Monash Bioethics Review

, Volume 37, Issue 3–4, pp 111–135 | Cite as

Ethical issues associated with solid organ transplantation and substance use: a scoping review

  • Lauren Notini
  • Denitsa Vasileva
  • Ani Orchanian-Cheff
  • Daniel Z. BuchmanEmail author
Original Article


While solid organ transplantation for patients with substance use issues has attracted ethical discussion, a typology of the ethics themes has not been articulated in the literature. We conducted a scoping review of peer-reviewed literature on solid organ transplantation and substance use published between January 1997 and April 2016. We aimed to identify and develop a typology of the main ethical themes discussed in this literature and to identify gaps worthy of future research. Seventy articles met inclusion criteria and underwent inductive content analysis. Four main ethical themes were identified: (1) personal responsibility; (2) utility; (3) moral character; and (4) fairness. Each theme had multiple sub-themes and there was substantial overlap between themes. This scoping review identified a disproportionate emphasis in the literature regarding personal responsibility, which was referenced by each of the other themes, and a narrow focus on alcohol and liver. We recommend future research further investigate these connections between ethical themes and focus on ethical issues associated with transplants from organ groups other than liver for patients who use substances other than alcohol.


Bioethics Organ transplantation Personal responsibility Scoping review Substance use 


Author contributions

Participated in the research design: DZB, LN, AO-C. Participated in the writing of the paper: LN, DZB, DV, AO-C. Participated in the performance of the research: LN, DV, DZB, AO-C. Participated in the data analysis: LN, DV, DZB.


Funding was provided by State Government of Victoria (Operational Infrastructure Program), University of Toronto (Fellowship in Clinical and Organizational Bioethics) and University Health Network (Salary Support).

Compliance with ethical standards

Conflict of interest

The authors of this manuscript have no conflicts of interest to disclose.

Supplementary material

40592_2019_100_MOESM1_ESM.docx (27 kb)
Appendix 1: Search strategies used for Medline and Medline in-process segments. Supplementary material 1 (DOCX 27 kb)
40592_2019_100_MOESM2_ESM.docx (29 kb)
Appendix 2: List of articles meeting inclusion criteria. Supplementary material 2 (DOCX 28 kb)


