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Blaming the Patient: The Ethical Failures of Responsibility-Based Liver Transplant Policy in Alcohol Use Disorder.

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Τίτλος: Blaming the Patient: The Ethical Failures of Responsibility-Based Liver Transplant Policy in Alcohol Use Disorder.
Συγγραφείς: Aillaud-De-Uriarte D; Center for Bioethics, Harvard Medical School, Boston, Massachusetts, USA.; Department of Bioethics and Health Humanities, University of Texas Medical Branch, Galveston, Texas, USA.
Πηγή: Bioethics [Bioethics] 2026 Oct; Vol. 40 (8), pp. 900-907. Date of Electronic Publication: 2026 May 19.
Τύπος έκδοσης: Journal Article
Γλώσσα: English
Στοιχεία περιοδικού: Publisher: Wiley-Blackwell Country of Publication: England NLM ID: 8704792 Publication Model: Print-Electronic Cited Medium: Internet ISSN: 1467-8519 (Electronic) Linking ISSN: 02699702 NLM ISO Abbreviation: Bioethics Subsets: MEDLINE
Imprint Name(s): Publication: Oxford : Wiley-Blackwell
Original Publication: Oxford ; New York : Basil Blackwell, c1987-
Ιατρικοί όροι (MeSH): Liver Transplantation*/ethics , Patient Selection*/ethics , Alcoholism* , Social Responsibility*, Humans ; Ethical Dilemmas
Περίληψη: Responsibility continues to shape how many transplant programs evaluate liver transplantation for patients with Alcohol Use Disorder (AUD), even in settings where the traditional 6-month abstinence rule has been abandoned. This article argues that using past drinking to lower transplant priority, or to break ties between candidates, is ethically mistaken and clinically harmful. Appeals to personal responsibility often misrepresent the nature of addiction and overestimate the degree of knowledge and control individuals possess when harmful drinking patterns begin and escalate. Early onset of alcohol use, trauma, and psychiatric comorbidity frequently constrain the range of meaningful options available long before transplantation becomes relevant. When these histories are treated primarily as evidence of blameworthy behavior, stigma is reinforced and patients may have fewer incentives to be honest about relapse risk or struggles in treatment. The article examines several influential arguments that defend the use of responsibility in transplant allocation and explains why they fail in practice. It then proposes an alternative framework. Allocation should rely on forward-looking criteria that are relevant to clinical outcomes and fairness, including medical urgency, expected benefit, engagement in treatment, reliability in follow-up care, and the presence of social support. These considerations can be assessed more transparently than retrospective judgments about deservingness and avoid penalizing patients for circumstances that contributed to their illness. The article concludes by considering the implications for transplant committees. Policies should reward engagement in care and support recovery rather than rely on retrospective moral judgments about past behavior. Doing so strengthens trust between clinicians and patients, improves adherence to treatment, and allocates a scarce resource on grounds that are ethically relevant to the success of transplantation.
(© 2026 John Wiley & Sons Ltd.)
References: J Med Ethics. 2006 May;32(5):263-5. (PMID: 16648275)
Am J Psychiatry. 2023 Aug 1;180(8):565-572. (PMID: 37525595)
J Med Philos. 1998 Feb;23(1):31-49. (PMID: 9555633)
Ann Transplant. 2026 Mar 10;31:e951641. (PMID: 41804063)
Alcohol Clin Exp Res. 2018 May;42(5):836-840. (PMID: 29489019)
Hastings Cent Rep. 2007 Jan-Feb;37(1):41-7. (PMID: 17348263)
Dig Dis Sci. 2020 Jun;65(6):1600-1607. (PMID: 32060813)
Curr Opin Organ Transplant. 2025 Feb 1;30(1):37-45. (PMID: 39629498)
Pharmacol Biochem Behav. 2020 May;192:172906. (PMID: 32179028)
J Med Ethics. 2019 Oct;45(10):636-644. (PMID: 31221764)
J Med Ethics. 2008 Jan;34(1):33-6. (PMID: 18156519)
Hastings Cent Rep. 2020 Jul;50(4):37-46. (PMID: 33448417)
J Med Ethics. 2009 Dec;35(12):739-42. (PMID: 19948929)
J Med Ethics. 2010 Nov;36(11):661-5. (PMID: 20817816)
Contributed Indexing: Keywords: addiction stigma; alcohol use disorder; clinical ethics; fairness in allocation; liver transplantation; moral responsibility
Entry Date(s): Date Created: 20260519 Date Completed: 20260912 Latest Revision: 20260914
Update Code: 20260914
PubMed Central ID: PMC13570757
DOI: 10.1111/bioe.70130
PMID: 42153301
Βάση Δεδομένων: MEDLINE
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  Data: Blaming the Patient: The Ethical Failures of Responsibility-Based Liver Transplant Policy in Alcohol Use Disorder.
