(212) Ethical and Psychosocial Considerations in Solid-Organ Transplant for Justice-Involved Patients: A Review of the Literature

Abstract:

Background:
Pre-transplant psychosocial evaluations are often conducted by consultation-liaison psychiatrists to assess a candidate’s suitability for solid-organ transplant. Despite the United Network for Organ Sharing’s declaration that prisoner status should not preclude consideration for transplant, justice-involved patients (i.e. patients currently or formerly incarcerated) continue to face barriers to care (Faber 2023), including psychosocial challenges and clinician bias.

Methods:
We conducted a comprehensive search of several databases from database inception to February 1, 2024, to identify articles addressing solid-organ transplantation with justice-involved patients as recipients. Databases searched were Ovid Medline, PsycINFO, and Embase, Scopus, via Elsevier, and Academic Search Premier via EBSCOhost. The search was limited to English-language articles; only full-text articles were included. Two independent reviewers screened records for inclusion and resolved any discrepancies.

Results:
A total of 289 records were identified, 15 of which met criteria for full-text review. Of these, 8 were narrative reviews, 4 were case reports, 2 were editorials, and 1 was a survey. Only 2 papers focused on patients who were formerly incarcerated. Types of organ transplants included kidney (4), heart (4), liver (3), and unspecified (4).

Considerations raised for solid-organ transplant in justice-involved patients fell into ethical, legal and logistical categories. Ethical debates centered on fair allocation of scarce organs, weighing justice and equity for those with criminal histories. Legal aspects covered the healthcare rights of incarcerated individuals. Logistical challenges addressed the practicalities of delivering transplant care in prison and maintaining continuity after release.

Discussion:
From an ethical and legal standpoint, our literature review supports the evaluation and listing of justice-involved patients for transplant. Given the disproportionate incarceration of Black and low-income individuals in the United States, (Dumont, 2012; Jeffers, 2019), excluding this population would exacerbate existing health disparities. However, justice-involved patients face numerous logistical barriers to successful transplant outcomes, including limited finances and social support along with frequent loss to follow-up (Ahmad, 2020). Transplant centers should think carefully about how to address these disparities through additional resources and support, such as longitudinal psychiatric follow-up after transplant to address ongoing psychosocial concerns.

Conclusion:
Psychiatrists play an important role in advocating for justice-involved patients to receive appropriate medical care, including organ transplantation. Further research is warranted to identify transplant outcomes in justice-involved patients and highlight psychosocial interventions to improve the physical and mental well-being of this vulnerable population.

References:
Ahmad MU, Eves MM. The structural conundrum of parolees and kidney transplantation. Clin Transplant. Dec 2020;34(12):e14104. doi:10.1111/ctr.14104

Dumont DM, Brockmann B, Dickman S, Alexander N, Rich JD. Public health and the epidemic of incarceration. Annu Rev Public Health. Apr 2012;33:325-39. doi:10.1146/annurev-publhealth-031811-124614

Faber LS, Lyons T, Davis MS. Are American transplant centers willing to transplant prisoners. Can J Urol. Oct 2023;30(5):11698-11702.

Jeffers JL. Justice Is Not Blind: Disproportionate Incarceration Rate of People of Color. Social Work in Public Health. 2019/01/02 2019;34(1):113-121. doi:10.1080/19371918.2018.1562404

Presentation Eligibility: Not previously published or presented.

Diversity, Equity, and Inclusion: Few empirical studies have been conducted on solid-organ transplant in justice-involved patients. Despite the UNOS declaration that prison status should not preclude transplant, many transplant centers are reluctant to evaluate and list justice-involved patients due to psychosocial concerns. Given the disproportionate incarceration of people of color in the United States, limiting access to transplant serves to exacerbate existing health disparities. Identifying barriers to transplant in this vulnerable population may pave the way for interventions to address psychosocial inequities and improve outcomes. C/L and transplant psychiatrists play a critical role in advocating for historically marginalized patients to receive necessary medical care.