Racial Inequalities in the Organ Transplantation Selection Process – How Can C-L Psychiatrists Be Part of the Solution

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Transplantation offers a chance for patients with end-stage organ failure to prolong and improve the quality of their lives. Transplant is not a cure, but a chance to live with a chronic medical condition and its many potential complications. Along with a medical and surgical evaluation, a psychosocial evaluation has been found to be an important part of the pre-transplant assessment and a predictor of post-transplant outcomes. The transplant psychiatrist plays an important role in this process to support the patients and strengthen their candidacy, but they also have the challenging role of identifying psychosocially high-risk candidates (e.g., limited support system, history of treatment non-adherence, untreated severe mental illness or active substance abuse). An outcome might be that patients are declined due to medical or psychosocial reasons thought to outweigh the actual benefit of transplant to the patient. However, especially in the current US climate of increased awareness of racial and ethnic inequality in multiple spheres of life, it behooves us to reflect on how racial and ethnic inequality influences the transplant selection process.

Emerging evidence does raise important questions. Even after controlling for other variables, Black patients with end-stage liver disease were less likely to be listed for a liver transplant list (Jesse et al, 2019). For lung transplant recipients, it took longer for non-white patients to make it to the list, even though both groups eventually had similar outcomes (Mooney et al, 2018). Race and ethnicity are intertwined with other psychosocial variables (e.g. stigma towards mental health diagnoses, socioeconomic status, social support availability, history of “treatment non-adherence” due to insurance or logistical problems). These inequalities will thus translate into the final outcomes of our psychosocial evaluation.

Until now, not much emphasis has been placed on how the psychosocial pre-transplant evaluation might assess for factors emanating from decades of discrimination and inequality, or how it might further perpetuate the discrimination and inequality by labeling patients high risk based on these factors.

This workshop is a first attempt at discussing how race and ethnicity as well as other factors (gender, sexual orientation, and socioeconomic status) might interplay with the process and outcome of transplantation by using didactics and illustrative cases to highlight these challenges in transplant evaluation. Jose Maldonado will critically evaluate the evidence for suggested domains of transplant psychosocial evaluation. Yelizaveta Sher will discuss the influence of race and ethnicity in the transplantation referral, transplantation evaluation, and transplant outcomes. Sheila Lahijani will discuss special considerations in bone marrow transplant populations. Filza Hussain will moderate a discussion as to how transplant and C-L psychiatrists can advocate for marginalized patients throughout the various stages of the transplant process.