Keren Ladin, Tufts University – Liver Transplants and Geography

Should liver transplant recipients be determined by geography?

Keren Ladin, assistant professor in the department of occupational therapy at Tufts University, delves into this question.

Dr. Ladin incorporates quantitative, qualitative, and normative approaches to study how systemic disadvantage affects health and the ability of individuals to make and pursue lifeplans. Specifically, her research aims to better understand how social networks impact health disparities, acute medical decision-making, and resilience in major life transitions. Her research aims to: (1) understand the role of social networks in complex medical decision-making, (2) harness social networks and social support to improve health care utilization among vulnerable populations, and (3) evaluate the impact of public policies on the health of vulnerable populations. Dr. Ladin’s research addresses health disparities in transplantation, mental health treatment, aging, and immigrant health. Dr. Ladin has conducted research in a number of health care settings, including in Chile and Germany. She is also currently a member of the Ethics Committee for the United Network of Organ Sharing (UNOS).

Dr. Ladin teaches courses in health policy, research methods, public health ethics, health disparities, and medical ethics. She received her Ph.D. in Health Policy from Harvard University and her Masters in Population and International Health from the Harvard School of Public Health.

The views and opinions expressed in this story are those of Tufts University Professor Keren Ladin, and do not reflect any official policies or positions held by the Ethics Committee for the United Network for Organ Sharing, where Professor Ladin serves as vice chair.

Liver Transplants and Geography


Liver transplantation remains the only lifesaving option for patients with end-stage liver disease and access to liver transplantation varies significantly across the United States. The organ shortage has intensified and depending on where a patient is listed, the likelihood of receiving a liver transplant within 90 days varies from 18 to 86%.

Some argue that geography is unfairly determinative for organ transplantation. Recently, the United Network for Organ Sharing put forth a proposal expanding geographic organ sharing. The proposal has been divisive, pitting centers likely to lose organs against those likely to gain. Opponents believe that broader sharing unfairly disadvantages local donors. Proponents assert that it will save more lives and justly prioritizes patients in areas with long waits.

Who’s right? Drawing upon ethical theory can help us decide. Utilitarianism suggests that the best option improves efficiency by saving more lives, irrespective of the geographic distribution. A Maximin approach argues for improving the position of those worst-off. The reciprocity principle suggests that bearing the most risk entails reciprocal benefits. Most people would disagree with distributing scarce organs based on a single approach.

Distributive justice problems in health care are challenging and plentiful. Amartya Sen’s “impartial spectator” approach suggests that, when attempting fair redistribution, we consider the imbalance of privilege as a guiding principle.

Our analysis of national data show disparities in public safety laws, healthcare infrastructure, and public funding may influence the risk of death and subsequent availability of donor organs. These risk factors are disproportionately prevalent in regions with high organ supply.

Redistributing organs from high to low-supply regions may exacerbate existing social and health inequalities, redistributing the single benefit (greater organ availability) of greater exposure to environmental and contextual risks. While the proposed policy may prevent some waitlist deaths, it may do so at the expense of vulnerable, identifiable populations, too heavily favoring efficiency over equity. Although transplantation cannot rectify broader health inequities it should not exacerbate the existing landscape. Variation in liver availability may not be an “accident of geography”, but rather a byproduct of disadvantage.