Penalised for precarious support: a luck egalitarian critique of the social support criterion used in determining organ transplant eligibility

The social support criterion is a significant factor used by US transplant centres to determine whether someone is eligible to be placed on the transplant list. Although intended to fairly allocate donor organs, it exacerbates inequities to transplant accessibility by unfairly excluding one-fifth of individuals seeking transplant listing. Ethical concerns regarding this criterion have been widely discussed, particularly due to bias in assessing the adequacy of support and inconclusive evidence that a strong social network improves transplant outcomes. However, luck egalitarianism-the view that injustices resulting from circumstances beyond one's control are unjust-has not been applied in this context. Inadequate social support is a circumstance shaped by uncontrollable factors such as mental health conditions, familial dynamics, geographic isolation and socioeconomic status. Thus, excluding candidates on this basis reinforces structural inequities.This paper begins by examining practices within the transplant system, particularly in the case of alcohol-related end stage liver disease, through luck egalitarian reasoning, and argues that this perspective helps to ethically evaluate the social support criterion. After establishing its relevance, the concept of luck egalitarianism is then applied to critique the use of the social support criterion, drawing on Organ Procurement and Transplantation Network guidelines and principles. Finally, this paper addresses the objection that removing this criterion would necessitate the elimination of all other non-voluntary criteria, specifically poor medical status and financial instability. Ultimately, the social support criterion is unjust as it penalises individuals for circumstances outside of their control without sufficient utilitarian justification for doing so.