Ethical analysis and consideration of health behaviors in organ allocation: focus on tobacco use

Health behaviors are significantly understudied in transplant patients, contributing to significant ethical debate among transplant professionals. Some of these health behaviors (tobacco use and overweight/obesity) are the leading preventable causes of mortality in the US general population and likely have a higher prevalence and impact among transplant populations. For example, tobacco use has been linked to worse graft survival, patient survival, complications, and comorbidities, whereas tobacco cessation has been associated with improved patient and graft survival. Over time, transplant professionals increasingly believe that tobacco use should be a relative contraindication to organ allocation. That belief seems to be strengthened after provider education on pertinent evidence linking tobacco use to medical consequences in both the general and the transplant populations. A core framework for ethical analysis of health behaviors in the context of organ allocation is described, using concepts of utility, justice, and respect for all persons. This framework is designed to help transplant professionals discuss and formulate policy on consideration of health behaviors in the context of organ allocation. More research is needed to advance our knowledge of the impact of health behaviors on transplant patient outcomes.