Should alcoholics be required to stop drinking for six months before they are eligible for a liver transplant in Ontario?
The issue has been raised by the widow of Mark Selkirk, a Toronto man well known as the person behind the moose sculptures that once appeared across the city.
Selkirk was also a lifelong alcoholic. In 2010, he was diagnosed with acute alcoholic hepatitis and told by doctors he would die without a liver transplant.
In Ontario, patients who need a new liver must abstain from drinking for six months before they are eligible for a transplant. Selkirk died two weeks after his diagnosis.
His widow, Debra Selkirk, is planning a constitutional challenge of the six-month policy. She intends to use the Charter of Rights and Freedoms to argue that the policy discriminates against patients who suffer from alcoholism and uses a moral judgment to deny patients a life-saving treatment.
"I believe that if doctors have a patient whose life they can save and they have a donor who's willing to give, that they have an obligation [to save their life]," she said in an interview on CBC Radio's As It Happens.
Click here to listen to Selkirk's interview on As it Happens Selkirk believes Ontario's six-month abstinence policy contravenes the charter and Canadians' right to universal access to health care.
She theorizes that if lifestyle choices were taken into account for all procedures, it would be seen by many as inhumane.
"Perhaps we should have a rating system for every disease and everything that comes into our hospital," she argues.
"If someone comes into the hospital bleeding to death and you're a gang member ... I say to him, OK, I'm going to look at my list ... 'Gang related.' We make them wait three hours [according to our lifestyle policy]. If you bleed to death in the meantime, oh well, you're a bad person.
"That's not what universal health care is. Universal health care is save every life you can."
Dr. Gary Levy, the former director of the Multi-Organ Transplant Program at University Health Network who now heads the living donor liver program there, said the policy is in place mainly because livers are a scarce and finite resource. He is not involved in Selkirk's case.
In an interview on CBC Radio's Metro Morning on Wednesday, Levy said last year more than 100 people died while waiting for a transplant.
"We have a shortage of suitable organs, we don’t have enough to meet the need," he said. "We have a responsibility to ensure the organs are used wisely."
Levy said studies have shown that alcoholics awaiting a liver transplant and who are able to abstain from drinking for six months have a very low rate of returning to drinking.
He said if a liver is donated to a patient who damages the new organ by continuing to drink "we don't have one death, we have two deaths."
Levy also denied suggestions that the six-month waiting period is about saving the cost of the transplant surgery.
"We've never denied an individual in our centre because of dollars and cents," he said. "Where a need exists and where people meet the criteria, we move quickly to provide them the service."
Selkirk plans to push ahead with her challenge, saying the current policy treats alcoholism as a "character flaw" instead of a medical condition.
She said the provincial government, which earns revenue from alcohol sales, has a responsibility to make sure everyone gets the medical treatment they need.
"We have an alcohol problem and it's not right to let people die because we don't want to address these problems," she said. "It's not for them to make moral judgment calls."
Hmmmm. This raises a lot of interesting questions.
Beyond the waiting period issue, would a patient have to be sober just for the transplant to even happen? I mean is that a requirement from a medical standpoint?
Post by tacosforlife on Jan 30, 2015 8:51:39 GMT -5
"If someone comes into the hospital bleeding to death and you're a gang member ... I say to him, OK, I'm going to look at my list ... 'Gang related.' We make them wait three hours [according to our lifestyle policy]. If you bleed to death in the meantime, oh well, you're a bad person.
I think this is a terrible analogy because of this:
"We have a shortage of suitable organs, we don’t have enough to meet the need," he said. "We have a responsibility to ensure the organs are used wisely."
Organs are a rare and finite resource. The resources needed to treat a wounded gang member may not actually be infinite, but they might as well be when compared to the availability of human organs.
But I also think this is incorrect:
"It's not for them to make moral judgment calls."
because I reject the premise that it's a MORAL judgment call. It's a MEDICAL judgment call based on probability of success and the best use of limited resources.
