Moral Complexity in Triaging Transplant Candidates with Substance Use History

Abstract

Substance use history has long shaped access to solid-organ transplantation, most visibly through the fixed pre-transplant abstinence period historically required of candidates with alcohol-associated liver disease. This policy analysis traces how that behavioral criterion emerged, why its evidentiary basis has eroded as outcomes data on early transplantation for severe alcoholic hepatitis has accumulated, and how comparable skepticism toward candidates with opioid use disorder has persisted even for those stabilized on
evidence-based medication-assisted treatment. We examine the philosophical difficulty of conditioning access to a scarce resource on judgments about a patient's responsibility for a relapsing medical condition, and the role that stigma plays in the subjective
components of psychosocial evaluation. Evidence on listing patterns further suggests that the shift from fixed sobriety rules toward individualized assessment has not eliminated disparity, with race, ethnicity, and structural social disadvantage continuing
to shape outcomes independent of documented clinical risk. We argue for organ-specific, evidence-based, and transparently applied behavioral criteria that can be audited in the way a MELD score or ejection fraction already can, rather than criteria left to unexamined
evaluator discretion.