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  Data: Responsibility continues to shape how many transplant programs evaluate liver transplantation for patients with Alcohol Use Disorder (AUD), even in settings where the traditional 6-month abstinence rule has been abandoned. This article argues that using past drinking to lower transplant priority, or to break ties between candidates, is ethically mistaken and clinically harmful. Appeals to personal responsibility often misrepresent the nature of addiction and overestimate the degree of knowledge and control individuals possess when harmful drinking patterns begin and escalate. Early onset of alcohol use, trauma, and psychiatric comorbidity frequently constrain the range of meaningful options available long before transplantation becomes relevant. When these histories are treated primarily as evidence of blameworthy behavior, stigma is reinforced and patients may have fewer incentives to be honest about relapse risk or struggles in treatment. The article examines several influential arguments that defend the use of responsibility in transplant allocation and explains why they fail in practice. It then proposes an alternative framework. Allocation should rely on forward-looking criteria that are relevant to clinical outcomes and fairness, including medical urgency, expected benefit, engagement in treatment, reliability in follow-up care, and the presence of social support. These considerations can be assessed more transparently than retrospective judgments about deservingness and avoid penalizing patients for circumstances that contributed to their illness. The article concludes by considering the implications for transplant committees. Policies should reward engagement in care and support recovery rather than rely on retrospective moral judgments about past behavior. Doing so strengthens trust between clinicians and patients, improves adherence to treatment, and allocates a scarce resource on grounds that are ethically relevant to the success of transplantation.<br /> (© 2026 John Wiley & Sons Ltd.)
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  Data: J Med Ethics. 2006 May;32(5):263-5. (PMID: <searchLink fieldCode="PM" term="%2216648275%22">16648275)</searchLink><br />Am J Psychiatry. 2023 Aug 1;180(8):565-572. (PMID: <searchLink fieldCode="PM" term="%2237525595%22">37525595)</searchLink><br />J Med Philos. 1998 Feb;23(1):31-49. (PMID: <searchLink fieldCode="PM" term="%229555633%22">9555633)</searchLink><br />Ann Transplant. 2026 Mar 10;31:e951641. (PMID: <searchLink fieldCode="PM" term="%2241804063%22">41804063)</searchLink><br />Alcohol Clin Exp Res. 2018 May;42(5):836-840. (PMID: <searchLink fieldCode="PM" term="%2229489019%22">29489019)</searchLink><br />Hastings Cent Rep. 2007 Jan-Feb;37(1):41-7. (PMID: <searchLink fieldCode="PM" term="%2217348263%22">17348263)</searchLink><br />Dig Dis Sci. 2020 Jun;65(6):1600-1607. (PMID: <searchLink fieldCode="PM" term="%2232060813%22">32060813)</searchLink><br />Curr Opin Organ Transplant. 2025 Feb 1;30(1):37-45. (PMID: <searchLink fieldCode="PM" term="%2239629498%22">39629498)</searchLink><br />Pharmacol Biochem Behav. 2020 May;192:172906. (PMID: <searchLink fieldCode="PM" term="%2232179028%22">32179028)</searchLink><br />J Med Ethics. 2019 Oct;45(10):636-644. (PMID: <searchLink fieldCode="PM" term="%2231221764%22">31221764)</searchLink><br />J Med Ethics. 2008 Jan;34(1):33-6. (PMID: <searchLink fieldCode="PM" term="%2218156519%22">18156519)</searchLink><br />Hastings Cent Rep. 2020 Jul;50(4):37-46. (PMID: <searchLink fieldCode="PM" term="%2233448417%22">33448417)</searchLink><br />J Med Ethics. 2009 Dec;35(12):739-42. (PMID: <searchLink fieldCode="PM" term="%2219948929%22">19948929)</searchLink><br />J Med Ethics. 2010 Nov;36(11):661-5. (PMID: <searchLink fieldCode="PM" term="%2220817816%22">20817816)</searchLink>
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