If we could be Oprah for livers - a liver for you! and you! and you! - then they could be given out without regard for the probability of success.
Post by irishbride2 on Jan 30, 2015 8:51:49 GMT -5
My uncle is in the 6 month wait right now. He's made it two months sober. We just hope he lives through the next 4 months.
eta: as harsh as this sounds, I have no problem with making him wait. because honestly I have little confidence that he will stay sober post transplant.
Post by penguingrrl on Jan 30, 2015 8:57:41 GMT -5
That's a really tough ethical question. Livers are such a finite resource that I can understand choosing who gets one based on prognosis after the transplant and I can see where alcohol abuse would give someone a worse prognosis when it comes to a liver transplant since it's well understood that alcohol abuse is related to liver failure. If livers were readily available for all those who need them I would feel very differently.
I think you should absolutely have to be sober. And I say this as someone whose father is slowly dying from complications due to diabetes. He was told over a year ago that he needed a kidney transplant, but that in order to do it, he'd have to lose at least 100 lbs. Yeah. That isn't happening- he didn't even make an attempt. So, now they are telling him that he really needs a double transplant of a new kidney and a pancreas. But I'm pretty sure that's not going to happen either. Organs are limited. Doctors have to have guidelines for figuring out which patients should get them. And if one of those guidelines lessons the chance that the new organ will be destroyed within a year, then I'm all for it.
Yes, they should be sober. There is a huge shortage of organs. The people who are going to follow protocol, take their meds, and do what they need to do to not reject the organ should be the highest priority. When my mom had a kidney transplant, I don't know if they asked about drinking but she did have to go through a lot of interviewing and work with a social worker to ensure that she would be willing and able to follow all the rules after the transplant. My dad was also included because he is her primary caregiver.
Is this true of other diseases that destroy a particular organ and a transplant only buys you more time? Like, if you have a disease that slowly destroys your lungs so that if you get new lungs they are only good for, say, ten years, does that makes you ineligible for a transplant?
I think (though I'm not sure) that you also can't get an organ transplant if you have a secondary terminal illness, like an untreatable terminal cancer or something.
Probably. MIL had kidney transplant 13 years ago. She had breast cancer before that. She had to get through that and be cancer free for a specified period of time (a year, perhaps) before they'd clear her for the transplant.
Also- this has nothing to do with morality. It's based heavily in the biology of transplantation science
Just like you have to stop smoking for a lung transplant. If you smoke, your transplant is less likely to succeed. You're more prone to anastomosis failure.
I can't even believe this is a question. I think, ethically, it would be wrong to give the liver to someone who hasn't demonstrated the ability to "care" for themselves properly.
It kind of reminds me of Frank from Shameless--it's just not a good idea!
Reading the article I'm a bit confused on one point: did Mark Selkirk have a living donor? I could kind of see his wife's argument if say, his sister was a match and was willing to be a living donor and he was still refused for the transplant. However, if she's talking about the transplant list, no. I'm just going to ditto everyone else on that.
Post by pinkdutchtulips on Jan 30, 2015 12:44:24 GMT -5
given the limited # of organs for transplants, those in the most dire of need who are SOBER and didn't have to become sober for the sake of getting a transplant should go first.
its my understanding (so PDQ) that xh's mom got a lung transplant due to smoking. post transplant guess what she resumed .. yep. I'm VERY hesitant to give a liver (partial or full) to a briefly sober documented alcoholic who will in all likelihood resume drinking once they get their new liver.
Is this true of other diseases that destroy a particular organ and a transplant only buys you more time? Like, if you have a disease that slowly destroys your lungs so that if you get new lungs they are only good for, say, ten years, does that makes you ineligible for a transplant?
