Should alcoholics compete equally for liver transplantation?

Article Abstract:

The publication in 1988 of a study showing that patients with alcohol-related end-stage liver disease (ARESLD) could survive as long after liver transplantation as patients with other terminal liver diseases raised important questions regarding the appropriate use of the very short supply of donated livers. These issues are particularly pressing since the Health Care Financing Administration decided to extend Medicare coverage for liver transplantation to patients with alcoholic cirrhosis (liver disease caused by alcoholism) who stop drinking. The authors take exception to this position. Liver transplantation is different from other lifesaving treatments for several reasons. Donor livers are extremely scarce, and including people with ARESLD, who represent more than half of the ESLD patients, as potential recipients would increase competition for the few (fewer than 2,000 in 1989) liver transplantation operations performed. While hearts are also in short supply, no one main cause for the type of heart disease requiring transplantation can be identified. Liver transplantation has been targeted for cost containment, and public support is needed if donor programs are to be successful. A proposal is presented to rank candidates for liver transplantation that would give the highest priority to those who develop ESLD through no fault of their own (because of congenital conditions or cirrhosis due to causes other than alcohol). The scarcity of donated livers dictates that ARESLD patients be judged differently than other patients. It is deemed fairer to give a child dying of biliary atresia (failure of the biliary system to develop) a first healthy liver than to give an ARESLD patient a second healthy one. The proposal does not discriminate against the poor, because alcoholism is present at all socioeconomic levels. The public, which holds lifesaving care for alcoholics in low regard, represents a force that must be considered in formulating health policy. Several other articles and editorials on this issue appear in the March 13, 1991 issue of The Journal of the American Medical Association. (Consumer Summary produced by Reliance Medical Information, Inc.)

Health aspects, Care and treatment, Social policy, Liver diseases, Alcoholics

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Ethics of liver transplantation with living donors

Article Abstract:

The proposal of performing partial liver transplants obtained from living donors to children with acute liver disease has been examined. This procedure has been developed using the model of a seriously ill infant who probably will not survive without a liver transplant. It involves the removal of a portion of the liver (a lobe section) from a healthy parent who would act as donor. The procedure is technically feasible but raises a number of complex ethical issues. A year of discussions and seminars on this topic was initiated by transplant physicians and clinical ethicists, and the entire university community at the University of Chicago was invited to participate and comment. A protocol was developed where the overall risks and benefits of this surgical procedure were examined. For the recipients the survival rate was approximately 80 percent, similar to whole liver transplant survival statistics. Because of the shortage of whole livers available from cadavers for transplant, many infants die waiting for a donor to become available. To ensure the best results it was recommended that this procedure be performed on infants with advanced liver disease but who were not critically ill. Consultation with a pediatric hepatologist and hepatic surgeon would be required. A complete physical and psychological examination for the donor would be performed. The mortality risk to the donor is considered to be low; in fact, no mortality has been reported when performed by surgeons experienced in the procedure. The benefit to the donor is a powerful psychological one, where the life of the child will probably be saved. A potential problem is the fact that the donor is also the individual to provide consent for both himself and the child. A two-week waiting period is recommended between consent and the procedure. Another factor is that information on this type of liver transplant is limited because the procedure is new. Further thought and discussion of the ethics and potential dilemmas that may be encountered in this procedure are encouraged.

Organ donors, Tissue donors

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Transplantation of liver grafts from living donors into adults -- too much, too soon

Article Abstract:

The health insurance industry and the federal government should collect data on the outcome of adults who receive a liver transplant from a living donor. Surgeons and transplantation programs should be certified and only certified centers should perform this procedure.

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