteria, transplant center reporting metrics may need to be revised to increase emphasis on pre-transplant access measures and do a better job risk-adjusting for post-transplant outcomes.

 

The OPTN has reviewed and revised its historical position statement on transplant candidacy for considerations, including non-medical criteria, on several occasions, most recently in 2015.[11],[12] At the time, the OPTN provided ethical analyses of several criteria cited in this document, including life expectancy, organ failure caused by behavior, compliance/adherence, and repeat transplantation. In deciding to pursue a revised version, it was determined that there may be aspects of the 2015 version that are outdated or could benefit from revision and updates. The following discussion offers an overview of the ethical challenges associated with the use of non-medical criteria. 

Life Expectancy

Supported largely by the principle of utility, as discussed in the Ethical Principles in the Allocation of Human Organs, potential transplant candidates with longer life expectancy may, with a successful transplant, achieve the greatest benefit in terms of years of life saved.[13] The OPTN concurs that a patient’s ability to benefit from transplant should align with the organ’s potential longevity. While both a patient’s life expectancy and current state of health may be correlated to age, age itself should not be used to restrict transplantation owing to considerations of justice and respect for persons.[14] There are ethical reasons to avoid the sole use of age as an eligibility criterion for transplantation, including concerns of justice and respect for autonomy. There are also legal limitations such as those articulated in the Age Discrimination Act of 1975,[15] which preclude federally funded programs, like the OPTN, from engaging in age discrimination. In kind, the Affordable Care Act prohibits health care programs or activities from discriminating on the basis of age alone.[16] While the use of age by itself should not be used as a sole criterion for determining eligibility for potential transplant, it is ethically permissible to consider longevity and success of the graft. Age does not offer the full picture in determining the life expectancy and it precludes the possibility of some individuals being listed who might otherwise have made good candidates, thereby not respecting their autonomy. 

Potentially Injurious Behavior

Ethical concerns persist with using potentially injurious behaviors (e.g. substance use, unhealthy eating, non-adherence to medical recommendations, etc.) as criteria to rule out transplant candidacy. The principle of utility, may support the use of potentially injurious behaviors in transplant evaluation, as these behaviors may be seen to influence graft survival and broader transplant outcomes. Reliance on potentially injurious behaviors for transplant listing decisions must be evidence-based. Evidence linking some potentially injurious behaviors to transplant outcomes is essential but currently inconclusive.[17],[18],[19],[20],[21] For other behaviors, there may be emerging evidence to suggest that their presence may be associated with poorer outcomes. Potentially injurious behaviors may be considered in transplant evaluations where they are ongoing, untreated, and are likely to compromise successful transplant outcomes. Persons actively engaging in potentially injurious behaviors may not medically benefit from transplantation owing to higher risk of graft failure. By contrast, mere history of potentially injurious behavior that has been addressed or effectively treated, should not, on its own, disqualify persons from access to transplantation. 

Utility considerations associated with use of potentially injurious behaviors must be weighed against considerations of justice and respect for persons. This entails clearly articulating the potential harms (exclusion of candidates in need, who may be disproportionately structurally disadvantaged) and weighing them against the benefits (superior post-transplant outcomes) needed to understand the tradeoffs in balancing ethical principles.[22],[23],[24],[25],[26] 

Potentially injurious behaviors associated with negative outcomes may be partly due to personal choice and as such may involve personal responsibility or autonomy. However, these behaviors are also known to be significantly influenced by underlying psychological, genetic, economic, and systemic factors, including early life exposures – factors over which patients may have little control.[27],[28] For example, one’s diet is not a straightforward reflection of personal choice, but rather determined by several factors including one’s access to a grocery store which sells healthy food. Factors predicting substance use disorders similarly are shared between genetic and social precursors, as only some are related to personal choice.[29],[30] While potentially injurious behaviors may be due, in part, to personal choice, transplant providers should, to the extent that is possible, balance the principles of utility, justice, and respect for persons, which requires that considerations meant to lessen the impact of behavioral factors, such as abstinence periods for alcohol use disorder, be objective and evidence-based.[31] Justice and respect for autonomy dictate that transplant centers consider social determinants that may affect patient behavior when potentially injurious behaviors are implicated. Transplant centers have an ethical duty to work with patients to help them overcome the structural barriers to obtaining treatment and remaining in remission before transplant to ensure a successful outcome after transplant. 