I don't think so. I believe, for example, that you can get a lung transplant with cystic fibrosis. Things that are congenital are treated differently because for many people, it's something congenital that puts them on the list to begin with. But again, that has to do with allocation of resources. Someone who has alcoholism doesn't necessarily need a liver transplant. They need to quit drinking. And in at least an abstract way, they can. By the time they need the transplant, we don't look at them and say, you can't have one because you got yourself into this and don't "deserve" it. That would be mixing morality with transplants. But we do look at them and say, you can control whether you end up on this list again and we ARE going to make you do that before giving you a liver. Again, we want to keep the list as short as possible. Saying to someone with CF that they should stop having CF doesn't change anything about their condition. Telling someone they have to quit smoking or drinking or lose weight does. There are also a ton of other requirements for transmutation that are clearly intended to encourage success of the transplant. Things like willingness and ability to be compliant with follow up care. Those are things that are compromised if you aren't sober, too.
My aunt had a liver transplant due to a liver disease (not alcohol related), she lived another 15 years with that liver and the disease eventually destroyed her second liver. She was on the liver transplant list until she went into hospice this fall and passed away. From talking with her and my uncle, she was not moved up higher on the list as her condition got worse b/c she had already had one transplant and other people hadn't even had one yet. It wasn't said like punishment, just that sometimes more terminal conditions can move you up if a match is available, but having already had one liver transplant sort of exempts you from that. (This info was 2nd hand from my uncle to my dad with me eavesdropping as I made dinner, so I might have misheard).
If what you said about the reasons he was transplanted are true, that program should be shut down. I work in liver transplant, we don't get to pick and choose. Some insurances require 6 months sobriety and some don't. Medicaid, for example, does. Medicare does not. There are federal guidelines and transplant programs are audited regularly. People are not listed willy nilly.
Personally, I think it's a good idea. There are more people waiting than we have organs for, and I feel we owe it to the donor families to allocate the resources as best as we can. That being said, I have seen people transplanted with little, to no, sobriety time. Sometimes it depends on how sick they are, and if their insurance will allow for it.
If a person comes in with fulminate liver failure some of the rules can be tossed out, that person could be transplanted without proper evaluation almost immediately.
I obviously don't know all specifics. I just know he was not required to have a period of sobriety for those reasons. He was likely days away from passing when he received the transplant (i know he was almost too far gone for transplant), so absent alcohol i am sure he would have been high on the list. So maybe this was an insurance issue?
A liver transplant saved my life 4 years ago. My liver failure was not caused by alcohol but my transplant center has a zero alcohol policy post transplant.
Now that I feel 100% better, not drinking is tough. If it's tough for me and I am not an alcoholic, I can't imagine how hard it would be for an alcoholic to not drink. I absolutely support the rule that you must show 6 months of sobriety. Anyone can say they will stop drinking and the 6 month rule will help prove their dedication.
Someone had to die for me to live. For me to start drinking again after this amazing gift, would be the absolute worst way to honor my donor.
Both my parents died of cirrhosis of the liver. My mom's was alcohol induced. My dad's was alcohol abuse for years compounded with hepC. In both cases the doctors offered info on how to get on the transplant list. I was abhorred that it would be a possibility for either of them, given the circumstances.
So, I don't think even those who are sober for 6 months should get an option for a new liver. I would feel differently with a longer waiting period. I don't know how long it should be though. And the idea that someone with hepC could get a transplant is crazy talk in my mind.
ETA: my relationship with my parents strongly colors my opinion on this matter.
Both my parents died of cirrhosis of the liver. My mom's was alcohol induced. My dad's was alcohol abuse for years compounded with hepC. In both cases the doctors offered info on how to get on the transplant list. I was abhorred that it would be a possibility for either of them, given the circumstances.
So, I don't think even those who are sober for 6 months should get an option for a new liver. I would feel differently with a longer waiting period. I don't know how long it should be though. And the idea that someone with hepC could get a transplant is crazy talk in my mind.
ETA: my relationship with my parents strongly colors my opinion on this matter.
This is why the decision is made by a team, regarding who gets listed. Hep C, in no way, should be a disqualifying diagnosis. Neither should alcoholism.
