Nursing bias—an unintended side-effect of liver transplants related to alcohol-associated cirrhosis

BEN SLATER*, AGE 56, arrives in the emergency department (ED) with his sister. He reports fever, fatigue, abdominal pain, and bloody vomit (hematemesis). His sister adds that she’s witnessed recent confusion with episodes of irritability. Little information exists in Mr. Slater’s past medical history, and records indicate that he hasn’t seen a provider in several years since his wife died. While obtaining his health history, the nurse records that Ben consumes five to seven alcoholic beverages per day and that his last drink was this morning. The nurse lets out an audible sigh as she adds the clinical institute withdrawal assessment column to her flowsheets.

After admission for further evaluation of his hematemesis, Mr. Slater undergoes a series of diagnostic tests, which he doesn’t understand. He receives little explanation for the rationale behind these interventions. Mr. Slater grows increasingly annoyed when a hepatologist comes into the room to discuss a diagnosis of cirrhosis, citing the patient’s recent years of alcohol abuse as the likely cause. The hepatologist recommends that Mr. Slater “get sober” to qualify for a liver transplant. Shocked by the doctor’s bluntness and the gravity of the diagnosis, Mr. Slater nods his head as if in agreement.

A subsequent meeting with the transplant coordinator outlines the eligibility requirements for transplantation, including 6 months of sobriety and the presence of a strong support system. Appointments are made with various doctors, and Mr. Slater receives alcohol cessation resources.

As the meeting concludes, Mr. Slater tells his sister and the transplant coordinator that he won’t continue down this path to transplantation. He expresses feelings of unworthiness and states that others are more deserving of a second chance at life.

This case highlights how stigma and biased communication can influence the patient experience and health outcomes. Mr. Slater’s withdrawal from the transplant process stems from his own internal stigma but also from a lack of patient-centered care. Nurses and providers didn’t engage him in shared decision-making, and eligibility discussions focused on requirements rather than an exploration of Mr. Slater’s values, concerns, and preferences. This led to him feeling alienated and unwilling to pursue life-saving interventions.

To ensure equitable outcomes, nurses and providers must recognize and address bias, promote open dialogue, and instill trust.

Liver transplantation and bias

Liver transplantation serves as a life-altering and life-saving procedure for patients with severe liver disease, which can result from a complex array of modifiable and nonmodifiable risk factors. The nonprofit United Network for Organ Sharing maintains a database for all organ transplant data, manages the waiting list, and matches organ donors to recipients. In 2024, 11,458 liver transplants took place in the United States, marking the highest annual number to date. Although final statistics haven’t yet been released, all available data indicate that 2025 will surpass that number as 200 to 300 people are added to the transplant waiting list each week.

Bias associated with liver transplants reflects underlying practices within healthcare that shape how it emerges and persists. Since 2014, as noted by Pimienta and colleagues, liver transplants due to alcohol-associated liver disease have increased by 2.4% each year, making it the most common indication for transplant. Patients with alcohol-associated liver disease who require transplantation face unique challenges as a result of stigmatization and bias due to the perceived self-inflicted nature of their illness.

Stubbe illustrates this point, emphasizing that people with substance use disorders experience public, structural, and even self-stigma. Whether the need for a transplant stems from metabolic disorders, hereditary fatty liver disease, trauma, cancer, or alcohol-associated liver disease, nurses must prioritize equitable, patient-centered care while actively confronting their own potential biases.

This raises important questions: How does bias operate within nursing care? Where does it originate? Bias influences the delivery of care and shapes patient experiences within healthcare environments, often affecting outcomes across different backgrounds and diagnoses. Exploring the impact of bias on liver transplantation due to alcohol use disorder, examining its origins, and discussing strategies for fostering a more impartial and empathetic approach to care can positively impact patients and nurses.

Alcohol use disorder

Alcohol use disorder involves a problematic pattern of alcohol consumption, which can include intermittent binge drinking. According to Roldan and colleagues, alcohol use disorder has a 12-month prevalence of 13.9% and a lifetime prevalence of 29.1% in the adult population in the United States. (See Alcohol intake and its impact.)

