BY KATE HSU
Social determinants of health
Poverty, education, mental health, and social environment are all social determinants
of health, and all have a major impact on an individual’s daily health choices and
long-term health outcome. There is a strong correlation between rates of liver
disease cases and socioeconomic deprivation, especially when it comes from
alcohol misuse. Data shows that individuals in the most deprived areas are five times
more likely to die from liver diseases than those in wealthier areas (British Liver
Trust, 2024b). This is because poverty can limit an individual’s ability to make
healthy lifestyle choices like having access to nutritious food or having support for
addiction (NHS England, 2024a). Furthermore, lower levels of education have a
strong relation to reduced health literacy, which may limit an individuals’
understanding of the risks of excessive alcohol consumption (UK Government,
2024).
Beyond socioeconomic and educational factors, psychological challenges like
depression, anxiety, and trauma all fall under mental heath issues, which are also
key contributors to substance misuse. In cases like these, liver damage due to
alcohol may be understood as a consequence of untreated mental illness rather than
a deliberate decision (NHS England’s, 2024b; Mind, 2024). In addition,
environmental factors can further the difficultly of avoiding harmful behaviour or
maintain sobriety (British Liver Trust, 2024c). These challenges question whether
unhealthy behaviours are due to inequality or free choice. If it is not by choice, then
using lifestyle as a criterion discriminates and marginalises vulnerable groups by
increasing disparity. Environmental factors can further enhance the difficulty of
avoiding harmful behaviour or maintaining sobriety (British Liver Trust, 2024c).
These overlapping challenges raise an ethical debate: if unhealthy behaviours are
caused by their socioeconomic status as opposed to choice, then using lifestyle as a
criterion for transplant eligibility risks increasing the healthcare divide and further
marginalising the most vulnerable members of society.
Case studies
Different countries have different approaches to liver transplant eligibility and
prioritisation, especially regarding how lifestyle and behaviour influence medical
decisions. The UK system emphasises clinical urgency and fairness and is operated
under the National Health Service (NHS) which is publicly funded and provides free
healthcare to all. The NHS considers multiple factors when allocation organs,
including blood type, tissue compatibility (including HLA matching), proximity to the
donor hospital, and difficulty in finding a match (NHSBT, 2024c). These criteria are
used in order to make it as fair as possible and improve long-term transplant success
rates. The UK also requires a six-month sobriety period for patients with ARLD to
show readiness and this is a medical requirement, not a moral requirement (British
Liver Trust, 2024c).
In contrast, the United States uses an insurance-based system called the United
Network for Organ Sharing (UNOS), where transplant eligibility relies heavily on
insurance status and financial resources (UNOS, 2024; Healthline, 2024). Patients
can sometimes list at multiple centres if they can afford it which increases their
chances of receiving a transplant. Compliance and lifestyle are also important factors
that are heavily weighted in the US system. Insurance companies may view certain
patients as poor investments if they have histories of substance abuse or other poor
medical adherence histories (NPR, 2018). Although both countries require a six-
month sobriety period, the US system uses this as a strict criterion rather than part of
an assessment (PMC, 2018).
Both systems not only reflect the different approaches but also the differing cultural
values about healthcare, responsibility, and fairness. Ultimately, the UK leans
towards good ethical practice and best medical outcomes, while US centres depend
more on financial status and perceived patient responsibility. This difference creates
disparities and inequality in access and questions whether patients are judged for
past behaviours or supported towards future recovery.
Alternatives
Due to the shortage of donor livers and the complex criteria involved, researchers
are starting to explore new and more innovative solutions. One promising approach
is 3D bioprinting. This is where scientists use special bio-inks which are made of
living cells to print tissue that closely mimick the structure of a human liver.
Advancements in this technology have significantly improved the accuracy and
realism (PMC, 2024; VoxelMatters, 2024). That said, it’s still really difficult to copy
the liver’s complex internal structure and keep the printed tissue alive and working
overtime.
Another emerging and potential solution is the development of the bio artificial liver
(BAL) systems. These devices combine both biological cells and mechanical parts to
temporarily support a patient’s liver function. Basically, it acts as a bridge while they
are waiting for a real transplant. For example, the Spheroid Reservoir Bioartifical
Liver (SRBAL) developed at the Mayo Clinic has shown encouraging results in
preclinical studies. (Science Direct, 2023; Mayo Clinic, 2024).
Xenotransplantation is a growing alternative, where researchers use animal organs,
especially pigs to treat humans. With the advancement of gene-editing technology,
scientists have been able to modify pig organs to make rejection by the human body
less likely. In 2025, a Chinese research team successfully transplanted a gene-
edited pig liver into a brain-dead human patient, and the organ worked for 10 days
with no signs of rejection; this was a massive breakthrough which made
xenotransplantation a promising alternative (TIME, 2025; The Guardian, 2025; AP
News, 2025). Even though these alternatives are not widely used yet, they show real
promise in helping to reduce dependence on human donors in the future and helping
to address transplant organ shortages.
Wanman