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.

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.

Numerous real-world systems, ranging from healthcare to energy grids, involve users competing for finite and potentially scarce resources. Designing policies for repeated resource allocation in such real-world systems is challenging for many reasons, including the changing nature of user types and their (possibly urgent) need for resources. Researchers have developed numerous machine learning solutions for determining repeated resource allocation policies in these challenging settings. However, a key limitation has been the absence of good methods and test-beds for benchmarking these policies; almost all resource allocation policies are benchmarked in environments which are either completely synthetic or do not allow any deviation from historical data. In this paper we introduce AllSim, which is a benchmarking environment for realistically simulating the impact and utility of policies for resource allocation in systems in which users compete for such scarce resources. Building such a benchmarking environment is challenging because it needs to successfully take into account the entire collective of potential users and the impact a resource allocation policy has on all the other users in the system. AllSim's benchmarking environment is modular (each component being parameterized individually), learnable (informed by historical data), and customizable (adaptable to changing conditions). These, when interacting with an allocation policy, produce a dataset of simulated outcomes for evaluation and comparison of such policies. We believe AllSim is an essential step towards a more systematic evaluation of policies for scarce resource allocation compared to current approaches for benchmarking such methods.

Recipient Organ Causeofdeath Name Mean (std.)

Breakthroughs, discoveries, and DIY tips sent six days a week. In Mary Shelley's, a mad scientist creates a monstrous creature with severed body parts. In certain film adaptations, a dismembered head is tacked onto the malformed body. Then, with the help of a lightning storm, a new life is born. From the first successful kidney transplant in 1954, modern organ transplantation has often been linked to the horrors of Frankenstein .

Numerous real-world systems, ranging from healthcare to energy grids, involve users competing for finite and potentially scarce resources.

Numerous real-world systems, ranging from healthcare to energy grids, involve users competing for finite and potentially scarce resources.