Causal Explanation-Guided Learning for Organ Allocation

A central challenge in organ transplantation is the extremely low acceptance rate of donor organ offers--typically in the single digits--leading to high discard rates and suboptimal use of available grafts. Current acceptance models embedded in allocation systems are non-causal, trained on observational data, and fail to generalize to policy-relevant counterfactuals. This limits their reliability for both policy evaluation and simulator-based optimization. In this work, we reframe organ offer acceptance as a counterfactual prediction problem and propose a method to learn from routinely recorded--but often overlooked--refusal explanations. These refusal reasons act as direction-only counterfactual signals: for example, a refusal reason such as old donor age implies acceptance might have occurred had the donor been younger. We formalize this setting and introduce ClexNet, a novel causal model that learns policy-invariant representations via balanced training and an explanation-guided augmentation loss. On both synthetic and semi-synthetic data, ClexNet outperforms existing acceptance models in predictive performance, generalization, and calibration, offering a robust drop-in improvement for simulators and allocation policy evaluation. Beyond transplantation, our approach provides a general method for incorporating human direction-only explanations as a form of model supervision, improving performance in settings where only observational data is available.