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General Considerations in Assessment for Transplant Candidacy

Reviewed in 2015

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

Preamble

The concept of non-medical transplant candidate criteria is an area of great concern. Most transplant programs in the United States use some type of non-medical evaluation of patients for transplantation. Historically, psychosocial evaluations of potential transplant candidates have been conducted and the results have influenced the possible listing of these patients in a variety of ways. There is general agreement that non-medical transplant candidate criteria need to be evaluated. The legitimate substance of such an evaluation could cover a very wide range of topics. To the greatest extent possible, any acceptance criteria should be broad and universal.

The UNOS Ethics Committee has chosen to address the criteria of life expectancy, organ failure caused by behavior, compliance/adherence, repeat transplantation and alternative therapies. The list is recognized as neither exhaustive nor immutable. The elements of non-medical transplant candidate evaluation will and should reflect changes that occur in technology, medicine and other related fields while reflecting the most current knowledge of scientific and social issues in transplantation. Therefore, the non-medical transplant candidate criteria should be continuously reassessed and modified as necessary. However, because we are serving individual human beings with highly complex medical situations, a process of individual evaluation must be maintained within the broad parameters.

The Ethics Committee also realizes the catalyst for all transplant candidate criteria is the shortage of available organs for transplantation. Because donated organs are a severely limited resource the best potential recipients should be identified. The probability of a good outcome must be highly emphasized to achieve the maximum benefit for all transplants. Were there an ample supply of transplantable organs, nearly every person in need could be a transplant candidate. To this end, it is affirmed that transplantation is not a universal option. Medical professionals, while honoring the moral obligations to extend life and relieve suffering whenever possible, must also recognize the limitations of transplantation in meeting these ends.

Life Expectancy

While the Committee would not recommend arbitrary age or co-morbidity limits for transplantation, members generally concur that transplantation should be carefully considered if the candidate's reasonable life expectancy with a functioning graft, based on factors such as age or co-morbid conditions, is significantly shorter than the reasonably expected "life span" of the transplanted organ.

Organ Failure Caused by Behavior

In social and medical venues, debate continues to focus upon alcoholism, drug abuse, smoking, eating disorders and other behaviors as diseases or character flaws. Such behaviors are associated with disease processes in many adults. The Ethics Committee has historically supported the conclusion that past behavior that results in organ failure should not be considered a sole basis for excluding transplant candidates. However, additional discussion of this issue in a societal context may be warranted.

Compliance/Adherence

It is difficult to apply broad measures of compliance to accepting transplant candidates, since empirical measures are limited and medical professionals often approach these issues subjectively. However, transplantation should be considered very cautiously for individuals who have demonstrated serious, consistent, and documented non-compliance in current or previous treatment.

Repeat Transplantation

The Ethics Committee acknowledges the issue of justice in considering repeat transplantation. Graft failure, particularly early or immediate failure, evokes significant concerns regarding repeat transplantation. However, the likelihood of long-term survival of a repeat transplant should receive strong consideration.

Alternative Therapies

The presence or absence of alternative therapies should be carefully weighed against other factors in evaluation. In some cases the need for a transplant may be delayed, even prevented, by judicious use of other medical or surgical procedures.