Excluding patients from transplantation due to potentially injurious behaviors that are influenced by factors beyond patients’ control can exacerbate disparities in health and access to health care, thereby undermining justice and respect for persons in access to transplantation. Considering the contribution of many factors to both behavior and subsequent organ loss, and the limited evidence supporting the use of some factors, the OPTN continues to affirm that evaluation and listing decisions should be driven primarily by medical benefit, and that potentially injurious behavior should not be considered a sole basis for excluding transplant candidates unless the overwhelmingly outweighs the benefit.[32],[33] 

Adherence

Adherence (understood to be a bi-directional, proactive process of discussion and agreement between the patient and the medical team, on a course of therapy or management)[34] has limited objective measures. Adhering to a medical regimen post-transplant increases the likelihood of a successful transplant, increasing utility. Thus, transplanting patients who will be adherent is supported by the principle of utility. However, there are few reliable predictors of post-transplant adherence, and medical professionals commonly approach these issues inconsistently.[35] 

Justice requires that a history of consistent and documented treatment of non-adherence be considered by the transplant team. Ideally, this should take place keeping in mind barriers to adherence and other medical and psychosocial criteria. A transplant program should also consider an individual’s expressed willingness to follow treatment regimes. Objective measures of adherence such as attending dialysis treatment and visits for transplant evaluation should be considered when available. These measures should be assessed in the context of disparities in access to care based on geography, resources and financial status, all of which can adversely affect both patients’ ability to adhere to recommendations, and the implicit perceptions held by the clinicians about their ability to adhere. For example, transportation, lack of job security or time off for treatment, and financial constraints may directly affect dialysis adherence. Transplant program staff should evaluate these barriers and provide support where possible, including ancillary services such as counseling to candidates who lack adequate resources or have psychosocial challenges. 

Repeat Transplantation

The OPTN acknowledges that repeat transplantation raises concerns about justice, namely, that repeatedly allocating organs to a single person may be considered less ‘fair’ while others await a first transplant. That said, graft failure can occur at any time after transplantation and for many reasons, many beyond the control of the patient, such as poor initial quality of the transplanted graft, or other factors, including having been a living donor. Evaluations of potential transplant candidates for repeat transplantation should consider psychosocial and medical factors as well as the likelihood of long-term survival of a repeat transplant. Repeat transplantation should not be regarded as the sole criterion either to restrict or promote candidacy. 

Incarceration Status

The OPTN recognizes that incarcerated individuals, as well as individuals who are at high risk for recidivism for incarceration (as determined by evidence-based indicators such as age, criminal history, negative peer associations, substance use, and antisocial personality disorder),[36] face barriers to successful transplantation. At present, not all transplant centers are willing to evaluate currently incarcerated individuals, most commonly citing fear of poor post-transplant follow up and medication adherence as perceived barriers.[37] The OPTN affirms its position established in the white paper, Convicted Criminals and Transplant Evaluation that “absent any societal imperative, one’s status as a prisoner should not preclude them from consideration for a transplant; such consideration does not guarantee transplantation.”[38] That is to say that unless a currently incarcerated individual’s comprehensive transplant evaluation concludes that there are other contraindications to transplant present, their status as an inmate should not be a contradiction on its own. Additional steps should be taken to collaborate with correctional authorities to provide comprehensive post-transplant care to incarcerated individuals in the event the patient be deemed a candidate for transplantation.

Immigration Status

Consistent with OPTN policy, immigration status should not be used as a criterion in determining transplantation candidacy. Consistent with OPTN policy, a candidate’s citizenship or residency status must not be considered when allocating deceased donor organs to candidates for transplantation.[39] While immigration status may be tightly intertwined with other psychosocial and financial factors that affect a person’s candidacy for transplantation,[40],[41],[42] immigration status alone should neither determine nor exclude a person’s candidacy for organ transplantation as these would be unduly compromise justice and respect for persons. 