  1. Anand, A.C., B.H. Ferraz-Neto, P. Nightingale, D.F. Mirza, A.C. White, P. McMaster, et al. 1997. Liver transplantation for alcoholic liver disease: Evaluation of a selection protocol. Hepatology 25: 1478–1484.Google Scholar
  2. Anantharaju, A., and D.H. Van Thiel. 2003. Liver transplantation for alcoholic liver disease. Alcohol Research & Health 27: 257–268.Google Scholar
  3. Arksey, H., and L. O’Malley. 2005. Scoping studies: Towards a methodological framework. International Journal of Social Research Methodology 8: 19–32.Google Scholar
  4. Artru, F., A. Louvet, and P. Mathurin. 2015. Should patients with alcoholic hepatitis be considered for liver transplantation? Clinical Liver Disease 6: 149–152.Google Scholar
  5. Bailey, D., S. Pathak, and N. Ahmad. 2013. Is liver transplant for alcohol-related end-stage liver disease appropriate? British Journal of Hospital Medicine 74: 439–442.Google Scholar
  6. Barrantes, F., F.L. Luan, M. Kommareddi, K. Alazem, T. Yaqub, R.S. Roth, et al. 2013. A history of chronic opioid usage prior to kidney transplantation may be associated with increased mortality risk. Kidney International 84: 390–396.Google Scholar
  7. Baumrucker, S., P. Mingle, D. Harrington, M. Stolick, G.T. Carter, and K.A. Oertli. 2011. Medical marijuana and organ transplantation: Drug of abuse, or medical necessity? American Journal of Hospice and Palliative Medicine 28: 130–134.Google Scholar
  8. BC Transplant. (2016). Liver transplant. Retrieved January 3, 2016, from
  9. Benjamin, M. 1997. Transplantation for alcoholic liver disease: The ethical issues. Liver Transplantation and Surgery 3: 337–342.Google Scholar
  10. Beresford, T. 2001. The limits of philosophy in liver transplantation. Transplant International 14: 176–179.Google Scholar
  11. Berlakovich, G.A. 2005. Wasting your organ with your lifestyle and receiving a new one? Annals of Transplantation 10: 38–43.Google Scholar
  12. Bramstedt, K.A., and N. Jabbour. 2006. When alcohol abstinence criteria create ethical dilemmas for the liver transplant team. Journal of Medical Ethics 32: 263–265.Google Scholar
  13. Bramstedt, K.A., J. Stowe, and M. Kotz. 2004. Shopping for a transplant: When noncompliant patients seek wait listing at multiple hospitals. Progress in Transplantation 14: 217–221.Google Scholar
  14. Bright, R.P. 2010. Denial of hepatic transplantation on the basis of smoking: Is it ethical? Current Opinion in Organ Transplantation 15: 249–253.Google Scholar
  15. Brudney, D. 2007. Are alcoholics less deserving of liver transplants? Hastings Centre Report 37: 41–47.Google Scholar
  16. Burak, K.W., and N.M. Kneteman. 2010. An evidence-based multidisciplinary approach to the management of hepatocellular carcinoma (HCC): The Alberta HCC algorithm. Canadian Journal of Gastroenterology 24: 643–650.Google Scholar
  17. Caccamo, L., B. Antonelli, and G. Rossi. 2014. Attitudes of Italian liver transplantation centers toward the eligibility of controversial candidates. Liver Transplantation 20: 497–498.Google Scholar
  18. Canadian Institute for Health Information. 2015. Canadian organ replacement register annual report: Treatment of end-stage organ failure in Canada, 2004–2013. Ottawa: Canadian Institute for Health Information.Google Scholar
  19. Chandok, N., M. Aljawad, A. White, R. Hernandez-Alejandro, P. Marotta, and E.M. Yoshida. 2013. Liver transplantation for alcoholic liver disease among Canadian transplant centres: A national study. Canadian Journal of Gastroenterology 27: 643–646.Google Scholar
  20. Congly, S.E., and S.S. Lee. 2013. Liver transplantation for alcoholic liver disease: A devilish dilemma. Canadian Journal of Gastroenterology 27: 625–626.Google Scholar
  21. Corbett, C., M.J. Armstrong, and J. Neuberger. 2012. Tobacco smoking and solid organ transplantation. Transplantation 94: 979–987.Google Scholar
  22. DiMartini, A., C. Crone, and M.A. Dew. 2011. Alcohol and substance use in liver transplant patients. Clinics in Liver Disease 15: 727–751.Google Scholar
