Critical Analysis Paper 1
Content
Julia Weston 11/23/03 NUR 462 The Ethics of Liver Transplantation in Alcoholics According to the United Network for Organs Sharing (UNOS), there were 17,310 patients waiting for a liver transplant in October of 2003. In 2002, there were 5,327 liver transplants performed. The most frequent indications for liver transplantation include chronic liver failure, acute liver failure, hepatocellular carcinoma, and other indications (Carithers, 2000). Many specific conditions fall under the generic name ‘chronic liver failure.’ Some of these are extrahepatic biliary atresia, hepatitis B and C, several metabolic disorders, and alcoholic liver disease. All of these patients are desperately waiting for a liver transplant, a procedure which may or may not save their lives. But there are so many thousands of patients, and so few livers to go around. UNOS bases their distribution of vital organs on a system of need (“sickest get them the quickest“), length of time on the waiting list, and how well of a match the organ is. One of the things that UNOS does not take into consideration, however, is the abuse/nonabuse of the organ, according to P.J. Geraghty, who is a Procurement Coordinator with the Washington Regional Transplant Consortium. And herein lies the ethical dilemma: is it truly right to provide an alcoholic, one who has abused their body for so many years and destroyed their liver, with a brand new one? Especially at the expense of others, when they are ill through no fault of their own? According to Carithers (2000), alcoholic liver disease is the most common cause of end-stage liver disease and cirrhosis in the United States, as well as in most
developed countries, with approximately 12,000 deaths each year in the U.S. alone. It was suggested in 1996, by Dr. Ronald Thurman of the University of North Carolina, that there may be as many as 600,000 new cases of alcoholic liver injury around the world each year; this number has probably increased. It is impossible to know how many of those on the liver transplant waiting list are alcoholics, due to confidentiality issues. The patient who is dying of alcoholic cirrhosis is truly very ill. They may suffer from, among other conditions, ascites, jaundice, coagulation disorders, peripheral neuropathy, hepatic encephalopathy, bleeding esophageal varices (a life-threatening complication), and hepatorenal syndrome, which is characterized by functional renal failure with advancing azotemia, oliguria, and intractable ascites. The only thing that can allow this patient to return to a semi-normal level of functioning is a liver transplant. It is, quite possibly, the only thing that can save their life. If this person is matched with a liver, and they are at the top of the list, they will receive it. But what if that person is “competing” for the liver, with someone who is not as quite as ill as they are? And what if the other potential recipient has a disease which could not be prevented? In other words, the other patient did not destroy their own liver. Does the “sicker gets it quicker” rule still apply? Or must we make a choice as to who is going to make better use of this liver? We, as health care professionals, must recall that alcoholism is a disease, and must be treated as such. But something that must be taken into consideration is the high relapse rate of alcoholism, and the absolute pointlessness of transplanting an organ into someone who may just destroy it all over again. One of the problems with ethical dilemmas in general is figuring out whose problem it really is. The bottom line is that this is everyone’s problem. It is our problem, for as
nurses, we need to clarify our feelings on this issue. It is the alcoholics’ problem, because they may or may not get their livers. It is the problem of all the other patients on the liver waiting list, because they may be getting passed by in favor of the alcoholic, because they are more ill, and the abuse has not been factored in. There is some logic for making it within the realm of the organ procurement agencies. They are the organizations that collect all the organs, and make all the decisions regarding who gets what and why. Why shouldn’t they start applying some ethics to the procedure? There would have to be a standard operating procedure, because everyone’s ethics and morals vary considerably, and it would not be right for an individual organ procurer to be applying their own code of ethics to his situation. On the other hand, if they start applying ethics and fairness to one group of people, they really have to extend that to all groups. In the end, who will make the decision as to who should get priority on a liver? It is extremely hard to say. No one will take a stand one way or the other. Doctors, the government, the organ procurement agencies, medical ethicists, or anyone who could possibly make an informed decision on this issue…no one is willing to come down on one side of the fence or the other. I believe that we are going to sit on the issue for so long, afraid to make a move, that eventually, someone is going to come out and make a decision on one side or the other. And it probably will not be someone we would have chosen to make that choice. In a perfect situation, there should be a panel of hepatologists, mental health experts, addiction experts, transplant surgeons, and other people who really knew about the issue and were able to make an informed choice. Any dilemma that deals with allocation of resources has the potential to send our society
