ORIGINAL ARTICLE
Ethical reasoning about patient eligibility in allogeneic BMT based
on psychosocial criteria
LW Foster
1
, L McLellan
2
, L Rybicki
3
, T Tyler
1
and BJ Bolwell
2
1
School of Social Work, Cleveland State University, Cleveland, OH, USA;
2
Department of Hematology and Medical Oncology,
Taussig Cancer Center, Cleveland Clinic, Cleveland, OH, USA and
3
Department of Quantitative Health Sciences, Cleveland Clinic,
Cleveland, OH, USA
Chairpersons of the hospital ethics committees (HECs)
and BMT clinicians were compared with regard to their
willingness to proceed with allogeneic BMT given select
psychosocial risk factors. A self-administered question-
naire was sent to 62 HEC chairpersons at hospitals with
an accredited BMT program; the response rate was 37%.
Items included background information, followed by six
case vignettes from a 2006 national survey on which BMT
physicians, nurses and social workers agreed not to
proceed with allogeneic BMT on the basis of the following
risk factors: suicidal ideation; use of addictive, illicit
drugs; history of non-compliance; absence of a caregiver;
alcoholism; and mild dementia from early onset of
Alzheimer’s disease. Opinions regarding transplant dif-
fered in one case only, in a patient with mild dementia;
27% of HEC chairpersons recommended not proceeding
with BMT, which was significantly lower than that of
nurses (68%, Po0.001), physicians (63.5%, Po0.001)
and social workers (51.9%, P¼ 0.05). Qualitative data
show patterns of informal reasoning, linking transplant
decisions to patient’s responsibility for their psychosocial
risk factor(s), as well as to medical benefit and outcome.
Bone Marrow Transplantation (2009) 44, 607–612;
doi:10.1038/bmt.2009.58; published online 23 March 2009
Keywords: allogeneic BMT; ethical reasoning; patient
eligibility; psychosocial risk factors
Introduction
Virtually all protocols in BMT have eligibility based on
biomedical criteria.
1
Increasingly, psychosocial issues are
being included in the discussion of patient selection.
Reasoning behind such discussions seems clinical, such as
the perceived acuity and severity of the psychosocial risk
factor, patient’s ability to comply with treatment protocols
given the risk factor, and its manageability for treatment-
related vulnerability and outcomes.
2
Although either
associated with or predictive of patient outcomes in
BMT,
3–15
psychosocial selection criteria raise concern that
such criteria might ‘y unwittingly hide value judgments
that could unjustly limit an individual patient’s access to
treatments.’
16
BMT decisions are often conditional and
patients are asked to take responsibility for improving their
psychosocial risk factor(s) before proceeding to transplant.
2
Clinical reasoning using psychosocial criteria is consis-
tent with, but secondary to, principles of medical utility
when deciding who to transplant to achieve the best
possible medical benefit and outcome. Furthermore,
inasmuch as accessing BMT is an ethical as well as clinical
issue, the inclusion of ethical reasoning is essential. Just as
no BMT program wants to risk patients dying because they
were less than diligent in patient screening, neither does a
program want patients and families angry and upset,
questioning the appropriateness and fairness of a ‘do not
proceed’ decision in BMT based on psychosocial risk
factors.
On the basis of the authors’ clinical experience, BMT
clinicians are often conflicted with regard to the ethical
issues and questions that denial of BMT raises when
constrained by psychosocial risk factor(s). Philosophically,
should proceeding with transplant depend on patients
taking responsibility for their psychosocial risk factors? Is
an element of patient choice in having a risk factor morally
relevant in transplant eligibility decisions? When does
foreseeable harm because of a psychosocial risk factor
justify a ‘do not transplant’ decision? Practically, is
delaying BMT for a patient to go through substance abuse
treatment morally justifiable when the patient has a
tenuous remission? Is it morally acceptable for a leukemia
patient with mild dementia to trade off quality of life for a
chance of a cure, but with risks of acute GVHD, resulting
in suffering and possible death? Is there a moral difference
between a patient dying without BMT and dying because of
a BMT owing to non-compliance with treatment protocols
or lack of caregiver support?
Access to health-care needs is commonly understood to
be an ethical issue, and the gravity of BMT as a potentially
life-saving decision begs the question: Are eligibility
Received 19 June 2008; revised 9 February 2009; accepted 9 February
2009; published online 23 March 2009
Correspondence: Dr LW Foster, School of Social Work,
Cleveland State University, 2121 Euclid Avenue, CB 202, Cleveland,
OH 44115-2214, USA.
E-mail: l.w.foster@csuohio.edu
Bone Marrow Transplantation (2009) 44, 607–612
& 2009 Macmillan Publishers Limited All rights reserved 0268-3369/09 $32.00
www.nature.com/bmt

decisions by clinicians in BMT viewed as ethically sound
when patients are denied transplantation based on psycho-
social risk factors? Responses and ethical reasoning of
chairpersons of hospital ethics committees (HECs) may
have some bearing on answering this question. Whether
they would agree with decisions of their clinical colleagues
in BMT is unknown, as is the nature of their ethical
reasoning, including the role of ethical theory and
principles in their decision-making.
