Reimagining justice and responsibility: A critical analysis of differential standards for patients with alcohol-associated liver disease or metabolic dysfunction-associated steatohepatitis.

The demand for liver transplantation compounds the challenges of achieving justice. Scarcity raises questions about how candidate review committees determine which patients are suitable for transplantation, particularly for perceived patient-induced diseases (PPIDs). PPIDs are conditions arising partly from behaviors considered to be within the patient's control. We explore ethical issues in using different candidate review committee standards for PPIDs, comparing alcohol-associated liver disease (ALD) and metabolic dysfunction-associated steatohepatitis (MASH). ALD, caused by alcohol use disorder, and MASH, linked to obesity, can both be perceived as self-inflicted. Patients with ALD have historically been required to demonstrate 6 months of abstinence, with current guidelines recommending a demonstrated commitment to life-long sobriety and treatment for alcohol use disorder. Contrarily, patients with MASH have less clear guidelines and are not consistently required to lose weight or demonstrate changed behaviors, nor provided with equivalent assistance in connecting with support resources. We argue transplant centers should use more consistent, standardized lifestyle evaluation criteria for patients with ALD and for those with MASH based on autonomous culpability, utility, and justice. Doing so can expand support for patients with MASH and decrease stigma for ALD. We provide recommendations to mitigate bias and potentially improve long-term outcomes for both patient groups.