down a moral and ethical slippery slope. If someone comes out and says that alcoholics are ineligible for liver transplants, who will be excluded next? The main ethical principle related to this problem is the principle of justice. Justice states that a person should be treated according to what is fair, and is given what they are due or owed. Each person should be treated according to need, to societal contributions, and to merit (Chally et al, 1998). In this case, is someone who drank heavily for 30 years, who destroyed their liver through their own actions, truly owed a new liver? On the other hand, is it really fair to deny someone a chance at life, no matter what they’ve done? Several studies have been done which show that patients with alcoholic liver disease who receive liver transplants have similar outcomes to patients who receive livers for other conditions. Carithers (2000) describes a 7-year survival rate of 60%. A French study found that there were no differences in several outcomes between alcoholics and non-alcoholics who received liver transplants, including survival, rejection, infection, and cancer. Thusly, the researchers concluded that liver transplantation is a viable option in alcoholic cirrhosis (Pageaux et al, 1999). Tomé et al (2002) found that “even the presence of severe alcoholic hepatitis does not worsen the outcome of liver transplantation for end-stage alcoholic liver disease.” In another study by Tomé and Lucey (2003), they state that: “…all transplant professionals agree that abstinence from alcohol prior to transplantation is an important criterion in selection of patients, and the majority of European and North American programs require a fixed period of abstinence lasting 6 months (the so-called 6month rule). The data regarding the utility of the 6-month rule as a predictor of long-term sobriety are controversial…Indeed, at least 59% of relapsing patients had at already achieved 6 months of abstinence, whilst 41% of patients who achieved 2 years of abstinence relapsed…strict application of this rule would exclude many alcoholic patients who are in need of transplantation but who are at no greater risk of relapse.”
Neuberger et al (1998) did a study comparing the priorities of the public and of clinicians (family doctors and gastroenterologists) regarding allocating livers to potential recipients. In all three groups, alcohol use was rated among the lowest; in other words, the one who should be lowest on the list to receive the liver. Public opinion is a killing point, for this issue may eventually fall to a governing body to decide. Special interest groups can make or break bills in Congress, and if enough people do not like the views of a candidate for office, he will not get voted in. The easiest solution, for most people in the country, would be to leave the system alone. People would get their livers in whatever order they get them, injustices will occur, and those of us who should be speaking out against it will be living with an ethical ache gnawing at our insides. The opposing viewpoint to this has already been stated: the injustices will continue. We will continue to give organs to those who possibly do not deserve them, and others who do deserve them will die. And though most do not like to admit it, the idea of an alcoholic receiving a donor liver may not sit well with some. Another solution would be completely radical: alcoholics are ineligible for liver transplants. One can imagine the screams from coast to coast, just at the mention of the idea. This is justice at its most twisted interpretation, everyone getting what is owed to them. All the patients getting what they deserve. The patients who are simply ill get their livers, the alcoholics die in agony. The opposing viewpoint to this option is that this is simply discrimination. It is true that alcoholics are not eligible for liver transplants until they have demonstrated 6-18 months of sobriety and show that they are able and willing to adhere to the treatment regimen. That, however, is simple prudence. The underlying disorder must be treated as thoroughly as possible before a transplant is even
