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A challenge to discriminating psychosocial eligibility criteria: exploring the ethical justification for excluding patients with psychosocial risk factors from hematopoietic cell transplantation

Bone Marrow Transplantation volume 53, pages 1474–1477 (2018)Cite this article

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A patient with high-risk AML who had been denied hematopoietic cell transplantation (HCT) at another institution due to “psychosocial vulnerability” presented to our center to pursue HCT. She had a history of substance abuse and lacked a stable caregiver. A history of adverse events and high transplant-related mortality have made practitioners rightly cautious about proceeding with such patients. Nearly all centers have incorporated psychosocial screening tests, alongside biomedical screening, in order to identify at-risk patients and inform eligibility decisions. This has led to the formation of formal or informal institution-specific psychosocial eligibility criteria. Eligibility criteria are intended to be discriminatory, that is, adjudicating between those who are transplant eligible and those who are not. While acknowledging that clean ethical constructs are elusive in HCT where outcomes are never certain, and morbidity and mortality are high, here, we explore the ethical justification for these eligibility criteria.

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References

  1. Foster LW, McLellan L, Rybicki L, Tyler T, Bolwell BJ. Ethical reasoning about patient eligibility in allogeneic BMT based on psychosocial criteria. Bone Marrow Transplant. 2009;44:607–612. https://doi.org/10.1038/bmt.2009.58

    Article  CAS  PubMed  Google Scholar 

  2. Prieto JM, Blanch J, Atala J, Carreras E, Rovira M, Cirera E, et al. Psychiatric morbidity and impact on hospital length of stay among Hematologic cancer patients receiving stem-cell transplantation. J Clin Oncol. 2002;20:1907–1917. https://doi.org/10.1200/jco.2002.07.101

    Article  PubMed  Google Scholar 

  3. Gregurek R, Labar B, Mrsic M, Batinic D, Ladika I, Bogdanic V, et al. Anxiety as a possible predictor of acute GVHD. Bone Marrow Transplant. 1996;18:585–589.

    CAS  PubMed  Google Scholar 

  4. Richardson DR, Huang Y, McGinty HL, Elder P, Newlin J, Kirkendall C, et al. Psychosocial risk predicts high readmission rates for hematopoietic cell transplant recipients. Bone Marrow Transplantation 2018. https://doi.org/10.1038/s41409-018-0118-4

    Article  CAS  Google Scholar 

  5. Loberiza FR, Rizzo JD, Bredeson CN, Antin JH, Horowitz MM, Weeks JC, et al. Association of depressive syndrome and early deaths among patients after stem-cell transplantation for malignant diseases. J Clin Oncol. 2002;20:2118–2126. https://doi.org/10.1002/jco.2002.08.757

    Article  PubMed  Google Scholar 

  6. Park JE, Kim KI, Yoon SS, Hahm BJ, Lee SM, Yoon JH, et al. Psychological distress as a negative survival factor for patients with hematologic malignancies who underwent allogeneic hematopoietic stem cell transplantation. Pharmacotherapy. 2010;30:1239–1246. https://doi.org/10.1592/phco.30.12.1239

    Article  PubMed  Google Scholar 

  7. Andrykowski MA, Brady MJ, Hensleedowney PJ. Psychosocial factors predictive of survival after allogeneic bone-marrow transplantation for leukemia. Psychosom Med. 1994;56:432–439.

    Article  CAS  Google Scholar 

  8. Molassiotis A, VanDenAkker OBA, Milligan DW, Goldman JM. Symptom distress, coping style and biological variables as predictors of survival after bone marrow transplantation. J Psychosom Res. 1997;42:275–285. https://doi.org/10.1016/s0022-3999(96)00298-x

    Article  CAS  PubMed  Google Scholar 

  9. Foster LW, McLellan LJ, Rybicki LA, Sassano DA, Hsu A, Bolwell BJ. Survival of patients who have undergone allogeneic bone marrow transplantation: the relative importance of in-hospital lay care-partner support. J Psychosoc Oncol. 2004;22:1–20. https://doi.org/10.1300/J077v22n02_01

    Article  Google Scholar 

  10. Hoodin F, Kalbfleisch KR, Thornton J, Ratanatharathom V. Psychosocial influences on 305 adults’ survival after bone marrow transplantation—depression, smoking, and behavioral self-regulation. J Psychosom Res. 2004;57:145–154. https://doi.org/10.1016/s0022-3999(03)00599-3