  23. Doane, A. 2014. The dilemma of liver transplant allocation for alcoholic patients. Gastroenterology Nursing 37: 318–325.Google Scholar
  24. Donckier, V., V. Lucidi, T. Gustot, and C. Moreno. 2014. Ethical considerations regarding early liver transplantation in patients with severe alcoholic hepatitis not responding to medical therapy. Journal of Hepatology 60: 866–871.Google Scholar
  25. Durand, C.M., M.G. Bowring, A.G. Thomas, L.M. Kucirka, A.B. Massie, A. Cameron, et al. 2018. The drug overdose epidemic and deceased-donor transplantation in the United States: A national registry study. Annals of Internal Medicine 168: 702–711.Google Scholar
  26. Dureja, P., and M.R. Lucey. 2010. The place of liver transplantation in the treatment of severe alcoholic hepatitis. Journal of Hepatology 52: 759–764.Google Scholar
  27. Elo, S., and H. Kyngäs. 2008. The qualitative content analysis process. Journal of Advanced Nursing 62: 107–115.Google Scholar
  28. European Association for the Study of the Liver. (2015). Clinical practice guidelines: Liver transplantation. Retrieved February 8, 2016, from
  29. Everson, G., G. Bharadhwaj, R. House, M. Talamantes, B. Bilir, R. Shrestha, et al. 1997. Long-term follow-up of patients with alcoholic liver disease who underwent hepatic transplantation. Liver Transplantation and Surgery 3: 263–274.Google Scholar
  30. Fleetwood, V.A., M. Hertl, and E.Y. Chan. 2015. Liver transplantation to the active smoker: Transplant provider opinions and how they have changed. Journal of Gastrointestinal Surgery 19: 2223–2227.Google Scholar
  31. Glannon, W. 1998. Responsibility, alcoholism, and liver transplantation. Journal of Medicine and Philosophy 23: 31–49.Google Scholar
  32. Glannon, W. 2009. Responsibility and priority in liver transplantation. Cambridge Quarterly of Healthcare Ethics 18: 23–35.Google Scholar
  33. Gramenzi, A., S. Gitto, F. Caputo, M. Biselli, S. Lorenzini, M. Bernardi, et al. 2011. Liver transplantation for patients with alcoholic liver disease: An open question. Digestive and Liver Disease 43: 843–849.Google Scholar
  34. Hancock, M.M., C.C. Prosser, K. Ransibrahmanakul, L. Lester, E. Craemer, J.A. Bourgeois, et al. 2007. Liver transplant and hepatitis C in methadone maintenance therapy: A case report. Substance Abuse Treatment, Prevention, and Policy 2: 5.Google Scholar
  35. Hewes, R.L., and P.J. Toriello. 1998. Societal attitudes and alcohol dependency: The impact on liver transplantation policy. Journal of Rehabilitation 64: 19–23.Google Scholar
  36. Ho, D. 2008. When good organs go to bad people. Bioethics 22: 77–83.Google Scholar
  37. Hsieh, H.F., and S.E. Shannon. 2005. Three approaches to qualitative content analysis. Qualitative Health Research 15: 1277–1288.Google Scholar
  38. Hyde, M.K., and K.M. White. 2011. A comparison of registered and unregistered organ donors’ perceptions about transplant recipients. Clinical Transplantation 25: 444–449.Google Scholar
  39. Jesudian, A.B., and R.S. Brown Jr. 2016. Acute alcoholic hepatitis as indication for liver transplantation. Current Opinion in Organ Transplantation 21: 107–110.Google Scholar
  40. Johnson, K., C. Jones, W. Compton, G. Baldwin, J. Fan, J. Mermin, et al. 2018. Federal response to the opioid crisis. Current HIV/AIDS Reports 15: 293–301.Google Scholar
  41. Kuntz, K., S.R. Weinland, and Z. Butt. 2015. Psychosocial challenges in solid organ transplantation. Journal of Clinical Psychology in Medical Settings 22: 122–135.Google Scholar
  42. Lim, J.K., and E.B. Keeffe. 2004. Liver transplantation for alcoholic liver disease: Current concepts and length of sobriety. Liver Transplantation 10: S31–S38.Google Scholar
