Ethical Challenges in Pediatric Liver Transplant Selection Related to Patient and Caregiver Social and Psychosocial Factors: A National Survey of Clinician Perspectives.

BACKGROUND

Disparities exist in pediatric liver transplantation in the United States. Clinician perspectives on how patient and family social and psychosocial factors affect patient selection remain unknown.

METHODS

A national, cross-sectional, mixed-methods survey was distributed to pediatric liver transplant committee members (June-November 2024). The survey assessed respondent and center characteristics, voting/conflict resolution practices, perceived influence of professional roles, social and psychosocial listing challenges, and moral distress. Quantitative analysis included descriptive statistics and multivariable linear/logistic regression; free-text responses underwent thematic analysis.

RESULTS

Among 162 eligible complete surveys, respondents represented multiple committee roles and sociodemographic backgrounds. Listing decisions were typically made verbally, with conflicts resolved through discussion, ethics consultation, or transplant surgeon tie-breaker vote. Professional role was strongly associated with perceived strength of voice, with physicians reporting substantially greater voice than non-physicians. Respondents reported moderate moral distress related to listing decisions involving social and psychosocial concerns. In adjusted models, social workers/psychologists and women reported higher moral distress ratings; social workers/psychologists also had increased odds of greater moral distress frequency, although confidence intervals were wide. Key social concerns included patient/caregiver non-adherence, mental health, housing instability, and insurance. Qualitative data identified that social and psychosocial factors often delay but do not contraindicate listing and require team collaboration.

CONCLUSIONS

Patient/family social and psychosocial factors influence pediatric liver transplant selection and contribute to clinician moral distress. To promote justice and mitigate distress, advocacy should focus on optimizing patient and family support from the listing phase onward, clinician ethics education, and more balanced decision-making frameworks.