considered. A third solution is that alcoholics can be eligible for livers just like anyone else, but they are not the priority. The “sickest gets it quickest” should not apply here unless the alcoholic is the only match, or happens to be the next on the list. This would require some revamping of the organ procurement and distribution procedures, to take the actual illness of the patient into account. The opposing viewpoint here is that it teeters on the edge of the ethical slippery slope. And is this truly fair to the alcoholic? They are still battling their addiction, as well as their liver failure. I found nothing in the professional literature about options to solve this problem, I reasoned these solutions out myself. There is plenty about the fact that transplantation works, and that the survival rates are good, and that there is no good reason why it can not be done. The question I continually ask here is, just because we can do something, does it mean that we should? My final position on this issue is that an alcoholic should not receive priority for a liver transplant, no matter how ill they may be. I do not feel that they should be straightout denied livers, that is simply morally wrong. But if I have a liver in my hands, and two patients before me, and one of whom has abused their body for years, I cannot in good conscience take the chance that s/he will not turn right around and destroy that liver. I believe that the organ should be given to the patient who will get the most use out of it, the one who is most likely to become a productive member of society. Even after reviewing literature about the success rates of transplantation in alcoholics, I think it comes down to the justice principle: someone getting what they deserve according to merit and societal contribution, people feeling that they should get what they are due or
owed. Alcoholism may be a disorder, but it starts with a choice. I do not believe that someone else should suffer because that person made a stupid choice. Does this conflict my overall value system? Of course it does, on some levels it tears me up that I have even written this paper. I don’t like denying anything to anyone, especially to patients. I don’t enjoy being a proponent of discriminatory practices. But the line has to be drawn somewhere. And if no one else is going to do it, I will. Ultimately, we in the health care profession are just going to go round and round on this issue. Ethical issues have a tendency to do that. They make us think, they make us sweat, and by the time we’re done gnawing at them, we’re no closer to an answer then we were when we started. But the bottom line is that we have started.
REFERENCE LIST 1. Carithers, R.J. (January 2000). AASLD Practice Guidelines. Liver Transplantation, 6(1). 122-135. 2. Chally, P.S., Loriz, L. (June 1998). Ethics in the Trenches: Decision Making in Practice. American Journal of Nursing, 98(6). 17-20.
3. Neuberger, J., Adams, D., MacMaster, P., Maidment, A., Speed, M. (July 1998) Assessing priorities for allocation of donor liver grafts: survey of public and clinicians. British Medical Journal, 317(7152). 172-175. 4. Pageaux, G-P., Michel, J., Coste, V., Perney, P., Possoz, P., et al. (September 1999) Alcoholic cirrhosis is a good indication for liver transplantation, even in cases of recidivism. Gut, 45(3). 421-426. 5. Tomé, S., Martinez-Rey, C., González-Quintela, A., Gude, F., Brage, A., et al. (February 2002). Influence of superimposed alcoholic hepatitis on the outcome of liver transplantation for end-stage alcoholic liver disease. Journal of Hepatology, 36(6). 793-798. 6. Tomé, S., Lucey, M.R. (2003). Timing of liver transplantation in alcoholic cirrhosis. Journal of Hepatology. Article 890, page numbers unknown. Retrieved from: http://www.elsevier.com/gej-ng/10/26/38/51/192/article.html
developed countries, with approximately 12,000 deaths each year in the U.S. alone. It was suggested in 1996, by Dr. Ronald Thurman of the University of North Carolina, that there may be as many as 600,000 new cases of alcoholic liver injury around the world each year; this number has probably increased. It is impossible to know how many of those on the liver transplant waiting list are alcoholics, due to confidentiality issues. The patient who is dying of alcoholic cirrhosis is truly very ill. They may suffer from, among other conditions, ascites, jaundice, coagulation disorders, peripheral neuropathy, hepatic encephalopathy, bleeding esophageal varices (a life-threatening complication), and hepatorenal syndrome, which is characterized by functional renal failure with advancing azotemia, oliguria, and intractable ascites. The only thing that can allow this patient to return to a semi-normal level of functioning is a liver transplant. It is, quite possibly, the only thing that can save their life. If this person is matched with a liver, and they are at the top of the list, they will receive it. But what if that person is “competing” for