Court Challenge to 6 Months Sobriety Rule for Liver Transplants

[Michael Hardner]

Mark was more than just a man of the community: he was a husband, father and grandfather. He was also a lifelong alcoholic.

It was acute alcoholic hepatitis that brought Mark to Toronto General Hospital in November 2010. The couple was told Mark needed a liver transplant.

“Basically the doctor walked into the room and said, ‘Your liver’s done. The risk of death is very high,’ ” Selkirk told the Star last week. “Her next question was, ‘When did you have your last drink.’ Mark said, ‘Six weeks.’ She said, ‘They won’t even look at you.”

In Ontario, patients in need of a liver transplant must be six months sober before they are put on the transplant list. It’s a policy set by the Trillium Gift of Life Network, the province’s organ and tissue donation agency, and enforced by transplant centres like Toronto General’s Multi-Organ Transplant Program (MOTP).

Two weeks after the couple was told Mark would need — but wasn’t eligible for — a liver transplant, he was dead, Selkirk said.

Mark didn't qualify for a transplant because the state deemed him too risky a recipient. Since healthcare is not a free market - how such should decisions be made by our glorious collective ? Thoughts ?

[Boges]

DEATH PANELS!!!!!

But seriously, it's a waste of resources and unfair to other more deserving candidates if he can't prove he won't go back to drinking.

Now the question will always arise, what about joint surgery for morbidly obese people and other medical treatment for people who participate in risky lifestyles.

[Michael Hardner]

Now the question will always arise, what about joint surgery for morbidly obese people and other medical treatment for people who participate in risky lifestyles.

Also - let's have some other heartwarming examples of the collective deciding that power brought by wealth has limits. It restores my faith in communis... I mean community.

[TimG]

Mark didn't qualify for a transplant because the state deemed him too risky a recipient. Since healthcare is not a free market - how such should decisions be made by our glorious collective ? Thoughts ?

One does not simply wake up one day and discover that one needs a liver transplant due to alcoholic hepatitis. He was likely repeatedly warned that his drinking could lead to consequences like this yet that was not enough to convince him to deal with his problem sooner. I am actually surprised that they only require 6 months. It usually takes 2 years of sobriety for the relapse risk to decrease significantly.

Personally, this is a no brainer. Organ transplants should go to the people will the highest chances of long term survival. This means favouring the young instead of the old and those with fewer additional health issues such as alcoholism or obesity.

Edited January 29, 2015 by TimG

[Mighty AC]

Personally, this is a no brainer. Organ transplants should go to the people will the highest chances of long term survival. This means favouring the young instead of the old and those with fewer additional health issues such as alcoholism or obesity.

Agreed, organs are in short supply and should go to the young with the best chance of survival. I suppose old alcoholics with money could still buy replacement parts in Thailand.

[overthere]

If he was only two weeks from death, he was already a very poor candidate for transplant anyway.

Given that there are fewer organs than there are potential recipients, death panels make these decisions all the time. It's a dirty job but somebody has to do it.

Personally, this is a no brainer. Organ transplants should go to the people will the highest chances of long term survival. This means favouring the young instead of the old and those with fewer additional health issues such as alcoholism or obesity.

It is almost never that easy. Patient A is a 35 year old drunk with six children . Patient B is a 60 year old saint and pillar of the community who caught hepatitis while working on an orphanage in Haiti. One liver available. Both will likely survive surgery. Which one gets it?

[Boges]

I think the complicating factor here is that the wife was willing to donate a portion of her Liver to him.

The request was still denied as it was deemed to be a waste of resources. Doctors, Hospital Time, Medication etc.

[TimG]

One liver available. Both will likely survive surgery. Which one gets it?

The older candidate. A 35 year old drunk with a failing liver has a much lower chance of long term survival. Favouring the young does not mean ignoring other criteria. What does not matter are subjective assessments of the "value" of the individual. i.e. doing charity work vs. supporting a family.

[guyser]

I listened in while this was debated the other day and an interesting comment came up from someone who studied this situation.

