Six months of abstinence a crummy compromise for liver transplants.
Ithink decent people are all pulling for Delilah Saunders, the Labrador activist for Aboriginal women ( and opera librettist) who has left an Ottawa hospital mere weeks after being in critical condition with liver failure. Saunders’ family and friends created a brief cause célèbre when she was in danger and was deemed ineligible for a new liver by the Ontario transplant co- ordinating agency, the Trillium Gift of Life Network ( TGLN).
Ontario, like most other jurisdictions, requires that patients with alcohol- related liver disease abstain from alcohol for six months before becoming transplanteligible. Perhaps it would be better to say “likes to have patients abstain”; not every transplant agency applies such a rule with total rigidity.
In a CBC interview, the wonderfully recovered Saunders had two points to make about the ethical side of her health crisis. She said, “I think people having equal access to health care is very important,” which is certainly true. And she claimed that the rule about abstinence “is not based on science by any means.”
This might seem slightly more controversial, but if you look into the bioethical discussion of triage for liver transplantation, you will discover that Saunders is pretty much right about this, too. There is no decisive body of medical evidence testifying that drinkers who have destroyed their livers should, or that they should not, be in line for a new one. The studies of how patients with alcohol issues fare with second livers are typically not too large, nor are they, in their findings, especially impressive. The followup is never as long as a reader would like.
The literature of the discussion leans surprisingly heavily on mere polling of different clinics and transplant agencies, making for a sort of Aristotelian inquiry into the ethics that different groups of people with credentials and power apply in practice. This literature is not above citing polls of the general public, either, which would be bound to horrify anybody who is in urgent need of a fresh liver. It’s a little bit like if the next 50 uninformed schlubs on the street got to vote on whether you will live or die.
The problem of transplanting healthy livers into drinkers is not so much an issue of equal access to “care,” as TGLN quite properly points out. It is an issue of access to the livers themselves. The supply of livers is highly inelastic: although almost everyone in medicine is working to encourage donation, we cannot simply go buy more. Our health- care system could pay for as many transplant surgeries as we can dream of performing, but the number of livers is what it is.
What this means is that putting a donor liver into s omeone who has used one up through behaviour may mean denying one to a hepatitis patient — or to someone else who was hit with liver disease randomly, as a bolt from the blue.
This puts the question about whether alcoholism is “really” a disease to the greatest logical challenge it can possibly face. It is definitely not the same kind of disease as hepatitis, and the clinical outcomes for alcohol abusers who relapse are definitely worse than those for other transplant recipients. With that said, most transplantees who had alcoholic liver disease do not relapse, and on the condition that they don’t, they do about as well as anyone else. If anything, a bit better.
The common requirement for six months of abstinence is actually a sort of crummy compromise, a three- quarters acknowledgment that alcoholism does have disease- nature. Some bioethicists are not sure that patients with alcoholic liver disease should be eligible for a transplant at all. The six- month guideline seems to exist somewhat in the spirit of giving them a fair shake.
No one “owns” the supply of donor livers, so we all collectively agree to spot you one liver if you can survive half a year on the waiting list (which not everyone can) and demonstrate the sincere intention to comply with a total treatment regimen — one that addresses both the dying organ in your body and the behavioural disorder that killed it.
The six- month requirement is certainly discriminatory, but we are in the position of literally having to discriminate somehow, and allowing victims of alcoholic liver disease unlimited access to the waiting list would greatly multiply the length of that list. There are other “discriminatory” factors that will make you ineligible for a liver, and if you are, say, a homeless individual with no family (or celebrity), the odds are unapologetically stacked against you. A serious mental illness will get you deflected from the list, as will plenty of other co-morbid conditions.
There i s, it should be said, one other non- ethical j ustification f or the sixmonth abstinence period. It’s not widely advertised: one might say it is admitted, or even confessed. It is that doctors are considerably less than perfect at liver prognosis.
Alcoholic patients t hought to have hopelessly compromised livers often prove to be capable of counterintuitive, nearimmediate recovery when obligated to quit drinking — even for a short time. Something of the kind seems to have happened for the thoroughly admirable Ms. Saunders: the “gift of life” is not always bestowed by physicians.
THE ‘GIFT OF LIFE’ IS NOT ALWAYS BESTOWED BY PHYSICIANS. — COSH