Canadian Society of Transplantation White Paper: Ethical and Legal Considerations for Alcohol and Cannabis Use in Solid Organ Listing and Allocation

Abstract

Alcohol and cannabis use as a contraindication to organ transplantation is a controversial issue. Until recently, patients in Canada with alcohol-associated liver disease were required to demonstrate abstinence for 6 mo to receive a liver transplant. There is no equivalent rule that is applied consistently for cannabis use. There is some evidence that alcohol and cannabis use disorder pretransplant could be associated with worse outcomes posttransplantation. However, early liver transplantation for patients with alcohol-associated liver disease in France and in the United States has led to challenges of the 6-mo abstinence rule in Canada in the media. It has also resulted in several legal challenges arguing that the rule violates human rights laws regarding discrimination in the provision of medical services and that the rule is also unconstitutional (this challenge is still before the court). Recent legalization of cannabis use for adults in Canada has led to questions about the appropriateness of limiting transplant access based on cannabis use. The ethics committee of the Canadian Society of Transplantation was asked to provide an ethical analysis of cannabis and alcohol abstinence policies. Our conclusions were as follows: neither cannabis use nor the 6-mo abstinence rule for alcohol use should be an absolute contraindication to transplantation, and transplant could be offered to selected patients, further research should be conducted to ensure evidence-based policies; and the transplant community has a duty not to perpetuate stigma associated with alcohol and cannabis use disorders.

Rising Trend in Waitlisting for Alcoholic Hepatitis With More Favorable Outcomes Than Other High Model for End-stage Liver Disease in the Current Era

“…In the last year, consensus recommendations in the United States and internationally have been developed to help ensure consistency in the selection of AH candidates. [29][30][31] Assessing centers' evolving adoption of this guidance will remain a challenge until an oversight mechanism is developed. As an example, we found that nearly 20% of AH candidates had grade 3-4 encephalopathy at listing-an issue that, if also present during the evaluation process, would prevent an accurate psychosocial assessment and be counter to recommended criteria.…”

Legislation and Policy Recommendations on Organ and Tissue Donation and Transplantation From an International Consensus Forum

“…For example, recent litigation in Canada involved an alcohol abstinence period before waitlisting people with alcohol-induced liver failure, in which alcohol use disorder was raised as a basis for the claim that the policy discriminates on the grounds of disability. 50 - 52 …”

“…53 However, accommodations in the form of adequate supports may address this risk. 54 At a minimum, jurisdictions should require through laws and regulations that any proposal that may disadvantage a class of people be supported by a robust scientific justification and subject to oversight by groups that include input from potentially impacted stakeholder groups.…”

“…For example, recent litigation in Canada involved an alcohol abstinence period before waitlisting people with alcohol-induced liver failure, in which alcohol use disorder was raised as a basis for the claim that the policy discriminates on the grounds of disability. [50][51][52] OTDT systems must consider how waitlist and transplant policies are affected by antidiscrimination laws. Because these policies seek to balance inconsistent principles of utility and equity, it is possible that allocation policies will often directly or indirectly disadvantage groups protected by these laws to some degree.…”

Substance use disorders in organ transplantation: perennial challenges and interprofessional opportunities

“…Furthermore, the incentive to qualify for SOT motivates the concealment of substance use. A careful, interprofessional, case-by-case clinical approach to cannabinoid use was recommended in a recently published white paper from the Canadian Society of Transplantation which also provides a thorough ethical analysis [43]. Several US transplantation psychiatry clinicians also recently published mental health-related and SUD-related recommendations regarding cannabinoid use [38 ▪ ].…”