  43. Lucey, M.R., K.A. Brown, G.T. Everson, J.J. Fung, R. Gish, E.B. Keeffe, et al. 1997. Minimal criteria for placement of adults on the liver transplant waiting list: A report of a national conference organized by the American Society of Transplant Physicians and the American Association for the Study of Liver Diseases. Liver Transplantation and Surgery 3: 628–637.Google Scholar
  44. Mailly, P. 2005. Fine wine and ideal theory: The questionable denial of liver transplantation in alcoholics. Windsor Yearbook of Access to Justice 23: 95–114.Google Scholar
  45. Marroni, C.A. 2015. Management of alcohol recurrence before and after liver transplantation. Clinics and Research in Hepatology and Gastroenterology 39: S109–S114.Google Scholar
  46. Martens, W. 2001. Do alcoholic liver transplantation candidates merit lower medical priority than non-alcoholic candidates? Transplant International 14: 170–175.Google Scholar
  47. Martin, P., A. DiMartini, S. Feng, R. Brown Jr., and M. Fallon. 2014. Evaluation for liver transplantation in adults: 2013 practice guideline by the American Association for the Study of Liver Diseases and the American Society of Transplantation. Hepatology 59: 1144–1165.Google Scholar
  48. Mathurin, P. 2005. Is alcoholic hepatitis an indication for transplantation? Current management and outcomes. Liver Transplantation 11: S21–S24.Google Scholar
  49. Mathurin, P., C. Moreno, D. Samuel, J. Dumortier, J. Salleron, F. Durand, et al. 2011. Early liver transplantation for severe alcoholic hepatitis. New England Journal of Medicine 365: 1790–1800.Google Scholar
  50. McCallum, S., and G. Masterton. 2006. Liver transplantation for alcoholic liver disease: A systematic review of psychosocial selection criteria. Alcohol and Alcoholism 41: 358–363.Google Scholar
  51. McDougall, R., and D.K. Sokol. 2008. The ethical junior: A typology of ethical problems faced by house officers. Journal of the Royal Society of Medicine 101: 67–70.Google Scholar
  52. Moher, D., A. Liberati, J. Tetzlaff, and D.G. Altman. 2009. Preferred reporting items for systematic reviews and meta-analyses: The PRISMA statement. British Medical Journal 339: 332–336.Google Scholar
  53. Moss, A.H., and M. Siegler. 1991. Should alcoholics compete equally for liver transplantation? Journal of the American Medical Association 265: 1295–1298.Google Scholar
  54. National Health Service. (2016). Assessment: Liver transplant. Retrieved February 6, 2016, from
  55. Neuberger, J. 1999. Allocating livers to substance and alcohol misusers. Addiction Biology 4: 385–390.Google Scholar
  56. Neuberger, J. 2007. Public and professional attitudes to transplanting alcoholic patients. Liver Transplantation 13: S65–S68.Google Scholar
  57. Pageaux, G.-P., J. Michel, V. Coste, P. Perney, P. Possoz, P.-F. Perrigault, et al. 1999. Alcoholic cirrhosis is a good indication for liver transplantation, even for cases of recidivism. Gut 45: 421–426.Google Scholar
  58. Pageaux, G.-P., P. Perney, and D. Larrey. 2001. Liver transplantation for alcoholic liver disease. Addiction Biology 6: 301–308.Google Scholar
  59. Parker, R., M.J. Armstrong, C. Corbett, E.J. Day, and J.M. Neuberger. 2013. Alcohol and substance abuse in solid-organ transplant recipients. Transplantation 96: 1015–1024.Google Scholar
  60. Rice, J.P., and M.R. Lucey. 2013. Should length of sobriety be a major determinant in liver transplant selection? Current Opinion in Organ Transplantation 18: 259–264.Google Scholar
  61. Rodrigue, J.R., S.J. Hoffman, T.L. Park, and S.F. Sears Jr. 1998. Perceptions of liver transplant candidates with or without an alcohol use history. Journal of Clinical Psychology in Medical Settings 5: 199–211.Google Scholar
  62. Sandhu, G.S., M. Khattak, R.S. Woodward, D.W. Hanto, M. Pavlakis, N. Dimitri, et al. 2011. Impact of substance abuse on access to renal transplantation. Transplantation 91: 86–93.Google Scholar
  63. Secunda, K., E.J. Gordon, M.W. Sohn, L.A. Shinkunas, L.C. Kaldjian, M.D. Voigt, et al. 2013. National survey of provider opinions on controversial characteristics of liver transplant candidates. Liver Transplantation 19: 395–403.Google Scholar