The take was that there is very minor lapsing , 2.5% of people who are alcholics revert to the same upon transplant.

The bigger argument that was made that the time lapse was never researched by those imposing the wait period. What is appears to be , is decisions made without any science behind it.

Sounds familiar.

[TimG]

The take was that there is very minor lapsing , 2.5% of people who are alcholics revert to the same upon transplant.

I don't believe that number. The chance of relapse for an alcoholic with a few weeks sobriety is >75%. Simply getting a transplant is not likely to reduce those odds much. It takes 2 years of sobriety to get the chance of relapse to 2.5%. At 6 months the chance of relapse >50%.

The bigger argument that was made that the time lapse was never researched by those imposing the wait period. What is appears to be , is decisions made without any science behind it.

Well - I have seen graphs of chance of relapse vs. sobriety timer and 6 months is close to the 50-50 mark if my memory is correct. So it seems to be that there is data supporting such a choice.

Edit: here a link to stats: http://www.spiritualriver.com/addiction-treatment-and-alcoholism-infographic/

According to that link it takes 4 years to get the chance of relapse below 15%.

Edited January 29, 2015 by TimG

[Big Guy]

These livers are very scarce. It is not if one was ready and they decided not to put a new one in. The process is also very complicated, expensive and requires many doctors being involved. I assume that the decision was based on a policy which prioritizes procedures with the greatest chance for success - as well as it should be.

[guyser]

I don't believe that number.

Thats certainly no surprise.

The chance of relapse for an alcoholic with a few weeks sobriety is >75%. Simply getting a transplant is not likely to reduce those odds much. It takes 2 years of sobriety to get the chance of relapse to 2.5%. At 6 months the chance of relapse >50%.

Well - I have seen graphs of chance of relapse vs. sobriety timer and 6 months is close to the 50-50 mark if my memory is correct. So it seems to be that there is data supporting such a choice.

Edit: here a link to stats: http://www.spiritualriver.com/addiction-treatment-and-alcoholism-infographic/

According to that link it takes 4 years to get the chance of relapse below 15%.

You shouldnt have done all that work when NONE of it relates to someone on the list for transplant and has already quit drinking.

[overthere]

The older candidate. A 35 year old drunk with a failing liver has a much lower chance of long term survival. Favouring the young does not mean ignoring other criteria. What does not matter are subjective assessments of the "value" of the individual. i.e. doing charity work vs. supporting a family.

I forgot to mention that the older guy has a recent conviction for pedophilia.

Same answer?

[TimG]

You shouldnt have done all that work when NONE of it relates to someone on the list for transplant and has already quit drinking.

You seemed to have missed the point about relapse. Simply quitting drinking does not mean an alcoholic will not relapse. Simply telling an alcoholic that their life depends on them quitting is often not enough either. There is a statistical relationship between the length of sobriety and the likelihood of a relapse. This statistical relationship provides the data necessary to decide on a cutoff and this data exists (despite your denials).

Yet you appear to want to ignore the available data and insist that only new data collected from a sub-set of alcoholics who get on transplant lists is acceptable. It is possible that the curve would be steeper than with alcoholics that are not on the transplant list but it still will be a curve where the chance of relapse declines with length of sobriety. The data would also be of limited use because a large percentage of people on transplant lists don't live long enough to determine their long term chance of relapse. I think the data from the general population of alcoholics is more than sufficient to determine a suitable cutoff and 6 months is more than reasonable given that data.

Edited January 29, 2015 by TimG

[TimG]

I forgot to mention that the older guy has a recent conviction for pedophilia.

There are few moral judgements on the worth of life that everyone would agree with which makes it problematic to include that as a criteria. There was a case in Alberta where a severely disabled teen was denied a lung transplant because his disability meant he could never live without some sort of care. His parents appealed to the courts and won. Personally, I think the original decision was reasonable but obviously his parents disagreed with me. This case means the pedophile should be entitled to the transplant as long as the long term survival prospects are higher than other possible recipients. Edited January 29, 2015 by TimG

[The_Squid]

I had a relation that if they received a new liver, they'd have drank until that one expired as well... People don't necessarily quit just because it is unhealthy and they might die.