the liver, with someone who is not as quite as ill as they are? And what if the other potential recipient has a disease which could not be prevented? In other words, the other patient did not destroy their own liver. Does the “sicker gets it quicker” rule still apply? Or must we make a choice as to who is going to make better use of this liver? We, as health care professionals, must recall that alcoholism is a disease, and must be treated as such. But something that must be taken into consideration is the high relapse rate of alcoholism, and the absolute pointlessness of transplanting an organ into someone who may just destroy it all over again. One of the problems with ethical dilemmas in general is figuring out whose problem it really is. The bottom line is that this is everyone’s problem. It is our problem, for as
nurses, we need to clarify our feelings on this issue. It is the alcoholics’ problem, because they may or may not get their livers. It is the problem of all the other patients on the liver waiting list, because they may be getting passed by in favor of the alcoholic, because they are more ill, and the abuse has not been factored in. There is some logic for making it within the realm of the organ procurement agencies. They are the organizations that collect all the organs, and make all the decisions regarding who gets what and why. Why shouldn’t they start applying some ethics to the procedure? There would have to be a standard operating procedure, because everyone’s ethics and morals vary considerably, and it would not be right for an individual organ procurer to be applying their own code of ethics to his situation. On the other hand, if they start applying ethics and fairness to one group of people, they really have to extend that to all groups. In the end, who will make the decision as to who should get priority on a liver? It is extremely hard to say. No one will take a stand one way or the other. Doctors, the government, the organ procurement agencies, medical ethicists, or anyone who could possibly make an informed decision on this issue…no one is willing to come down on one side of the fence or the other. I believe that we are going to sit on the issue for so long, afraid to make a move, that eventually, someone is going to come out and make a decision on one side or the other. And it probably will not be someone we would have chosen to make that choice. In a perfect situation, there should be a panel of hepatologists, mental health experts, addiction experts, transplant surgeons, and other people who really knew about the issue and were able to make an informed choice. Any dilemma that deals with allocation of resources has the potential to send our society
down a moral and ethical slippery slope. If someone comes out and says that alcoholics are ineligible for liver transplants, who will be excluded next? The main ethical principle related to this problem is the principle of justice. Justice states that a person should be treated according to what is fair, and is given what they are due or owed. Each person should be treated according to need, to societal contributions, and to merit (Chally et al, 1998). In this case, is someone who drank heavily for 30 years, who destroyed their liver through their own actions, truly owed a new liver? On the other hand, is it really fair to deny someone a chance at life, no matter what they’ve done? Several studies have been done which show that patients with alcoholic liver disease who receive liver transplants have similar outcomes to patients who receive livers for other conditions. Carithers (2000) describes a 7-year survival rate of 60%. A French study found that there were no differences in several outcomes between alcoholics and non-alcoholics who received liver transplants, including survival, rejection, infection, and cancer. Thusly, the researchers concluded that liver transplantation is a viable option in alcoholic cirrhosis (Pageaux et al, 1999). Tomé et al (2002) found that “even the presence of severe alcoholic hepatitis does not worsen the outcome of liver transplantation for end-stage alcoholic liver disease.” In another study by Tomé and Lucey (2003), they state that: “…all transplant professionals agree that abstinence from alcohol prior to transplantation is an important criterion in selection of patients, and the majority of European and North American programs require a fixed period of abstinence lasting 6 months (the so-called 6month rule). The data regarding the utility of the 6-month rule as a predictor of long-term sobriety are controversial…Indeed, at least 59% of relapsing patients had at already achieved 6 months of abstinence, whilst 41% of patients who achieved 2 years of abstinence relapsed…strict application of this rule would exclude many alcoholic patients who are in need of transplantation but who are at no greater risk of relapse.”
