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Should an Alcoholic Be Allowed to Get a Second Liver Transplant?

Considering the question of how to allocate a scarce resource: human organs.

by
Theodore Dalrymple

Bio

July 30, 2013 - 9:00 am
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In private health-care systems, rationing of health care is by price; in public health care it is by waiting lists and administrative fiat. Both have their defenders, usually ferocious and bitterly opposed, but the fact remains that there are some treatments that have to be rationed however much money is available for health care: as when, for example, there are more people needing organ transplants than there are organs to be transplanted. Few people would be entirely happy to allocate organs merely to the highest bidder.

A recent article in the New England Journal of Medicine tackles the problem of allocation of lung transplants. A system was in place in the United States that excluded children under 12 years of age from receiving adult lungs as transplants, an exclusion that parents of a child with cystic fibrosis challenged in the courts. The problem for children under the age of 12 requiring lung transplants is that there are very few child donors, so in effect the system discriminated against them.

The reason for the exclusion was that most children for whom lung transplants are considered have cystic fibrosis, a condition for which the results of such transplants are equivocal given the constantly improving medical treatment of the disease. Moreover, children are especially liable to complications from the procedure, though these can be partially overcome by using not whole adult lungs for transplant but only resected lobes of them.

The American system of allocation of lungs for transplant into adults takes into account various factors, such as years of potential benefit from transplant, the imminence of death without transplant, the statistical chance of success of transplant, and so forth. Ability to pay does not come into it; in other words it is a socialized system, but there is a mechanism of appeal for those relegated to low priority which the more educated and wealthier are better able to take advantage of. No explicit judgment is made about the relative social or economic worth of the individual, however, for that way madness, or at least extreme nastiness, lies. And the authors of the article think that, on the whole, the system works well, for it seems to stand to reason that those who would benefit most should go to the top of the waiting list.

I once had a small transplant dilemma of my own…

Comments are closed.

Top Rated Comments   
Why do you think the IRS, keepers of the records of which political party you donated to, are in highly involved in Obamacare?
It is pretty clear that Democratic Party donators will get to the top of any medical procedure list. If you don't believe that can happen, then you haven't paid any attention to the current problems concerning the 501(c) organizations.
51 weeks ago
51 weeks ago Link To Comment
Good points. Politicizing medical decisions has been a bad idea that's been happening for a long time. SF and the AIDS crisis was a recent one.
Medical decisions need to be based on science, not emotion. Sux, but there it is.
51 weeks ago
51 weeks ago Link To Comment
you conveniently forget to mention that the 10 year old failed in 24 hours. has now had a second, which will fail for the simple reason that even if all else goes well, she will grow. adult lungs will not. also cystic fibrosis is a multi-organ disease.

in the early days of transplant, recipients were chosen in part on the chance of success. now it is public relations. if the donor pool is insufficient, the low probability success shouldn't be done. and self inflicted disease should be down the list. disease made worse by immunosuppression should be way down.

transplant is a zero sum game. if someone gets the organ, another does not. the soccer player had killed his liver then a second. give someone else a chance to live.
1 year ago
1 year ago Link To Comment
All Comments   (44)
All Comments   (44)
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I suppose the point is to think about this: Should a medical welfare system, like the old-style British welfare system, divide the users into "deserving sick" and "undeserving sick"? In other words - even with doctors running the system - should the criteria be strictly medical ("this man will benefit more, and live longer, from the procedure") or moral as well ("he did it to himself, and will probably do it again, so he's low priority")?

(And given what we know, could we keep it from getting political - "To whom does he donate; which party will benefit if this high-profile case doesn't get treatment...?" - or tribal - "Hey, you're finding my race has lots of undeserving sick - more treatment for us!"?)

The author comes from a medical ethics tradition that points to the first answer - doctors, as an ethical obligation, do not look into the patient's own morals, but only his medical needs. (By analogy, public defenders don't decide to give less representation to undeserving clients, but portion out their efforts according to where they can do the most good.)

