Ethical and allocation issues in liver transplant candidates with alcohol related liver disease

Identifying High-Priority Ethical Challenges for Precision Emergency Medicine: Nominal Group Study

Background

Precision medicine promises to revolutionize health care by providing the right care to the right patient at the right time. However, the emergency department's unique mandate to treat "anyone, anywhere, anytime" creates critical tensions with precision medicine's requirements for comprehensive patient data and computational analysis. As emergency departments serve as health care's safety net and provide a growing proportion of acute care in America, identifying and addressing the ethical challenges of implementing precision medicine in this setting is crucial to prevent exacerbation of existing health care disparities. The rapid advancement of precision medicine technologies makes it imperative to understand these challenges before widespread implementation in emergency care settings.

Objective

This study aimed to identify high priority ethical concerns facing the implementation of precision medicine in the emergency department.

Methods

We conducted a qualitative study using a modified nominal group technique (NGT) with emergency physicians who had previous knowledge of precision medicine concepts. The NGT process consisted of four phases: (1) silent generation of ideas, (2) round-robin sharing of ideas, (3) structured discussion and clarification, and (4) thematic grouping of priorities. Participants represented diverse practice settings (county hospital, community hospital, academic center, and integrated managed care consortium) and subspecialties (education, ethics, pediatrics, diversity, equity, inclusion, and informatics) across various career stages from residents to late-career physicians.

Results

A total of 12 emergency physicians identified 82 initial challenges during individual ideation, which were consolidated to 48 unique challenges after removing duplicates and combining related items. The average participant contributed 6.8 (SD 2.9) challenges. These challenges were organized into a framework with 3 themes: values, privacy, and justice. The framework identified the need to address these themes across 3 time points of the precision medicine process: acquisition of data, actualization in the care setting, and the after effects of its use. This systematic organization revealed interrelated concerns spanning from data collection and bias to implementation challenges and long-term consequences for health care equity.

Conclusions

Our study developed a novel framework that maps critical ethical challenges across 3 domains (values, privacy, and justice) and 3 temporal stages of precision medicine implementation. This framework identifies high-priority areas for future research and policy development, particularly around data representation, privacy protection, and equitable access. Successfully addressing these challenges is essential to realize precision medicine's potential while preserving emergency medicine's core mission as health care's safety net.

The landscape of liver transplantation for patients with alcohol-associated liver disease in the United States

Indications for liver transplants have expanded to include patients with alcohol-associated liver disease (ALD) over the last decade. Concurrently, the liver allocation policy was updated in February 2020 replacing the Donor Service Area with Acuity Circles (ACs). The aim is to compare the transplantation rate, waitlist outcomes, and posttransplant survival of candidates with ALD to non-ALD and assess differences in that effect after the implementation of the AC policy. Scientific Registry for Transplant Recipients data for adult candidates for liver transplant were reviewed from the post-AC era (February 4, 2020-March 1, 2022) and compared with an equivalent length of time before ACs were implemented. The adjusted transplant rates were significantly higher for those with ALD before AC, and this difference increased after AC implementation (transplant rate ratio comparing ALD to non-ALD = 1.20, 1.13, 1.61, and 1.32 for the Model for End-Stage Liver Disease categories 37-40, 33-36, 29-32, and 25-28, respectively, in the post-AC era, p < 0.05 for all). The adjusted likelihood of death/removal from the waitlist was lower for patients with ALD across all lower Model for End-Stage Liver Disease categories (adjusted subdistribution hazard ratio = 0.70, 0.81, 0.84, and 0.70 for the Model for End-Stage Liver Disease categories 25-28, 20-24, 15-19, 6-14, respectively, p < 0.05). Adjusted posttransplant survival was better for those with ALD (adjusted hazard ratio = 0.81, p < 0.05). Waiting list and posttransplant mortality tended to improve more for those with ALD since the implementation of AC but not significantly. ALD is a growing indication for liver transplantation. Although patients with ALD continue to have excellent posttransplant outcomes and lower waitlist mortality, candidates with ALD have higher adjusted transplant rates, and these differences have increased after AC implementation.

Alcohol Use Disorder and Alcohol-Associated Liver Disease: New Definitions, Screening, and Treatment

Alcohol-associated liver disease (ALD) poses a significant global health burden and is a leading cause of liver-related morbidity and mortality. ALD encompasses a spectrum of disease states ranging from asymptomatic steatosis to acute hepatitis and cirrhosis. Alcohol use disorder (AUD) significantly increases the risk of developing ALD, and insight into AUD can provide a more complete understanding of ALD and the patients affected by these interrelated diseases. Accurate and timely identification of AUD, even in primary care, through validated screening tools combined with blood tests and imaging techniques facilitates early detection of ALD. Although liver transplantation (LT) remains the most effective treatment for end-stage ALD, patient outcomes post-LT have evolved because of shifting perspectives on ALD transplant eligibility, comprehensive pre-LT evaluations, and advancements in post-LT ALD detection. Nonetheless, addressing disparities in LT practices for ALD is paramount for ensuring equitable access to this life-saving intervention. This article offers an updated synopsis of ALD definitions, screening methodologies, and contemporary management approaches, particularly in the context of LT.

Geographic disparities in access to liver transplant for advanced cirrhosis: Time to ring the alarm!

Decompensated cirrhosis and hepatocellular cancer are major risk factors for mortality worldwide. Liver transplantation (LT), both live-donor LT or deceased-donor LT, are lifesaving, but there are several barriers toward equitable access. These barriers are exacerbated in the setting of critical illness or acute-on-chronic liver failure. Rates of LT vary widely worldwide but are lowest in lower-income countries owing to lack of resources, infrastructure, late disease presentation, and limited donor awareness. A recent experience by the Chronic Liver Disease Evolution and Registry for Events and Decompensation consortium defined these barriers toward LT as critical in determining overall survival in hospitalized cirrhosis patients. A major focus should be on appropriate, affordable, and early cirrhosis and hepatocellular cancer care to prevent the need for LT. Live-donor LT is predominant across Asian countries, whereas deceased-donor LT is more common in Western countries; both approaches have unique challenges that add to the access disparities. There are many challenges toward equitable access but uniform definitions of acute-on-chronic liver failure, improving transplant expertise, enhancing availability of resources and encouraging knowledge between centers, and preventing disease progression are critical to reduce LT disparities.

Ethics of allocation of donor organs

PURPOSE OF REVIEW

There is no widely accepted single ethical principle for the fair allocation of scarce donor organs for transplantation. Although most allocation systems use combinations of allocation principles, there is a particular tension between 'prioritizing the worst-off' and 'maximizing total benefits'. It is often suggested that empirical research on public preferences should help solve the dilemma between equity and efficiency in allocation policy-making.

RECENT FINDINGS

This review shows that the evidence on public preferences for allocation principles is limited, and that the normative role of public preferences in donor organ allocation policy making is unclear. The review seeks to clarify the ethical dilemma to the transplant community, and draws attention to recent attempts at balancing and rank-ordering of allocation principles.

SUMMARY

This review suggests that policy makers should make explicit the relative weights attributed to equity and efficiency considerations in allocation policies, and monitor the effects of policy changes on important ethics outcomes, including equitable access among patient groups. Also, it draws attention to wider justice issues associated not with the distribution of donor organs among patients on waiting lists, but with barriers in referral for transplant evaluation and disparities among patient groups in access to waiting lists.