Secunda et al.1 recently reported the opinions of US transplant providers toward the eligibility of patients with controversial characteristics for liver transplantation (LT). We agree with the authors that the candidate selection process for LT presents challenging ethical issues and requires both accurate and objective evaluations independent of the influence of social and cultural opinions. For a similar reason, in 2012, we designed a questionnaire that included 15 categories, both clinical and psychosocial, of controversial candidates for the listing process (Table 1). Respondents were asked to evaluate each category as not contraindicated, relatively contraindicated, or absolutely contraindicated. The directors of all active adult LT programs received the questionnaire. The results were evaluated after the activity of each center was classified as follows: low-volume (<40 transplants/year), medium-volume (40-59 transplants/year), or high-volume (>59 transplants/year). Twenty adult LT centers were active (7 were high-volume, 6 were medium-volume, and 7 were low-volume according to 2011 transplantation activity), and the questionnaire response rate was 95%. In 79% of the cases, the local program directors filled out the questionnaire. For some of the proposed issues, the referred opinions were rather homogeneous: no transplantation for a patient > 70 years old (95% concordance), acceptance of moderately expanded criteria for hepatocellular carcinoma (HCC) within the limits of the Up-to-7 paradigm (79%), possibility of an evaluation of hepatitis C virus (HCV)–related graft failure (84%), and irrelevance of a patient's smoking habit (84%). As for social characteristics, both indigent patients (95%) and inmates (79%) were commonly accepted for listing. A selection disparity between centers was observed for the remaining issues, and when the results were sorted by center activity, the contraindication rate was lower for medium- and high-volume centers versus low-volume centers (24% versus 39%, respectively; Fig. 1). Nevertheless, high-volume centers reported more conservative opinions about both the maintenance of the 6-month rule for alcoholics (83% of high-volume centers versus 33% and 57% of medium- and low-volume centers, respectively) and caution with cocaine users (66% of high-volume centers versus 50% and 42% of medium- and low-volume centers, respectively). Moreover, center activity reflected the rate of uncertainty, as indicated by the relative contraindication option, which was rarely used by high-volume centers (5% versus 9% and 11% of medium- and low-volume centers, respectively). There are several differences between Secunda et al.'s survey1 and ours, and these are largely due to either cultural perceptions (eg, age limits) or social perceptions (eg, inmate status) rather than evidence. The influence of cultural issues on the decision process has been reported in a comparison of LT attitudes in Canada and the United States2: these issues have led to a certain variability in opinions about opioid and methadone use. Moreover, for the latter, a relatively low rate of acceptance has previously been reported along with the request for weaning before LT.3 In conclusion, our national survey confirms that an LT center's experience, represented by the transplantation volume, contributes to reducing disparities in the evaluation of controversial potential candidates because of either less uncertainty in defining absolute contraindications or a lower rate of nonacceptance. Efforts must be made to provide equitable access to listing for LT on the basis of evidence. The authors appreciate the participation of the following Italian adult LT centers in the survey: Ancona, Bari, Bergamo, Cagliari, National Cancer Institute (Milan), Niguarda (Milan), Modena, Naples, Padua, Palermo, Pisa, Gemelli (Rome), San Camillo (Rome), San Eugenio (Rome), Umberto I (Rome), Turin, Verona, and Udine. Lucio Caccamo, M.D., Ph.D. Barbara Antonelli, M.D. Giorgio Rossi, M.D. Liver Transplant Center andHepatobiliopancreatic Surgery Unit Ca' Granda-Maggiore Polyclinic Hospital Foundation, Scientific Institute for Research,Hospitalization, and Health Care Milan, Italy