I doubt that they set this 6 month policy in an arbitrary fashion... there is probably good data that says it is too risky to waste a liver on an alcoholic.

[guyser]

You seemed to have missed the point about relapse. Simply quitting drinking does not mean an alcoholic will not relapse. Simply telling an alcoholic that their life depends on them quitting is often not enough either.

No point missed at all. The data that was referenced (and I do not have) was said to show very low relapse rate for those w the disease and needing transplants.

There is a statistical relationship between the length of sobriety and the likelihood of a relapse. This statistical relationship provides the data necessary to decide on a cutoff and this data exists (despite your denials).

But not for those needing transplant....and I am denying?

Yet you appear to want to ignore the available data ....

Only that data that does nothing to show the relapse rate for those on the list who have quit drinking

Edited January 29, 2015 by Guyser2

[TimG]

Only that data that does nothing to show the relapse rate for those on the list who have quit drinking

And I am saying the data which you heard in passing is either being misrepresented or simply false because a 2.5% relapse is not plausible given the nature of addiction and the other stats which are available.

[guyser]

And I am saying the data which you heard in passing is either being misrepresented or simply false because a 2.5% relapse is not plausible given the nature of addiction and the other stats which are available.

Fair enough.

Lets call it at 5% then.

http://www.medicalnewstoday.com/articles/266995.php

The research team found that of the 300 patients who had received liver transplants as a result of ALD who survived at least 1 year, 16% experienced alcohol relapse.

Of these, 5.3% submitted to continuous heavy drinking. These patients showed increased allograft loss and reduced graft survival, compared with patients who had not continued heavy drinking, described as "alcohol use without any periods of sobriety."

[The_Squid]

No point missed at all. The data that was referenced (and I do not have) was said to show very low relapse rate for those w the disease and needing transplants.

But not for those needing transplant....and I am denying?

Only that data that does nothing to show the relapse rate for those on the list who have quit drinking

Then link to the data showing that a transplant drops the rate to 2.5%.

And if it is that, then is that maybe because the transplant program forces them to be sober for several months prior to getting on the list?

[The_Squid]

Fair enough.

Lets call it at 5% then.

http://www.medicalnewstoday.com/articles/266995.php

The research team found that of the 300 patients who had received liver transplants as a result of ALD who survived at least 1 year, 16% experienced alcohol relapse.

Of these, 5.3% submitted to continuous heavy drinking. These patients showed increased allograft loss and reduced graft survival, compared with patients who had not continued heavy drinking, described as "alcohol use without any periods of sobriety."

You may want to read your own linked study... those stats are for people who are in treatment programs before and after the transplant. Not just anyone who suddenly quits drinking shortly before their transplant, like in the case in the OP.

"Our study highlights the need for ongoing assessments of alcohol use as part of post-transplant care. Given the shortage of available donor livers, maintaining sobriety is critical to maximizing organ use and patient outcomes following transplantation."

[guyser]

You may want to read your own linked study... those stats are for people who are in treatment programs before and after the transplant. Not just anyone who suddenly quits drinking shortly before their transplant, like in the case in the OP.

I read it. Did I suggest otherwise?

[TimG]

Lets call it at 5% then.

Your numbers say 16% had a relapse which brings it into believable territory. But these numbers are biased because they exclude people who never lived long enough to get the transplant and those who were simply declared not eligible because of active drinking and were not considered for the transplant.

My argument is the data for non-transplant patients provides sufficient justification for a cut-off. Your data also implies that getting treatment before transplant is important and getting treatment is a process that lasts at least 90 days. This also supports the argument for a cut off.

Edited January 29, 2015 by TimG

[guyser]

Your numbers say 16% had a relapse which brings it into believable territory.

16% RElapse, meaning they had a drink.

5.3% back to heavy drinking.

[Boges]

I'm a little unclear on your argument here Guyser. Are you saying people shouldn't prove they can be sober for 6 months before taking someone else's liver?