17
Therefore, this research attempts to address these
questions and reports on the responses and ethical reason-
ing of HEC chairpersons in cases of patients who have been
determined, by our earlier published survey of BMT
programs,
2
to be inappropriate candidates for allogeneic
BMT on the basis of select psychosocial risk factors.
Materials and methods
This survey is a continuation of an earlier published study
in which questionnaires were sent to BMT physicians,
nurses and social workers regarding their willingness to
proceed to allogeneic transplant given select psychosocial
risk factors. Among 17 case vignettes presented in that
survey, the consensus ‘not to proceed’ was achieved among
the three professional groups for six cases.
2
As a follow-up,
these six cases were included in this survey in which a self-
administered questionnaire was sent to HEC chairpersons
at hospitals with a BMT program that performs adult
allogeneic BMT and is accredited by the Foundation for
the Accreditation of Cellular Therapy and designated as a
National Marrow Donor Program Transplant Center. The
list of HEC chairpersons was developed by calling the
eligible hospitals and obtaining the names and mailing
addresses; after three mailings, 23 of 62 chairpersons
responded to the survey (37%). The questionnaire included
background information, a brief overview of allogeneic BMT
and the case facts and circumstances in each case vignette. A
self-addressed postage-paid envelope was included; both the
survey and return envelope were numbered to maintain
confidentiality. Approval for the study was obtained from the
authors’ Institutional Review Board.
Questionnaire items
Respondent background variables include age, gender,
position title and years of experience in bioethics. Each
respondent was asked to indicate agreement/disagreement
with the BMT team’s ‘do not proceed’ decision and to
provide a brief statement of reasoning justifying their
decision with regard to the six earlier identified psychoso-
cial risk factors: current suicidal ideation, use of addictive
illicit drugs, history of being non-compliant with treatment,
residing 6 h away from the hospital and having no
caregiver, drinking several alcoholic drinks daily and being
told he is an alcoholic, and having mild dementia from
early onset of Alzheimer’s disease; these risk factors are
rank-ordered and highlighted in bold in Table 1.
Case facts and circumstances given in each of the above
six cases include the following: allogeneic BMT is the only
curative option, the patient has leukemia, a matched donor
and both the patient and family want to proceed; the BMT
team, including the oncologist, nurse coordinator and
social worker, recommends not proceeding to transplant on
the basis of the presenting psychosocial risk factor’s acuity,
severity and manageability; plans for allogeneic BMT are
on hold; the patient and family disagree with the team’s
decision; and they believe that the decision to proceed or
not should not be based on psychosocial issues and request
an ethics review.
Statistical analysis
Age and years of experience variables were compared
among professional groups using analysis of variance.
Gender and response to six case vignettes were compared
among professional groups using the w
2
-test. Pairwise
comparisons of P-values were calculated for variables,
which were found to differ among the four professional
groups; the only pairwise comparisons of interest were of
HEC chairpersons relative to each of the other three
professional groups. P-values were not adjusted for multi-
ple comparisons. For each of the six case vignettes,
multivariable logistic regression analysis was used to assess
HEC chairpersons’ opinion of whether to proceed with
transplant relative to the other three professional groups
after adjusting for three variables that were found to differ
among the professional groups (age, gender and years of
experience). All analyses were carried out using SAS
software. All statistical tests were two sided; Po0.05 was
used to indicate statistical significance.
Results
Demographics
With respect to HEC chairpersons’ background variables
(Table 2), median age is 54 years, with gender being split
Table 1 Summary of case vignettes, rank-ordered by ‘do not
proceed’ response
Case vignettes
a
Do not proceed
No. of responses No. %
Case #1 Suicidal ideation 567 492 86.8
Case #2 Uses addictive illicit drugs 562 459 81.7
Case #3 History of non-compliance 570 459 80.5
Case #4 Has no lay caregiver 561 389 69.3
Case #5 Alcoholic 551 357 64.8
Case #6 Mild dementia/Alzheimer’s disease 531 342 64.4
Case #7 Significant financial problems 547 261 47.7
Case #8 Morbidly obese 550 148 26.9
Case #9 Caregiver has mental problems 538 127 23.6
Case #10 Daily use of marijuana 581 106 18.2
Case #11 Cognitively impaired 569 100 17.6
Case #12 Borderline personality disorder 540 92 17.0
Case #13 Controlled schizophrenia 565 92 16.3
Case #14 Two suicide attempts 575 91 15.8
Case #15 Treated for major depression 565 89 15.8
Case #16 Current tobacco smoker 576 89 15.5
Case #17 Convicted of a felony 548 68 12.4
a
Case vignettes are rank-ordered from highest to lowest percentage of those
who respond ‘do not proceed,’ with the highest percentage or top six in this
study highlighted in bold.
Ethical reasoning about patient eligibility
LW Foster et al
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Bone Marrow Transplantation