Many noncitizens participate in the transplant system as donors.[43] The principle of reciprocity implies that it is unjust for a system to use organs from a group of persons categorically excluded from access. Participation as organ donors and long-term residents in the U.S. also means that undocumented immigrants are not considered “transplant tourists” under the definition of the Declaration of Istanbul.[44] 

Theories of distributive justice, including some interpretations of Rawls’ Theory of Justice, suggest that persons, irrespective of immigration status, can be considered members of the society by virtue of participating in complex schemes of social cooperation (through sustained social ties, participation in community organizations, paid and unpaid labor, taxes, etc.).[45] Furthermore, the Difference Principle[46] sometimes referred to as the “maximum” principle, has been used to support granting access to transplant for persons irrespective of immigration status because such persons are often vulnerable members of society, facing unique challenges owing to language barriers, often lower socioeconomic status, and access to fewer safety net resources. 

Social Support

Social support can refer to informal care and emotional ties to others, which for many is comforting and helpful especially during health challenges and transitions, such as transplant evaluation and recovery.[47],[48] Transplant teams using social support criteria commonly require a potential transplant candidate to demonstrate social support to assist a wide range of post-transplant requirements, including: transportation, medication management, and symptom monitoring. Social support requirements vary significantly by program and organ type, and often require multiple people to be available for extended time periods.[49] These requirements may not be transparent or well understood by patients. 

Evidence that social support is predictive of graft failure or graft survival is limited, possibly due to selection bias. Social support has mostly been associated with improved quality of life post-transplant, but not outcomes such as graft or overall survival.[50],[51],[52],[53],[54] Use of social support in transplantation evaluations as a proxy for a patient’s ability to meet functional needs (e.g., self-care transportation), motivation, or future adherence may obscure the true demands (transportation to appointments, etc.) undermining transparency, and may unintentionally introduce implicit biases into listing decisions.[55] Difficulty demonstrating adequate social support is commonly associated with social vulnerabilities or with having non-traditional supports (e.g. friends, distant relatives, coworkers, etc.), amplifying social justice concerns. Demonstrating social support may be more challenging for persons with limited English language proficiency, and inflexible employment schedules. As such, use of social support to determine transplant eligibility may exacerbate socioeconomic, racial, ethnic, and gender disparities.[56] 

The OPTN affirms that access to life-saving and/or life-enriching care should not be contingent upon demonstrating social support or relationships. Patients’ ability and willingness to meet vital post-operative demands (e.g. transportation, medication sorting, etc.) should be assessed with interventions aimed at ensuring equitable access to all candidates who may benefit from transplant. 

Additional research should identify factors most predictive of post-transplant challenges that could negatively impact success after transplant, alongside interventions likely to reduce related risks. These include interventions to support post-transplant recovery and rehabilitation. 

Considerations for Pediatric, Adolescent and Young Adult Patients

As with pediatric priority in organ allocation, the committee recognizes that pediatric, adolescent and young adult candidates for transplantation require separate and special consideration as children are dependent and vulnerable.[57] Due to their age and developmental stage, children rely on adult caregivers and other social supports to be successful transplant candidates. As a result, psychosocial assessments inherently include both the patient and their caregivers. Children are not considered responsible for, nor do they have control over, factors such as their caregivers’ limitations, citizenship, ability to pay, family function or dysfunction, or their environment. At present, there is limited objective data on the impact of these caregiver factors on a child’s transplant outcomes.[58] As with adults, these criteria and assessments of nonadherence may be impacted by implicit or explicit biases about race and ethnicity.[59],[60] 

Children are generally considered a vulnerable population for which the “best interest” standard is commonly applied in decision-making. Successful transplantation is clearly in a child’s best interest as it fulfills essential medical and developmental needs, and thereby should not be denied solely due to limited caregiver resources. As such, psychosocial assessments should identify patient and family strengths and risk factors that could affect post-transplant outcomes with the goal of bolstering support for children (and their families) to be successful transplant recipients. This may involve leveraging local, community, or state resources to promote child flourishing and success as a transplant recipient. Involving a multidisciplinary team of experts including social workers, educators, school counselors, pediatricians, and other stakeholders in addition to the immediate family may be helpful to address some of these psychosocial factors early. Transplant centers should consider standardizing and ensuring accessibility of evaluations to promote transparency and equity in the transplant evaluation process. 