    Article  PubMed  Google Scholar 

  11. Chang G, Antin JH, Orav EJ, Randall U, McGarigle C, Behr HM. Substance abuse and bone marrow transplant. Am J Drug Alcohol Abus. 1997;23:301–308. https://doi.org/10.3109/00952999709040948

    Article  CAS  Google Scholar 

  12. Foster LW, McLellan L, Rybicki L, Dabney J, Copelan E, Bolwell B. Validating the positive impact of in-hospital lay care-partner support on patient survival in allogeneic BMT: a prospective study. Bone Marrow Transplant. 2013;48:671–677. https://doi.org/10.1038/bmt.2012.208

    Article  CAS  PubMed  Google Scholar 

  13. Pidala J, Craig BM, Lee SJ, Majhail N, Quinn G, Anasetti C. Practice variation in physician referral for allogeneic hematopoietic cell transplantation. Bone Marrow Transplant. 2013;48:63–67. https://doi.org/10.1038/bmt.2012.95

    Article  CAS  PubMed  Google Scholar 

  14. Murphy KC, Jenkins PL, Whittaker JA. Psychosocial morbidity and survival in adult bone marrow transplant recipients—a follow-up study. Bone Marrow Transplant. 1996;18:199–201.

    CAS  PubMed  Google Scholar 

  15. Jenkins PL, Lester H, Alexander J, Whittaker J. A prospective-study of psychosocial morbidity in adult bone-marrow transplant recipients. Psychosomatics. 1994;35:361–367.

    Article  CAS  Google Scholar 

  16. Pillay B, Lee SJ, Katona L, Burney S, Avery S. Psychosocial factors predicting survival after allogeneic stem cell transplant. Support Care Cancer. 2014;22:2547–2555. https://doi.org/10.1007/s00520-014-2239-7

    Article  PubMed  Google Scholar 

  17. Foster LW, McLellan L, Rybicki L, Dabney J, Visnosky M, Bolwell B. Utility of the psychosocial assessment of candidates for transplantation (PACT) scale in allogeneic BMT. Bone Marrow Transplant. 2009;44:375–380. https://doi.org/10.1038/bmt.2009.37

    Article  CAS  PubMed  Google Scholar 

  18. Graf SA, Vaughn JE, Chauncey TR, Storer BE, Gopal AK, Holmberg LA, et al. Comorbidities, alcohol use disorder, and age predict outcomes after autologous hematopoietic cell transplantation for lymphoma. Biol Blood Marrow Transplant. 2016;22:1582–1587. https://doi.org/10.1016/j.bbmt.2016.06.007

    Article  PubMed  PubMed Central  Google Scholar 

  19. Gragert L, Eapen M, Williams E, Freeman J, Spellman S, Baitty R, et al. HLA match likelihoods for hematopoietic stem-cell grafts in the US registry. New Engl J Med. 2014;371:339–348. https://doi.org/10.1056/NEJMsa1311707

    Article  CAS  Google Scholar 

  20. Detsky AS, Baerlocher MO. Do nice patients receive better care? JAMA—J Am Med Assoc. 2011;306:94–95. https://doi.org/10.1001/jama.2011.883

    Article  CAS  Google Scholar 

  21. FitzGerald C, Hurst S. Implicit bias in healthcare professionals: a systematic review. BMC Med Ethics 2017;18. https://doi.org/10.1186/s12910-017-0179-8

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Authors and Affiliations

  1. Division of Hematology/Oncology, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, USA

    Daniel R. Richardson

  2. Division of Hematology, The Ohio State University, Columbus, Ohio, USA

    Steven M. Devine

  3. Center for Bioethics and Medical Humanities, and Department of Palliative Care, The Ohio State University, Columbus, Ohio, USA

    Ryan Nash

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  1. Daniel R. Richardson
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  2. Steven M. Devine
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  3. Ryan Nash
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Correspondence to Daniel R. Richardson.

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Richardson, D.R., Devine, S.M. & Nash, R. A challenge to discriminating psychosocial eligibility criteria: exploring the ethical justification for excluding patients with psychosocial risk factors from hematopoietic cell transplantation. Bone Marrow Transplant 53, 1474–1477 (2018). https://doi.org/10.1038/s41409-018-0213-6

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