*Purpose: Clinicians’ judgments about patients’ social support often affect whether patients are listed for transplantation. Decision-making is thought to be based on two systems of information processing: automatic (System 1) and controlled (System 2). System 1 processing is fast, intuitive, largely subconscious, and highly bias-prone. By contrast, System 2 utilizes effortful, intentional, and conscious thinking to inform decision-making. Subjective criteria, such as social support, can unwittingly introduce bias that may disproportionately harm structurally disadvantaged populations. We examined clinician perspectives and experiences using social support and identified cognitive biases associated with this criterion.

*Methods: Semi-structured, cognitive interviews were conducted as part of a national mixed-methods study of social support in transplantation. Clinicians were recruited following purposive sampling criteria: gender, clinical role (e.g. surgeon, social worker), organ type, region, and percentage of patients excluded from transplant due to social support in the prior year. Interviews were audiorecorded, transcribed, and analyzed thematically using inductive and deductive approaches.

*Results: We completed 45 semi-structured interviews with transplant clinicians at 34 centers across all UNOS regions. Approximately 47% of these clinicians were women, 11-44% for each organ, 49% psychosocial providers. We found widespread lack of objective criteria in assessing social support facilitate reliance on System 1 error-prone intuition, rather that conscious, deliberate, and evidenced-based decision-making. Discussion of social support at listing meetings commonly triggered invocation of social worth beliefs, and contributed to stereotyping patients with limited social support as less deserving of an organ. Confirmation bias, Hindsight Bias, Availability Bias, and Group Think were most commonly associated with use of social support in waitlist decisions. Examples of clinicians engaging in System 2 processing were examined. These clinicians seldom relied on social support in waitlist determinations.

*Conclusions: Social support requirements may reinforce transplant inequities by increasing susceptibility to cognitive biases, contributing to biased and inconsistent listing procedures. Although patients’ ability to meet post-operative demands associated with social support should be assessed, a strengths-based approach and interventions aimed at reducing bias are needed to ensure equitable access to transplant.

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