Concerns for nonadherence may be particularly high for patients in adolescence and early adulthood.[61] Recognition of this concern should promote early assessment and strategies to foster adherence in the pediatric candidate, particularly during the period of developing patient autonomy, independence, and transition to adult medicine. Programs should also work closely together to ensure seamless transition of listed pediatric or adolescent candidates between centers. This may be especially important in pediatrics as a child’s behavior may be viewed as more dynamic and past behavior may be less predictive of future behavior. The principles of justice, utility, and equity in the current context should be balanced with the urgency of transplant for pediatric patients, allowing them to thrive in the future. 

Summary/Conclusion

Ensuring equity in access to transplantation requires assessment and mitigation of structural barriers disproportionately impacting disadvantaged potential candidates who could medically benefit from transplantation. Such barriers include use of non-medical criteria, which can unwittingly introduce bias based on race, ethnicity, socioeconomic status, gender, and other non-clinical factors that may have a significant discriminatory impact on structurally disadvantaged populations. These criteria may compound the effect of social and healthcare disparities resulting in under referral of structurally disadvantaged patients for transplant evaluation and lower listing rates among those referred. 

Transplant centers are encouraged to develop their own guidelines for potential transplant candidate evaluations. Listing guidelines used by transplant programs should be applied without bias. Use of non-medical criteria continues to raise ethical concerns insofar as they commonly: (1) lack clear standards and thresholds; (2) are inconsistently applied; (3) are susceptible to stereotyping and instrumental value judgments; (4) are not transparent to patients; and (5) are not consistently supported by evidence. As such, transplant evaluations should not exclusively rely on non-medical criteria. The transplant community should continue to research the use of non-medical criteria with regard to who gets a transplant in order to apply them in an evidence-based manner; work to reduce bias and stereotyping; and increase transparency and consistency in the evaluation. 

Appendix A: State Legislation Enacted Prohibiting Discrimination in Transplantation Against Individuals With Physical and/or Intellectual Disabilities as of April 23, 2021

 

  • California, California Acts of Assembly, Chapter 96.
  • New Jersey, P.L. 2013, Chapter 80.
  • Maryland, 2015 Laws of Maryland, Chapter 383.
  • Massachusetts, 2016 General Laws, Chapter 111.
  • Oregon, 2017 Laws, Chapter 396.
  • Delaware, 2017 Laws of Delaware, Volume 81, Chapter 169.
  • Kansas, 2018 House Bill 2343.
  • Ohio, 2018 House Bill 332.
  • Pennsylvania, 2018 Public Law 594, No. 90.
  • Washington, 2019 Laws, Chapter 315.
  • Louisiana, Acts 2019, No. 57, §.3, eff. May 30, 2019.
  • Indiana, 2019 Public Law 2.
  • Virginia, 2020 Virginia Acts of Assembly, Chapter 217.
  • Iowa, 2020 Iowa Acts, Chapter 1101.
  • Missouri, CCS HCS SB 551. Effective Date August 28, 2020.
  • Florida, 2020 Chapter No. 2020-139.

References

[1]Department of Health and Human Services, Office of Civil Rights, Discrimination on the Basis of Disability in Critical Health and Human Service Programs or Activities, RIN 0945-AA15, Washington, D.C.: January 2021, https://www.hhs.gov/sites/default/files/504-rfi.pdf (accessed April 8, 2021).

[2] 42 C.F.R. § 482.90.

