Many people believe people with alcohol use disorder are responsible for the liver damage, and therefore are less deserving of a transplant. (NMK-Studio/Shutterstock)
In a nutshell
- Americans judge transplant candidates based on perceived personal responsibility, with the least support given to those seen as responsible for their condition, such as individuals with alcohol use disorder.
- Race and ethnicity had little impact on public attitudes, defying expectations. In fact, when differences appeared, support slightly favored Black and Hispanic patients over White patients.
- Political ideology shaped responses, with conservatives more likely to deny transplants to those seen as blameworthy. However, differences between liberals and conservatives were smaller than anticipated.
COLLEGE STATION, Texas — When someone needs a kidney, liver, or lung transplant, should their past choices matter? A new study of over 4,000 Americans suggests most people think they should, but the findings reveal some unexpected twists about how we judge who deserves these precious, life-saving organs.
Two patients need new organs. One is a coal miner whose lungs failed from decades of workplace dust exposure. The other is someone with liver damage from alcohol use disorder. Who should get priority? According to the research, Americans have strong, and surprisingly consistent, opinions about cases like these.
The study, published in Social Science Quarterly, found that Americans differentiate between who should and should not get an organ transplant based on the extent to which their situation might be attributed to internal or external factors. However, race and ethnicity had virtually no impact on these judgments, defying decades of research showing racial bias influences many other areas of healthcare and public policy.
Researchers from Utah Valley University and Texas A&M University wanted to understand how the public thinks about organ allocation during America’s ongoing transplant crisis. With over 100,000 people waiting for lifesaving organ transplants, and 16 people dying each day while waiting, tough decisions about who gets these scarce resources happen daily.
Current allocation systems rely on medical factors like immune compatibility, time on waiting lists, and survival odds. Public opinion isn’t officially part of the equation, but understanding these attitudes could help improve the system and potentially increase organ donation rates.
Researchers surveyed 4,177 Americans from March to April 2022, presenting them with four different scenarios about people needing transplants. Each case tested different levels of what researchers call “blame attribution,” how much responsibility the person bore for their condition.
The scenarios included: someone with genetic kidney disease (low blame), a coal miner with lung disease from workplace exposure (low blame), an unvaccinated person needing a lung transplant after severe COVID-19 (moderate blame), and someone requiring a liver transplant due to alcohol use disorder (high blame).
To test for racial bias, researchers used names that clearly indicated different ethnicities: Ronny Nielsen (White), DeShawn Washington (Black), Luis Hernandez (Hispanic), and Yang Chen (Asian).
What Americans Really Think
Results showed Americans definitely judge transplant candidates based on their perceived responsibility for their condition. Support was highest for the coal miner with black lung disease, with roughly 8-9 out of 10 respondents saying they should be eligible for transplant across all racial groups. Genetic kidney disease garnered similar support.
Support dropped for the unvaccinated COVID-19 patient (about 6 out of 10 Americans supported transplant eligibility) and lowest for alcohol use disorder (roughly 5 out of 10 supported eligibility).
But race made almost no difference in these judgments. In the few cases where racial differences emerged, they actually slightly favored Black and Hispanic patients over White patients.
Political Differences
Political ideology influenced opinions, though not always as expected. Conservatives were generally harsher on patients perceived as responsible for their conditions, particularly those with alcohol use disorder. However, conservatives showed more support than liberals for unvaccinated COVID-19 patients who were Black or Hispanic, a finding that may reflect ongoing political divisions around COVID-19 policies.
Liberals showed more support for the patient with alcohol use disorder across different racial scenarios, while the differences between political groups were smaller than researchers initially expected.
Despite alcohol use disorder being medically recognized as a disease, patients in these scenarios consistently received the least support for transplants. This suggests a lingering stigma that views addiction through a moral rather than medical lens, creating a disconnect between medical understanding and public attitudes.
Americans strongly factor personal responsibility into their judgments about who deserves lifesaving medical care. The research suggests any policy changes incorporating public opinion would need to carefully balance medical ethics with community values.
For families affected by the organ shortage, these attitudes could influence both policy decisions and individual donation choices. Understanding how the public thinks about these issues might ultimately help increase organ donation, potentially saving more of those 16 lives lost daily while waiting for transplants.
“The larger question here is whether and how public attitudes should be included in transplant allocations,” says study author Simon F. Haeder from Texas A&M University, in a statement. “On the one hand, better aligning allocation decisions with public opinion might lead more people to become donors, but on the other hand, the scarcity of organs means that rules for their use are critically important.”
Should someone’s life choices affect their access to lifesaving care? While Americans seem to think so, the medical community continues grappling with how much these moral judgments should influence life-and-death decisions in determining transplant recipients.
Paper Summary
Methodology
Researchers surveyed 4,177 Americans using an online platform called Lucid, which uses quota sampling to create representative samples based on demographics like age, race, gender, education, and income. Participants read four vignettes about people needing organ transplants: genetic kidney disease, coal miner with black lung disease, unvaccinated COVID-19 patient needing lung transplant, and someone with alcohol use disorder needing liver transplant. To test racial bias, researchers used ethnically identifiable names (White, Black, Hispanic, and Asian). Participants rated whether each person should be eligible for transplant on a scale from “definitely not” to “definitely yes.”
Results
Americans ranked transplant candidates in a clear hierarchy based on perceived responsibility for their condition. Coal miners with black lung disease received highest support (78-92% favorable), followed by genetic kidney disease patients (80-85%), unvaccinated COVID-19 patients (56-66%), and alcohol use disorder patients (47-50%). Race had minimal impact on these judgments, with only slight preferences for Black and Hispanic patients over White patients in some scenarios. Political ideology showed some influence, with conservatives being harsher on alcohol use disorder cases but more supportive of unvaccinated minority COVID-19 patients.
Limitations
The study used brief vignettes that may not capture the complexity of real medical decisions. Only four scenarios were tested, limiting generalizability to other conditions. The research relied on racially identifiable names, which may not have been recognized by all participants. The study was cross-sectional and didn’t account for factors like religious values or other personal beliefs that might influence attitudes. Researchers noted their findings might be conservative estimates since they didn’t emphasize the severity of the organ shortage to participants.
Funding and Disclosures
The paper doesn’t specify funding sources in the provided sections. Data supporting the findings are available from the corresponding author upon reasonable request, as stated in the Data Availability Statement.
Citation
The paper “Who’s to Blame? How Recipient Deservingness Influences Attitudes About Access to the Organ Transplants” was authored by Steven M. Sylvester and Simon F. Haeder. It was published in Social Science Quarterly (106, no. 3, e70021) in 2025.
