Early Liver Transplantation in Acute Alcoholic Hepatitis

More than 16,000 Americans are waiting for a liver transplant, according to federal data from the Organ Procurement and Transplant Network. Only 6,000 organs are available a year and nearly 2,000 people will die waiting for one to become available. Should an alcoholic who is likely to die from liver cirrhosis in the immediate future be allowed an early transplant (i.e. prior to the required six months of abstinence), if she is commits to abstinence from alcohol and has family support to help keep her promise, even as thousands of others who have not abused their bodies with alcohol or drugs await a new liver?

We first must agree that there are circumstances in which human beings deserve a second chance. Mistakes are made, and we ought to have the opportunity to learn from them. If the mistake is egregious enough, we, as a society, invoke laws requiring restitution and punishment. When found guilty in a court of law, a criminal may pay a fine, provide community service, or spend time in prison (or sometimes a combination of all three). Only then can the person return to society as a free citizen. A former criminal may also be subject to a period of probation, during which the individual must prove she can adhere to the rules of society without recidivism.

There are also circumstances in which society determines that a criminal does not deserve a second chance to be a free citizen. In these cases, the criminal may be banished from society permanently, sentenced to prison for life or put to death. These offenses almost always involve intense violation of someone else’s bodily integrity, not one’s own. Applying this dichotomy, if one views alcoholism as a “crime” that involves “fault,” it is certainly not worthy of complete condemnation; alcoholics deserve a second chance.

Sometimes, that second chance at life is a liver transplant. If so, should all alcoholics not abide by some form of "penance," i.e., evidence of abstinence from alcohol, in order to be eligible for a transplant? In fact, the United States transplant system already includes this requirement. Patients must abstain for at least six months before they can receive a new liver. These six months are the required justification to become a "free citizen" again, and be accorded the same rights as other persons to "life, liberty, and the pursuit of happiness." Some will argue that despite this six month penance, despite the probation, reformed alcoholics still deserve to be treated as second class citizens in terms of priority for liver transplantation. It is their fault, so they should wait behind those who have not ravaged their bodies with alcohol.

While this argument may “comport with basic intuitions about fairness” (Wikler, 110), society generally discards the notion that personal fault should play a role in medical treatment. The medical community, in particular, has rejected this idea of “priority” based on fault entirely, believing that all patients deserve medical treatment regardless of whether or not they may have caused their own illness. Imagine an Emergency Room where physicians prioritize patient care in terms of “fault” instead of “need.” A doctor would be obligated to treat a patient with warts before an individual who is bleeding to death from a skiing accident. While the latter person had arguably knowingly engaged in a dangerous sport, can a lack of immediate treatment truly be justified? Few would argue so.

Some scholars also argue that social injustices account for many health injustices, and thus society cannot be completely exculpated. Daniel Wikler presents this view eloquently in Personal and Social Responsibility for Health, and it is worth noting that the belief that alcoholics are completely at fault for their illness is shaky at best. There are too many genetic and societal factors that contribute to this disease. Without a clear concept of “fault,” it follows that “need” is the only justifiable means of priority, despite limited resources.

Unfortunately with liver disease, sometimes six months of abstinence is a death sentence in itself. Patients with severe alcoholic hepatitis may deteriorate over days and weeks, not months. So if we agree that these patients are morally justified in obtaining a new liver after six months of abstinence, what of their dire prognosis? I believe there are two requirements for providing a new liver without strict adherence to the six month rule. The first deals with “intent.” The patient must state her intention to become or remain abstinent. If the opposite were true, the patient would never actually have completed the required penance in the first place. Therefore, a new liver would not have been transplanted, and would not be justified.

I would further argue that this patient population (those who are alcoholics, have less than six months to live, and swear abstinence) should be studied in terms of rates of recidivism. If 100% of these patients typically fall back into alcoholism post-surgery, then one could argue that early transplantation is not morally justified. However, if patients who meet these criteria are found to have similar rates of recidivism to those who were able to abstain for six months, there is no question that early transplantation would be moral justifiable. There is current evidence to support this argument. Thus, with the caveats of “intent” and that it would be prudent to study the population at hand, our patient with acute alcoholic hepatitis deserves a new liver.


References

• Wikler, Daniel. “Personal and Social Responsibility for Health.” Public Health, Ethics, and Equity. Eds: Sudhir Anand, Fabienne Peter, Amartya Sen. New York: Oxford University Press, 2004. 109-134.
• Mathurin P, Moreno C, Samuel D, et al. Early liver transplantation for severe alcoholic hepatitis. N Engl J Med. 2011;365(19):1790-800.
• Brown RS Jr. Transplantation for alcoholic hepatitis—time to rethink the 6-month “rule.” N Engl J Med. 2011; 365(19):1836-8.