Amid a nationwide organ shortage, people dying from alcoholic liver disease (ALD) are often the last to receive transplants in the United States. Meanwhile, more than 21,000 Americans die from the condition every year, many of them might have been saved by the surgery, The Washington Post reports.

ALD is a spectrum of liver damage caused by excess alcohol consumption and is the second most common chronic liver problem in the country, behind hepatitis C virus (HCV). The condition is known to cause severe damage, cirrhosis and even fatal liver failure if left untreated. However, many ALD patients are unable to enroll in organ donor waiting lists to improve their illness because of an informal policy in place at nearly all of the nation’s 140 transplant centers requiring that patients demonstrate six months of sobriety before they are allowed to register. 

According to doctors, the rationale is multifaceted. First, they’re checking to see whether a patient’s liver can restore function on its own in the absence of alcohol. Second, they use the probational period to determine whether patients are serious enough about a transplant that they won’t abuse the liver after the surgery. Third, the shortage of livers in the United States forces doctors and transplant selection committees to make tricky moral judgments about which patients are eligible to receive a lifesaving organ.

The United Network for Organ Sharing (UNOS) estimates around 7,000 people receive new livers through the national transplant waiting list. However, more than twice as many sick patients are cleared for that list than there are livers available, and nearly 15,000 patients are still in line for a transplant. 

But some doctors argue that, although generally accepted, the six-month rule is not based on hard data. Current practice data from the American Association for the Study of Liver Diseases (AASLD) show that “only a small fraction” of ALD transplant patients revert to heavy alcohol use or abuse postsurgery and that survival rates for alcohol-related and nonalcoholic-related organ recipients are similar. 

At the same time, the AASLD also notes that most alcoholic patients are never formally evaluated for transplantation due to “perceptions that ALD is self-induced [and to] the possibility of recidivism or noncompliance” as well as the current nationwide shortage of organs. 

Meanwhile, UNOS reports that nearly 21 percent of people on the U.S. transplant waiting list have alcoholic cirrhosis, a severe manifestation of ALD. For most of them, the condition will be fatal.