Eta: I do get this is a personal issue for you, sorry for your experiences:(
It's just good I wasn't on the team in those cases. I couldn't ever be on a team like that. I'm glad there are knowledgeable teams of people making unbiased decisions. As it should be.
A liver transplant saved my life 4 years ago. My liver failure was not caused by alcohol but my transplant center has a zero alcohol policy post transplant.
Now that I feel 100% better, not drinking is tough. If it's tough for me and I am not an alcoholic, I can't imagine how hard it would be for an alcoholic to not drink. I absolutely support the rule that you must show 6 months of sobriety. Anyone can say they will stop drinking and the 6 month rule will help prove their dedication.
Someone had to die for me to live. For me to start drinking again after this amazing gift, would be the absolute worst way to honor my donor.
I was never told not to drink. I don't drink in excess but I have a glass of wine here and there. I have never been asked at appts if I drink either. Interesting.
I also think an alcoholic doesn't just wake up in need of a liver. The disease progresses. If they had stopped drinking at the first warning signs, it may not have progressed. Etc etc
Is this true of other diseases that destroy a particular organ and a transplant only buys you more time? Like, if you have a disease that slowly destroys your lungs so that if you get new lungs they are only good for, say, ten years, does that makes you ineligible for a transplant?
I don't think so. I believe, for example, that you can get a lung transplant with cystic fibrosis. Things that are congenital are treated differently because for many people, it's something congenital that puts them on the list to begin with. But again, that has to do with allocation of resources. Someone who has alcoholism doesn't necessarily need a liver transplant. They need to quit drinking. And in at least an abstract way, they can. By the time they need the transplant, we don't look at them and say, you can't have one because you got yourself into this and don't "deserve" it. That would be mixing morality with transplants. But we do look at them and say, you can control whether you end up on this list again and we ARE going to make you do that before giving you a liver. Again, we want to keep the list as short as possible. Saying to someone with CF that they should stop having CF doesn't change anything about their condition. Telling someone they have to quit smoking or drinking or lose weight does. There are also a ton of other requirements for transmutation that are clearly intended to encourage success of the transplant. Things like willingness and ability to be compliant with follow up care. Those are things that are compromised if you aren't sober, too.
CF is a genetic level defect, it doesn't actually start doing the same damage to the new lungs that it did to the old ones. The new lungs have "good genes" and properly mange the chloride channel so that the mucus build up/inflammation/infection cycle is broken. The problem can be that the whole sinus system may still be harboring infections that can then impact the new lungs, or any of the other issues one gets transplants in general with rejection and whatnot. It's not actually that the CF spreads into the new lungs.
The compliance with care, medication, and follow up are huge. If you don't do things exactly right, you can fuck up your new organ pretty damn fast. Also, given that he died two weeks after diagnosis... I'm not really convinced they would have been able to clear him for transplant before he got too sick to get one should an organ have become available. There are a lot of ifs in there even if it weren't a bad idea to give new livers to active alcoholics (given that alcohol is not good for livers, at all), and that is treating it like the disease it is, not a moral judgment.
Both my parents died of cirrhosis of the liver. My mom's was alcohol induced. My dad's was alcohol abuse for years compounded with hepC. In both cases the doctors offered info on how to get on the transplant list. I was abhorred that it would be a possibility for either of them, given the circumstances.
So, I don't think even those who are sober for 6 months should get an option for a new liver. I would feel differently with a longer waiting period. I don't know how long it should be though. And the idea that someone with hepC could get a transplant is crazy talk in my mind.
ETA: my relationship with my parents strongly colors my opinion on this matter.
I know you said you have personal experience with this, so I can see where your feelings come into play and color your view. I'm sorry you had to experience that.
However, Hep C is not the result of alcoholism, in fact baby boomers are told to consider getting tested for it, as there are a lot of undiagnosed patients in that age group, so, IMO, people with Hep C, shouldn't automatically be disqualified.