• Claire Alexandra Chew, Shridhar Ganpathi Iyer, Kow Alfred Wei Chieh AWC National University Hospital, Singapore., Krishnakumar Madhavan, Andrea Sze Teng Wong, Karim J Halazun, Narendra Battula, Irene Scalera, Roberta Angelico, Shahid Farid, Bettina M Buchholz, Fernando Rotellar, Albert Chi-Yan Chan, Kim Jong Man JM Samsung Medical Center, Sungkyunkwan University, Seoul, Republic of Korea., Chih-Chi Wang, Maheswaran Pitchaimuthu, Mettu Srinivas Reddy, Arvinder Singh Soin, Carlos Derosas, Oscar Imventarza, John Isaac, Paolo Muiesan, Darius F Mirza, and Bonney Glenn Kunnath GK National University Hospital, Singapore; SurgiCAL ProtEomics Laboratory, National University of Singapore, Singapore. Electronic address: glenn_bo.
• National University Hospital, Singapore.
• J. Hepatol. 2020 Oct 1; 73 (4): 873-881.

Background & AimsThe outbreak of COVID-19 has vastly increased the operational burden on healthcare systems worldwide. For patients with end-stage liver failure, liver transplantation is the only option. However, the strain on intensive care facilities caused by the pandemic is a major concern. There is an urgent need for ethical frameworks to balance the need for liver transplantation against the availability of national resources.MethodsWe performed an international multicenter study of transplant centers to understand the evolution of policies for transplant prioritization in response to the pandemic in March 2020. To describe the ethical tension arising in this setting, we propose a novel ethical framework, the quadripartite equipoise (QE) score, that is applicable to liver transplantation in the context of limited national resources.ResultsSeventeen large- and medium-sized liver transplant centers from 12 countries across 4 continents participated. Ten centers opted to limit transplant activity in response to the pandemic, favoring a "sickest-first" approach. Conversely, some larger centers opted to continue routine transplant activity in order to balance waiting list mortality. To model these and other ethical tensions, we computed a QE score using 4 factors - recipient outcome, donor/graft safety, waiting list mortality and healthcare resources - for 7 countries. The fluctuation of the QE score over time accurately reflects the dynamic changes in the ethical tensions surrounding transplant activity in a pandemic.ConclusionsThis four-dimensional model of quadripartite equipoise addresses the ethical tensions in the current pandemic. It serves as a universally applicable framework to guide regulation of transplant activity in response to the increasing burden on healthcare systems.Lay SummaryThere is an urgent need for ethical frameworks to balance the need for liver transplantation against the availability of national resources during the COVID-19 pandemic. We describe a four-dimensional model of quadripartite equipoise that models these ethical tensions and can guide the regulation of transplant activity in response to the increasing burden on healthcare systems.Copyright © 2020 European Association for the Study of the Liver. Published by Elsevier B.V. All rights reserved.

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