One advantage to a purely free-market system is that it takes that kind of decisionmaking away from the state. Of course there'd still be charity hospitals -- but in that case the people who paid would decide the criteria, and the state would not ("faithful first, infidels last" or whatever). Be that good or bad, I think this is a good article for getting readers to think about that.
42 weeks ago
42 weeks ago Link To Comment
I am not sure what the point of this is. Are we being invited to join in the
Obamic pastime of deciding who should live and die?

There is already a triage process for things like this, and it is run by doctors.
If they, not bureaucrats (and certainly not me) are permitted to continue to run it, that will be fine with me.
43 weeks ago
43 weeks ago Link To Comment
Dalrymple has been marinated in British Socialism for so long that he can't even imagine a defense of allocating livers by the free enterprise method. In fact he's horrified that people who are literate or intelligent or energetic enough to work the system might have any sort of a leg up on people who aren't. It's obviously never occurred to him that SOCIETYbenefits if those sorts of people disproportionately survive.
49 weeks ago
49 weeks ago Link To Comment
1. You are shooting a moving target. The progress of medicine is more likely to change the treatment. The problem is temporary.

2. The world is round, just like a cheese. If a person with lots of money wants a liver, the person can get the liver outside your area of legislation.

3. There is a lot of economic theory around this topic. It is likely true that there are more livers to go around if people buy them from people who want to sell them. A lot more. Begging is not a good way to get large volumes of product. The down side perhaps is that some wealthy lush quoting George Raft gets to buy a liver with his money.

4. You don't have to donate the whole liver. Generally a lobe will do. If you think little poster girl should have a liver, give her a lobe of yours. When you do, we will be able to smell the self esteem for blocks.

Bring it.
50 weeks ago
50 weeks ago Link To Comment
Absolutely not; but we might offer them a spleen.
50 weeks ago
50 weeks ago Link To Comment
The answer is yes. There is no reason not to. Moreover, there is no one competent to make the decision. The second you add any question of social right and wrong, or benefit or utility you subscribe to the survival of the fittest and make the Nanny State look tame - and you justify the Nanny State.

The greatest pretense in the world happens when a stranger says "This is in your interest" or "This is what is society's interest".

More goods have been denied to people for no reason at all than have the few necessary with-holdings from people taken place when we have empowered and allowed doctors and others to think they live world where it is up to them to involve themselves in questions outside of their competency.

51 weeks ago
51 weeks ago Link To Comment
in other words it is a socialized system, but there is a mechanism of appeal for those relegated to low priority which the more educated and wealthier are better able to take advantage of. No explicit judgment is made about the relative social or economic worth of the individual, however, for that way madness, or at least extreme nastiness, lies. And the authors of the article think that, on the whole, the system works well, for it seems to stand to reason that those who would benefit most should go to the top of the waiting list.

This is just confirmation of my opinion that the American system wasn't broken (even though improvements could be made), and certainly did not need the intervention of an amorphous mass of goo like Obamacare.
51 weeks ago
51 weeks ago Link To Comment
As a recovering drunk, I have some knowledge of the problem. I have been sober for three decades plus. I don't think a practicing alcoholic is a proper recipient for such a limited resource. Unless the alcoholic is committed to recovery, the solution is temporary at best and the liver is wasted. Some may say that a new liver will give the alky a reason to recover. Personal experience with alcoholics who were recipients show otherwise. Just another branch on the enabling tree.
51 weeks ago
51 weeks ago Link To Comment
Hopefully, in another 5 to 10 years, either organ regeneration from adult stem cells or successful xenografting (transplants from [genetically modified] animals) will make the whole issue obsolete. (Amusingly, the best candidate "donors" for xenografts are not primates but gen-modded pigs.)
If you could/will be able to grow a replacement organ from the patient's own stem cells, there will be no transplant rejection since it will effectively be an autograft. All you need then is enough time left.
51 weeks ago
51 weeks ago Link To Comment
As Instsapundit says, "Faster, please."
51 weeks ago
51 weeks ago Link To Comment
People who rape children, kill innocents citizens, and commit mass murder get 'life' on the dole of the taxpayers.

And here we are bitching about liver transplants...

Really? Millions are spent housing the evil that consumes our society and yer bitching about organ transplants?

51 weeks ago
51 weeks ago Link To Comment
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