Improving equity in the kidney transplant continuum for non-European-born patients living in Italy: preliminary case-series findings of the contribution of pre-transplant ethical assessments

Abstract

The care of migrants pursuing kidney transplant (KT) is emergent in Europe. Studies emphasize the ethical duty to adopt a holistic approach to these patients to enable the identification of modifiable risk factors and provide tailored interventions to prevent inequities. The ethical challenge at the time of pre-transplant evaluations is to determine – and balance – the prospective benefit of KT for individual patients (beneficence/non-maleficence) and all candidates pursuing KT (justice), without disrespecting persons (autonomy). This case-series study aims to explore the contribution of ethical assessments – by means of clinical ethics consultation – to pre-transplant evaluations for the prevention of inequities in KT, and to determine the limitations of standardized tools for pre-transplant psychosocial evaluations in non-European- born populations living in Italy. A case-series of first-generation immigrant patients enrolled for KT was analyzed using the Four-Boxes Method to explore the ethical dimensions of individual cases, and the Stanford Integrated Psychosocial Assessment for Transplant for psychosocial analyses. Ethical assessments allow identification of the individual and contextual features with the potential for detrimental impacts on equity in KT. Standardized tools do not consider the conditions associated with immigrant status which may affect the score and ability to tailor interventions to the patients’ individual circumstances and disadvantage immigrant populations accordingly. This case-series study newly shows that ethical assessments may be a useful supplement to guide the examination of the ethical dimensions of individual clinical cases and to complement pre-transplant multidisciplinary evaluations, enabling a co-construction of the care process between individual patients and the transplant team. This approach shows potential to improve equity in KT care and to respect the principles of autonomy, beneficence/non-maleficence, and justice.