Research by the National Institute on Alcohol Abuse and Alcoholism focused on the role of chemistry and neurobiology in the brain’s reward system shows that repeated alcohol intake negatively affects dopamine, thus requiring increased consumption to achieve feelings of pleasure. Magnetic resonance imaging studies by Xie and colleagues indicate an association between chronic alcohol use and volume reductions in the frontal cortex, grey matter, white matter, and cerebellum. This typically progressive atrophy is linked not only to structural changes but also to significant behavioral and cognitive impairments. These impairments may lead to deficits in self-control, inhibition, and emotional stability.

Genetic factors may predispose some individuals to develop alcohol use disorder and dependence. Abuse (physical and emotional) and many mental health conditions (including anxiety, depression, trauma, and chronic high stress) also can contribute to alcohol use disorder. These causes, along with several other factors—including peer pressure, social norms, or lack of education—point to the complexity of alcohol use disorder and demonstrate the difficulty associated with diagnosing and treating patients and the underlying causes of this disease process.

Alcohol affects many body systems, and its misuse can lead to cancer, cardiomyopathy, liver failure, and trauma associated with accidents. Roldan and colleagues report that alcohol intake is the seventh leading cause of death worldwide, while alcohol-associated liver disease accounts for 5.1% of all diseases and injuries.

Patients with alcohol use disorder may present to a healthcare provider or ED with abdominal pain in the right upper quadrant, jaundice, ascites, easy bruising or bleeding, or confusion. They might receive a diagnosis of steatosis of the liver (excessive fat accumulation in liver cells), acute hepatitis, cancer, cirrhosis, or acute liver failure. (See Diagnoses, symptoms, and treatment.)

Understanding nurse bias

Unconscious and social biases involve thinking patterns shaped by culture, community, socioeconomic class, faith, and other external factors that affect behaviors, judgment, and perspectives. The American Association of Colleges of Nursing’s The Essentials: Core Competencies for Professional Nursing Education outlines expectations for education on social determinants of health and bias mitigation, but it remains unclear what gaps persist as these competencies are integrated into nursing school curricula.

Frequently, nurses enter the profession unaware of their biases until they’re required to complete self-evaluations or find themselves in a situation that challenges their beliefs. Unfortunately, as Kruse and colleagues observed, these biases negatively affect patient care and outcomes, especially in relation to care planning, communication, pain management, empathy, advocacy, and treatment adherence.

Nurses who care for patients receiving liver transplants due to alcohol-associated liver disease must examine their own potential bias against patients battling alcohol use disorder. They should consider thoughts that arise, such as “Other patients are more deserving of this organ” or “I would never donate my organs to a patient like this.” These thoughts or feelings don’t make someone a bad nurse; rather, they’re an opportunity to explore, understand, and combat biases that may otherwise have gone undetected.

Biases don’t exist out in the open like beliefs, and trying to uncover them takes practice and time. Nurses—adaptable, lifelong learners—can overcome obstacles standing between themselves and excellent patient-centered care. Overcoming bias frequently begins with self-evaluation or reflection, followed closely by education.

Self-evaluation and reflection

Self-evaluation involves examining stereotypes and challenging beliefs, which may uncover bias. When nurses see a patient beyond perceived stereotypes, that patient becomes a person, not their disease. In the case of a patient with alcohol use disorder, a nurse might ask, “Would I treat this person differently if they didn’t have this condition?” or “Why am I uncomfortable with this patient?”

In addition, the Gibbs’ Reflective Cycle provides a structured framework for nurses to examine their experiences and apply what they learn to future practice. The six stages of reflection include description, feelings, evaluation, analysis, conclusion, and action. By working through each stage of the cycle, nurses can explore how their biases may have influenced patient care, while simultaneously enhancing self-awareness and supporting ongoing professional development.

The Institute for Healthcare Improvement recommends counter-stereotyping by imagining a person as the opposite of their stereotype.

When nurses use these methods to break down stereotypes, they can offer individualized care plans rather than taking a one-size-fits-all approach.

Education

After self-evaluation to identify biases, nurses should consider pursuing educational opportunities to help them better understand those biases and unlearn them. Nurses who seek evidence-based research can improve their critical-thinking skills, which will inform their clinical decision-making. Ultimately, this work enhances their professional practice and the quality of patient care they provide.