[3] The following references identify specific ethical concerns related to the use of non-medical criteria: (a) Disability: National Council on Disability, Organ Transplant Discrimination Against People with Disabilities, September 25, 2019, accessed September 23, 2020. https://ncd.gov/sites/default/files/NCD_Organ_Transplant_508.pdf; (b) Immigration: David Ansell et al., "Illinois Law Opens Door to Kidney Transplants for Undocumented Immigrants," Health Affairs (Project Hope) 34, no. 5 (2015): 781-87, https://doi.org/10.1377/hlthaff.2014.1192; (c) Immigrant Kidney Transplantation Outcomes: Jenny I. Shen et al., "Association of Citizenship Status With Kidney Transplantation in Medicaid Patients," American Journal of Kidney Diseases 71, no. 2 (2018): 182-90., https://doi.org/10.1053/j.ajkd.2017.08.014; and (d) Poverty: Mary Simmerling, "Beyond Scarcity: Poverty as a Contraindication for Organ Transplantation." The Virtual Mentor 9, no. 6 (2007): 441, https://doi.org/10.1001/virtualmentor.2007.9.6.pfor1-0706.

[4] Ellen Jean Hirst, “Hunger Strikers Demand Chance at Organ Transplants,” Chicago Tribune, August 6, 2013, https://www.chicagotribune.com/news/ct-xpm-2013-08-06-ct-met-hunger-strike-northwestern-0806-20130806-story.html.

[5] Keren Ladin et al., "A Mixed-Methods Approach to Understanding Variation in Social Support Requirements and Implications for Access to Transplantation in the United States," Progress in Transplantation 29, no. 4 (2019): 344-53, https://doi.org/10.1177/1526924819874387.

[6] R. A. Majeske, "Transforming Objectivity to Promote Equity in Transplant Candidate Selection," Theoretical Medicine and Bioethics 17, no. 1 (1996): 45-59, https://doi.org/10.1007/BF00489740.

[7] Pikli Batabyal et al., "Clinical Practice Guidelines on Wait-listing for Kidney Transplantation: Consistent and Equitable?," Transplantation 94, no. 7 (2012): 703-13, https://doi.org/10.1097/TP.0b013e3182637078.

[8] OPTN, Ethical Principles in the Allocation of Human Organs, June 2015, https://optn.transplant.hrsa.gov/resources/ethics/ethical-principles-in-the-allocation-of-human-organs/ (accessed October 2, 2020).

[9] OPTN, Ethical Principles in the Allocation of Human Organs, June 2015, https://optn.transplant.hrsa.gov/resources/ethics/ethical-principles-in-the-allocation-of-human-organs/ (accessed September 19, 2020).

[10] OPTN, Ethical Principles in the Allocation of Human Organs, June 2015, https://optn.transplant.hrsa.gov/resources/ethics/ethical-principles-in-the-allocation-of-human-organs/ (accessed September 19, 2020).

[11] OPTN, Report to the Board of Directors, March 2-3, 2009.

[12] OPTN, General Considerations in Assessment for Transplant Candidacy, January 2014, https://optn.transplant.hrsa.gov/resources/ethics/general-considerations-in-assessment-for-transplant-candidacy/ (accessed September 23, 2020).

[13] OPTN, Ethical Principles in the Allocation of Human Organs, June 2015, https://optn.transplant.hrsa.gov/resources/ethics/ethical-principles-in-the-allocation-of-human-organs/ (accessed September 19, 2020).

[14] Benjamin Eidelson, "Kidney Allocation and the Limits of the Age Discrimination Act," The Yale Law Journal 122, no. 6 (2013): 1635-652.

[15] 42 U.S.C. §§ 6101-6107.

[16] 42 U.S.C. § 18116; and National Council on Disability, Organ Transplant Discrimination Against People with Disabilities, September 25, 2019, https://ncd.gov/sites/default/files/NCD_Organ_Transplant_508.pdf (accessed September 23, 2020).

[17] Monika Koch and Peter Banys, "Liver Transplantation and Opioid Dependence," JAMA: The Journal of the American Medical Association 285, no. 8 (2001): 1056-058, https://doi.org/10.1001/jama.285.8.1056.

[18] Sarah E. Wakeman et al.,"Opioid Use Disorder, Stigma, and Transplantation: A Call to Action," Annals of Internal Medicine 169, no. 3 (2018): 188-189, https://doi.org/10.7326/M18-1099.