Neuberger et al (1998) did a study comparing the priorities of the public and of clinicians (family doctors and gastroenterologists) regarding allocating livers to potential recipients. In all three groups, alcohol use was rated among the lowest; in other words, the one who should be lowest on the list to receive the liver. Public opinion is a killing point, for this issue may eventually fall to a governing body to decide. Special interest groups can make or break bills in Congress, and if enough people do not like the views of a candidate for office, he will not get voted in. The easiest solution, for most people in the country, would be to leave the system alone. People would get their livers in whatever order they get them, injustices will occur, and those of us who should be speaking out against it will be living with an ethical ache gnawing at our insides. The opposing viewpoint to this has already been stated: the injustices will continue. We will continue to give organs to those who possibly do not deserve them, and others who do deserve them will die. And though most do not like to admit it, the idea of an alcoholic receiving a donor liver may not sit well with some. Another solution would be completely radical: alcoholics are ineligible for liver transplants. One can imagine the screams from coast to coast, just at the mention of the idea. This is justice at its most twisted interpretation, everyone getting what is owed to them. All the patients getting what they deserve. The patients who are simply ill get their livers, the alcoholics die in agony. The opposing viewpoint to this option is that this is simply discrimination. It is true that alcoholics are not eligible for liver transplants until they have demonstrated 6-18 months of sobriety and show that they are able and willing to adhere to the treatment regimen. That, however, is simple prudence. The underlying disorder must be treated as thoroughly as possible before a transplant is even
considered. A third solution is that alcoholics can be eligible for livers just like anyone else, but they are not the priority. The “sickest gets it quickest” should not apply here unless the alcoholic is the only match, or happens to be the next on the list. This would require some revamping of the organ procurement and distribution procedures, to take the actual illness of the patient into account. The opposing viewpoint here is that it teeters on the edge of the ethical slippery slope. And is this truly fair to the alcoholic? They are still battling their addiction, as well as their liver failure. I found nothing in the professional literature about options to solve this problem, I reasoned these solutions out myself. There is plenty about the fact that transplantation works, and that the survival rates are good, and that there is no good reason why it can not be done. The question I continually ask here is, just because we can do something, does it mean that we should? My final position on this issue is that an alcoholic should not receive priority for a liver transplant, no matter how ill they may be. I do not feel that they should be straightout denied livers, that is simply morally wrong. But if I have a liver in my hands, and two patients before me, and one of whom has abused their body for years, I cannot in good conscience take the chance that s/he will not turn right around and destroy that liver. I believe that the organ should be given to the patient who will get the most use out of it, the one who is most likely to become a productive member of society. Even after reviewing literature about the success rates of transplantation in alcoholics, I think it comes down to the justice principle: someone getting what they deserve according to merit and societal contribution, people feeling that they should get what they are due or
owed. Alcoholism may be a disorder, but it starts with a choice. I do not believe that someone else should suffer because that person made a stupid choice. Does this conflict my overall value system? Of course it does, on some levels it tears me up that I have even written this paper. I don’t like denying anything to anyone, especially to patients. I don’t enjoy being a proponent of discriminatory practices. But the line has to be drawn somewhere. And if no one else is going to do it, I will. Ultimately, we in the health care profession are just going to go round and round on this issue. Ethical issues have a tendency to do that. They make us think, they make us sweat, and by the time we’re done gnawing at them, we’re no closer to an answer then we were when we started. But the bottom line is that we have started.
REFERENCE LIST 1. Carithers, R.J. (January 2000). AASLD Practice Guidelines. Liver Transplantation, 6(1). 122-135. 2. Chally, P.S., Loriz, L. (June 1998). Ethics in the Trenches: Decision Making in Practice. American Journal of Nursing, 98(6). 17-20.
3. Neuberger, J., Adams, D., MacMaster, P., Maidment, A., Speed, M. (July 1998) Assessing priorities for allocation of donor liver grafts: survey of public and clinicians. British Medical Journal, 317(7152). 172-175. 4. Pageaux, G-P., Michel, J., Coste, V., Perney, P., Possoz, P., et al. (September 1999) Alcoholic cirrhosis is a good indication for liver transplantation, even in cases of recidivism. Gut, 45(3). 421-426. 5. Tomé, S., Martinez-Rey, C., González-Quintela, A., Gude, F., Brage, A., et al. (February 2002). Influence of superimposed alcoholic hepatitis on the outcome of liver transplantation for end-stage alcoholic liver disease. Journal of Hepatology, 36(6). 793-798. 6. Tomé, S., Lucey, M.R. (2003). Timing of liver transplantation in alcoholic cirrhosis. Journal of Hepatology. Article 890, page numbers unknown. Retrieved from: http://www.elsevier.com/gej-ng/10/26/38/51/192/article.html
