Background: Psychosocial criteria constitute absolute and relative contraindications to listing, which can bar patients from access to organ transplantation at a program. Refusing to list patients for psychosocial factors is ethically permissible as long as these factors distinguish those who will benefit most from receiving an organ. Empiric evidence must demonstrate poorer outcomes in patients meeting these criteria before they can be considered contraindications. We conducted a survey study to identify variation in listing practices among transplant programs nationwide.

Methods: We distributed an online Qualtrics survey to 650 active adult and pediatric transplant programs in heart, kidney, liver, and lung from August 2016 to March 2017. The full survey listed 38 psychosocial characteristics, and participants were asked 1) if each characteristic functioned as an absolute, relative, or irrelevant contraindication to listing, 2) whether their program retained formal, informal, or no guidelines regarding the characteristic, and 3) whether their program had encountered the characteristic. This study examines a subset of the 38 characteristics including legal status, criminal status, and substance use.

Results: A majority of programs completed the survey (response rate = 52.8%). Regarding undocumented status, 15- 41% of programs considered undocumented status to be irrelevant (Irr), in contrast to 23-38% that considered in an absolute contraindication (AC). Eight to 26% considered history of violent crime an AC, while 3-12% had formal guidelines for the characteristic. More programs considered recreational marijuana an AC (24-77%) than medical marijuana (12-59%). Compared to heart and lung programs, kidney and liver programs are less likely to consider current substance use an AC (p = <2.2e-16 ~ 0.006). Although more adult than pediatrics programs encountered patients with a criminal history (p << 0.001), 19-47% of pediatrics programs have still encountered these patients.

Discussion: Transplant programs vary in how they consider psychosocial criteria in making listing decisions. Variation in practice violates the principle of equality and invites prejudice into listing process. Further research is needed on post- transplant outcomes of patients with psychosocial criteria so that programs can make evidence-based judgments.

CITATION INFORMATION: Lee G., Wall A., Maldonado J., Magnus D. Legal Status, Criminal History, and Substance Use in Listing Decisions Am J Transplant. 2017;17 (suppl 3).

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