[19] Brian P. Lee et al., "National Trends and Long-term Outcomes of Liver Transplant for Alcohol-Associated Liver Disease in the United States," JAMA Internal Medicine 179, no. 3 (2019): 340-48, https://doi.org/10.1001/jamainternmed.2018.6536.

[20] Patrizia Burra and Michael R. Lucey, "Liver Transplantation in Alcoholic Patients," Transplant International 18, no. 5 (2005): 491-498, https://doi.org/10.1111/j.1432-2277.2005.00079.x.

[21] Sudha Kodali et al., "Alcohol Relapse After Liver Transplantation for Alcoholic Cirrhosis—Impact on Liver Graft and Patient Survival: A Meta-analysis," Alcohol and Alcoholism 53, no. 2 (2018): 166-72, https://doi.org/10.1093/alcalc/agx098.

[22] K. L. Lentine et al., “Prescription Opioid Use before and after Kidney Transplant: Implications for Posttransplant Outcomes,” American Journal of Transplantation 18, no. 12 (2018): 2987-999, https://doi.org/10.1111/ajt.14714.

[23] K. L. Lentine et al., “Predonation Prescription Opioid Use: A Novel Risk Factor for Readmission After Living Kidney Donation,” American Journal of Transplantation 17, no. 3 (2017):744-53, https://doi.org/10.1111/ajt.14033.

[24] K. L. Lentine et al., “Associations of Pre-Transplant Prescription Narcotic Use with Clinical Complications after Kidney Transplantation,” American Journal of Nephrology 41, no. 2 (2015):165-76, https://doi.org/10.1159/000377685.

[25] K. L. Lentine et al., “Prescription Opioid Use before and after Heart Transplant: Associations with Posttransplant Outcomes,” American Journal of Transplantation 19, no. 12 (2019):3405-414, https://doi.org/10.1111/ajt.15565.

[26] Ngan N. Lam et al., “Outcome implications of benzodiazepines and opioid co-prescriptions in kidney transplant recipients,” Clinical Transplantation 34, no. 9 (2020): E14005-N/a, https://doi.org/10.1111/ctr.14005.

[27] U.S. Department of Health and Human Services, Centers for Disease Control and Prevention, Morbidity and Mortality Weekly, January 14, 2011, Chapters addressing obesity, diabetes, hypertension, and binge drinking, https://www.cdc.gov/mmwr/pdf/other/su6001.pdf (accessed April 8, 2021).

[28] U.S. Department of Health and Human Services, National Institutes of Health, National Institute on Alcohol Abuse and Alcoholism, “Understanding Alcohol Use Disorder,” last updated April 2021, https://www.niaaa.nih.gov/publications/brochures-and-fact-sheets/understanding-alcohol-use-disorder, (accessed April 8, 2021).

[29] L. Bevilacqua and D. Goldman, "Genes and Addictions," Clinical Pharmacology and Therapeutics 85, no. 4 (2009): 359-61, https://doi.org/10.1038/clpt.2009.6.

[30] Rajita Sinha, "Chronic Stress, Drug Use, and Vulnerability to Addiction," Annals of the New York Academy of Sciences 1141, no. 1 (2008): 105-30, https://doi.org/10.1196/annals.1441.030.

[31] Ajay Singhvi et al.,"Ethical Considerations of Transplantation and Living Donation for Patients with Alcoholic Liver Diseases," AMA Journal of Ethics 18, no. 2 (2016): 163-73, https://doi.org/10.1001/journalofethics.2017.18.2.sect1-1602.

[32] 42 U.S.C. § 18116; and National Council, Organ, September 25, 2019.

[33] Settlement Agreement Between the United States of America and Massachusetts General Hospital Under the Americans with Disabilities Act, DJ # 202-36-304, August 7, 2020, accessed April 8, 2021, https://www.ada.gov/mass_gen_hosp_sa.html.

[34] World Health Organization, Adherence to Long-term Therapies: Evidence for Action, (Geneva: World Health Organization, 2003), ProQuest Ebook Central.