Many hospitals and professional nursing organizations offer competencies and resources related to respecting cultures and beliefs, as well as practices nurses can implement to help overcome bias. For example, some hospitals incorporate educational opportunities into nurse residency programs and hospital-based online learning platforms, while professional organizations offer synchronous and asynchronous webinars and self-directed modules addressing implicit bias, cultural competence, and communication skills and literature.

These resources also support nurses in embracing diversity and inclusivity, which is essential to professional growth and development. In addition, nurses might benefit from reviewing social determinants of health, modifiable risk factors, or diseases that may influence their perceptions of patients and contribute to implicit bias.

Treatment and support

According to Shi and colleagues, overlapping and frequently nonspecific symptoms may delay the diagnosis and treatment of liver conditions in patients with alcohol use disorder. Typically, treatment begins with lifestyle modifications, but patients may require liver resections or transplants in the event of severe liver damage. Bias within the clinical setting may influence decision making in the transplant process, as providers’ concerns about potential relapse and nonadherence among patients with alcohol use disorder frequently become heightened.

Regardless of the treatment plan, lifestyle changes and support systems remain the core of potential positive outcomes for these patients. Interdisciplinary teams must treat both the alcohol use disorder and the failing liver. Patients require physical, mental, and emotional support from their care teams, families, and friends. Nurses can support patients by practicing therapeutic communication, providing education, and actively involving patients in their own care throughout the evaluation process to determine the need for a liver transplant.

In addition to the physical healing associated with a liver transplant, patients also have psychosocial needs that require attention. They’ll require new patterns of living that include active alcohol treatment and abstinence, which may necessitate severing ties with loved ones or refraining from certain interactions. They’ll need daily immunosuppressive medications to avoid organ rejection as well as routine provider visits and laboratory work. Immunosuppressive medications make patients more susceptible to illness, which may prevent them from participating in social activities, potentially leading to isolation. Some patients experience guilt after a liver transplant, knowing their survival comes from someone else’s loss. Unbiased, compassionate nursing care during this critical and vulnerable recovery phase can help to ensure successful outcomes.

Destigmatizing alcohol use disorder

Destigmatization begins with a new perspective. Nurses who find themselves with feelings of bias toward patients with alcohol use disorder may benefit from learning about the disease process, the same way they would any other illness. Just as a nurse wouldn’t blame a patient for a diagnosis of leukemia, they shouldn’t attribute personal blame to a patient with alcohol use disorder.

Language plays an important role in influencing care. Stigmatizing language can lead to delays in patients with alcohol use disorder seeking care, frequently to the detriment of their overall health. Person-first language puts the individual before their illness or diagnosis: the person has a condition or illness rather than the person is the condition or illness. Todt suggests “person with alcohol use disorder” rather than “alcoholic,” “person who misuses alcohol” rather than “drunk,” and “person in recovery” rather than “former addict.” When nurses and other healthcare providers use person-first, inclusive, and nonjudgmental language, patients are more likely to seek the treatment needed to save their lives.

I’ve found that practicing empathy and active listening enables nurses to understand patients’ specific wants and needs. By engaging in individuation and learning about the patient beyond their illness and outside the clinical setting, nurses can help patients overcome the stigmas they may carry into the healthcare environment. Making this connection with patients also provides a way to foster empathy.

Leading by example also helps to combat bias. By modeling self-awareness and reflection practices, nurses can acknowledge and normalize conversations about the influence of biases on decision-making. Demonstrating inclusive, evidence-based care by using person-first language, for example, sets the stage for equitable care. In addition, speaking up to respectfully offer alternative perspectives creates an atmosphere of accountability and a commitment to justice.

Compassion and respect

Provision 1 of the American Nurses Association Code of Ethics for Nurses emphasizes that “the nurse practices with compassion and respect for the inherent dignity, worth, and unique attributes of every person.” By actively recognizing and addressing bias in liver transplantation related to alcohol use disorder, nurses lead the charge in delivering equitable, patient-centered care that prioritizes medical management, recovery, and long-term outcomes. They also help to promote a deeper understanding of the unique needs of this patient population, increasing the likelihood that patients will engage with the healthcare system while ultimately improving their quality of life and that of their families.

*Name is fictitious.

Sarah Matola is a part-time clinical faculty member at Kent State University in Kent, Ohio.

References

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Key words: liver transplant, bias, stigma, alcohol-associated liver disease