  64. Singal, A.K., and A. Duchini. 2011. Liver transplantation in acute alcoholic hepatitis: Current status and future development. World Journal of Hepatology 3: 215–218.Google Scholar
  65. Singhvi, A., A.N. Welch, J. Levitsky, D. Singhvi, and E.J. Gordon. 2016. Ethical considerations of transplantation and living donation for patients with alcoholic liver diseases. American Medical Association Journal of Ethics 18: 163–173.Google Scholar
  66. Steinman, T.I., B.N. Becker, A.E. Frost, K.M. Olthoff, F.W. Smart, W.N. Suki, et al. 2001. Guidelines for the referral and management of patients eligible for solid organ transplantation. Transplantation 71: 1189–1204.Google Scholar
  67. Stroh, G., T. Rosell, F. Dong, and J. Forster. 2015. Early liver transplantation for patients with acute alcoholic hepatitis: Public views and the effects on organ donation. American Journal of Transplantation 15: 1598–1604.Google Scholar
  68. Testino, G., P. Burra, F. Bonino, F. Piani, A. Sumberaz, R. Peressutti, et al. 2014. Acute alcoholic hepatitis, end stage alcoholic liver disease and liver transplantation: An Italian position statement. World Journal of Gastroenterology 20: 14642–14651.Google Scholar
  69. Thornton, V. 2009. Who gets the liver transplant? The use of responsibility as the tie breaker. Journal of Medical Ethics 35: 739–742.Google Scholar
  70. Transplantation Society of Australia and New Zealand. (2011). Organ transplantation from deceased donors. Consensus statement on eligibility criteria and allocation protocols. Retrieved January 25, 2016, from
  71. Ubel, P.A. 1997. Transplantation in alcoholics: Separating prognosis and responsibility from social biases. Liver Transplantation and Surgery 3: 343–346.Google Scholar
  72. Ubel, P.A., J. Baron, and D.A. Asch. 1999. Social responsibility, personal responsibility, and prognosis in public judgments about transplant allocation. Bioethics 13: 57–68.Google Scholar
  73. Ubel, P.A., C. Jepson, J. Baron, T. Mohr, S. McMorrow, and D.A. Asch. 2001. Allocation of transplantable organs: Do people want to punish patients for causing their illness? Liver Transplantation 7: 600–607.Google Scholar
  74. Ursic-Bedoya, J., S. Faure, H. Donnadieu-Rigole, and G.-P. Pageaux. 2015. Liver transplantation for alcoholic liver disease: Lessons learned and unresolved issues. World Journal of Gastroenterology 21: 10994–11002.Google Scholar
  75. Webb, K., L. Shepherd, E. Day, G. Masterton, and J. Neuberger. 2006. Transplantation for alcoholic liver disease: Report of a consensus meeting. Liver Transplantation 12: 301–305.Google Scholar
  76. Weill, D., C. Benden, P.A. Corris, J.H. Dark, R.D. Davis, S. Keshavjee, et al. 2015. A consensus document for the selection of lung transplant candidates: 2014—An update from the Pulmonary Transplantation Council of the International Society for Heart and Lung Transplantation. Journal of Heart and Lung Transplantation 34: 1–15.Google Scholar
  77. Weinrieb, R.M., D.H.A. Van Horn, A.T. McLellan, and M.R. Lucey. 2000. Interpreting the significance of drinking by alcohol-dependent liver transplant patients: Fostering candor is the key to recovery. Liver Transplantation 6: 769–776.Google Scholar

Copyright information

© Monash University 2019

Authors and Affiliations

  1. 1.Joint Centre for BioethicsUniversity of TorontoTorontoCanada
  2. 2.Melbourne Law SchoolThe University of MelbourneCarltonAustralia
  3. 3.Biomedical Ethics Research GroupMurdoch Children’s Research InstituteParkvilleAustralia
  4. 4.University Health NetworkTorontoCanada
  5. 5.Library and Information ServicesUniversity Health NetworkTorontoCanada
  6. 6.Bioethics Department, Toronto Western HospitalUniversity Health NetworkTorontoCanada
  7. 7.Dalla Lana School of Public HealthUniversity of TorontoTorontoCanada
  8. 8.Krembil Research InstituteTorontoCanada

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