[35] Fabienne Dobbels et al.,"Pretransplant Predictors of Posttransplant Adherence and Clinical Outcome: An Evidence Base for Pretransplant Psychosocial Screening," Transplantation 87, no. 10 (2009): 1497-504, https://doi.org/10.1097/TP.0b013e3181a440ae.

[36] Government of Western Australia, Office of the Inspector of Custodial Services, Recidivism rates and the impact of treatment programs, ISSN 1445-3134, September 2014, https://www.oics.wa.gov.au/wp-content/uploads/2014/09/OICS-Recidivism-review.pdf (accessed October 8, 2020).

[37] Lauren S. Faber, Madeline Palmer, Michael Davis, and Tania Lyons, “Disparities in Access to Kidney Transplantation: Are American Transplant Centers Willing to Transplant Inmates?” (poster, American Society of Transplant Surgeons, 2021 Winter Symposium).

[38] OPTN, Convicted Criminals and Transplant Evaluation, January 2014, https://optn.transplant.hrsa.gov/resources/ethics/convicted-criminals-and-transplant-evaluation/ (accessed September 23, 2020).

[39] OPTN, Policy 5.4.A: Nondiscrimination in Organ Allocation, effective April 1, 2021, https://optn.transplant.hrsa.gov/media/eavh5bf3/optn_policies.pdf (accessed October 2, 2020).

[40] Ellen Jean Hirst, “Hunger Strikers Demand Chance at Organ Transplants,” Chicago Tribune, August 6, 2013, https://www.chicagotribune.com/news/ct-xpm-2013-08-06-ct-met-hunger-strike-northwestern-0806-20130806-story.html.

[41] Axel Rahmel and Sandy Feng, "Liver Transplants for Noncitizens/nonresidents: What Is the Problem, and What Should Be Done?," American Journal of Transplantation 18, no. 11 (2018): 2620-621, https://doi.org/10.1111/ajt.15059.

[42] Anthony J. Bleyer, "Office Visit: Kidney Transplantation of a Dreamer," Nephron (2015) 139, no. 4 (2018): 283-85, https://doi.org/10.1159/00048895.

[43] Aaron Wightman and Douglas Diekema, "Should an Undocumented Immigrant Receive a Heart Transplant?," AMA Journal of Ethics 17, no. 10 (2015): 909-13, https://doi.org/10.1001/journalofethics.2015.17.10.peer1-1510.

[44] Steering Committee Summit, "Organ Trafficking and Transplant Tourism and Commercialism: The Declaration of Istanbul," The Lancet (British Edition) 372, no. 9632 (2008): 5-6, https://doi.org/10.1016/S0140-6736(08)60967-8.

[45] Norman Daniels and Keren Ladin, “Immigration and Access to Health Care,” In Routledge Companion to Bioethics, ed. John D. Arras, Elizabeth Fenton and Rebecca Kukla, (Abingdon: Routledge, 2014).

[46] John. A Rawls, A Theory of Justice (Cambridge: Harvard University Press, 1971).

[47] Manuel Barrera, "Distinctions between Social Support Concepts, Measures, and Models," American Journal of Community Psychology 14, no. 4 (1986): 413-45, https://doi.org/10.1007/BF00922627.

[48] Benjamin H. Gottlieb and Anne E. Bergen, "Social Support Concepts and Measures," Journal of Psychosomatic Research 69, no. 5 (2010): 511-20, https://doi.org/10.1016/j.jpsychores.2009.10.001.

[49]Keren Ladin et al., "A Mixed-Methods Approach to Understanding Variation in Social Support Requirements and Implications for Access to Transplantation in the United States," Progress in Transplantation 29, no. 4 (2019): 344-53, https://doi.org/10.1177/1526924819874387.

[50] Keren Ladin et al., "Is Social Support Associated with Post-transplant Medication Adherence and Outcomes? A Systematic Review and Meta-Analysis," Transplantation Reviews 32, no. 1 (2017): 16-28, https://doi.org/10.1016/j.trre.2017.04.001.

[51] Sasha Deutsch-Link et al., “The Stanford Integrated Psychosocial Assessment for Transplant Is Associated With Outcomes Before and After Liver Transplantation,” Liver Transplantation 27, no. 5 (2020): 652-57.

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