The Impact of Social Factors on Organ Transplant Eligibility: Examining the Varied Criteria and Disparities
When Beth Lehman, 49, of Sandy Springs, Ga., was 47, her doctors told her she would die if she didn’t have a liver transplant. At the time, she was drinking two to three bottles of wine a day. Lehman’s transplant center wanted her to complete six months of sobriety counseling before she could get on the transplant waiting list, but her doctors thought she might not have that long to live. “I was rapidly going downhill, so they had my therapist sign a letter saying that I was currently in [counseling], and I signed a letter of intent to complete it,” she said.
On April 18, 2021, after planning her own funeral, Lehman got the call that a new liver was waiting for her. She had her transplant the next day. Nearly three years later, she remains sober and is the healthiest she has been in years. Lehman was lucky. Another center might have rejected her.
More than 100,000 people in the United States are on wait lists for an organ transplant. With a shortage of needed organs, transplant centers must choose among hopeful patients, accepting those candidates deemed to have the greatest need and highest chances of success.
What many people don’t realize is that medically qualifying for a transplant is just part of that process. Other factors, including the perceived strength of a person’s support network, play a role, too, adding a variability to the process that works against some patients, critics say.
“This aspect of transplant isn’t regulated. There are really no established best practices,” said Lisa McElroy, an endowed assistant professor in surgery at Duke University School of Medicine who has started a consortium to improve equity in transplants. “When people think about eligibility for transplant, they may just think about ‘Do they qualify medically?’ But the transplant evaluation is actually a multidisciplinary evaluation.”
Why social factors matter
The evaluation process is designed to gauge, among other things, whether a patient is up to the rigors of post-transplant recovery.
That means transplant panels assess what are known as psychosocial factors, including whether a patient appears likely to get to multiple post-surgery doctor’s appointments and to follow a strict medication regimen that includes expensive immunosuppressant drugs designed to keep the body’s immune system from attacking a new organ. The panel also wants assurance that the patient will avoid using drugs and alcohol, and that they understand general medical processes.
One challenge of psychosocial predictors is the high degree of variability from center to center on how they are weighed.
An official with the American Society of Transplant Surgeons (ASTS) said such variability is necessary. “There is not a ‘one size fits all’ approach, as each center has their own criteria based on program size, outcomes, and experience,” Samantha Halpern, associate councilor for ASTS, wrote in an email.
“All patients should have equitable access” to the national organ transplant waiting list, the United Network for Organ Sharing (UNOS) said in a statement.
‘Disproportionately impacted’
Liver transplantation offers a lens into the complex evaluation process common to solid organ transplantation. In 2023, a study led by researchers at the University of North Carolina and the University of Pennsylvania said 44 percent of patients evaluated for liver transplants were not placed on organ wait lists. Of this group, nearly 17 percent were rejected because of psychosocial or financial reasons.
Another study led by Keren Ladin, an associate professor in the Department of Community Health at Tufts University and the former chair of the UNOS Ethics Committee, found that 10 percent to 20 percent of patients are rejected from transplant listing because of inadequate social support.
Using survey responses from 604 clinicians at 202 transplant centers, Ladin’s team reported that “inadequate social support excludes up to 20% of transplant candidates needing an organ transplant.” Further, a “majority of transplant providers believed that social support criteria disproportionately impacted patients of low socioeconomic status, and nearly half of providers lacked confidence in current social support criteria,” the researchers concluded.
There’s a “large bucket of kind of subjective … nondescript factors, including motivation and readiness,” Ladin said. “All of those factors are concerning and likely to exacerbate structural disparities in access to transplant even among those who are already referred, which we know is a very small subset of the patients who would benefit.”
Some centers are also better able to manage complex factors beyond medical need, one expert said.
“If you have more resources, you can probably take more risks,” said Robert S. Brown, professor of medicine and chief of the Division of Gastroenterology and Hepatology at Weill Cornell Medicine. “If a center is able to invest in more post-transplant addiction treatment or willing to invest, they
