Should Alcoholics Get Liver Transplants? March 1, 2009
Posted by Bob Aronson in Alcohol.trackback
This is a “think piece.” I’m hoping this blog will challenge your thinking and cause you to comment. I am taking no position on this issue, I am simply asking some very important questions.
Heavy drinking or alcoholism can severely damage our organs and the liver seems to be the most susceptible to such damage. So – if you were to ask the average person if alcoholics should be eligible for liver transplants the answer would likely be a resounding, “NO!”
As with most things in life, though, nothing is that simple. If transplant eligibility depended on us living healthy lifestyles then there would be no organ shortage because few people would qualify for the life-saving procedure.
According to a study, published in the April 25th edition of the Archives of Internal Medicine, led by Mathew J. Reeves who is the lead researcher and epidemiologist at Michigan State University, only 3% of Americans lead a healthy lifestyle. Reeves says a healthy lifestyle that includes not smoking, maintaining a healthy weight, regular exercise and a diet containing lots of fruits and vegetables lessens the risk of developing diabetes, cardiovascular disease and cancer. http://www.qualityeldercare.com/healthy.html
Back to the question on heavy drinking and liver transplants. Just what is heavy drinking? You may be surprised to learn that population-based surveys indicate that 68 percent of adult Americans drink at least one alcoholic beverage per month. About 10 percent consume more than two drinks per day, which is a commonly used definition of “heavy drinking”. Two drinks a day! http://www.enotalone.com/article/11240.html
Let’s ask the question again, “Should alcoholics or heavy drinkers be eligible for liver transplants?” Well, I am an alcoholic and had a heart transplant eighteen months ago. It Is likely that my alcoholism contributed to the disease that destroyed my original heart. I quit drinking in 1982 and have had no relapses but I am an alcoholic and always will be. Should I have been denied a transplant?
Should the obese person suffering from diabetes be denied treatment? Driving too fast is one of the top killers of American men, should the person with a speeding record be denied a transplant because they are likely to kill themselves? What about people who have anorexia, bulimia and other lifestyles that could be considered self destructive? Should prisoners be denied transplants even though they might someday be released? I fear that once we go down this road it is unlikely we would treat or transplant anyone.
I am not trying to justify transplanting livers into practicing alcoholics, but if you accept the American Medical Association (AMA) position that alcoholism is a disease, should the patient be punished because of it? Do we punish cancer patients because they have cancer? There is a school of thought based on limited research that suggests a liver-transplant recipient was statistically more likely to reject a new liver than to destroy it from continued drinking. The fact is that most transplant programs around the world require at least six months of alcohol abstinence before they will consider a transplant. But if two drinks a day is heavy drinking, the average person may be only a few drinks a week away from being a member of that group.
I began by saying that this is a “think piece.” I wrote it because I want to hear from you. Where do we draw the line on who is and who is not eligible for a transplant? The medical community has some solid guidelines, for example cocaine use in most cases will automatically eliminate a person from being considered for a transplant. The public however, as was evidenced in the Mickey Mantle case, may not agree with the medical professionals. What do you think? Being as there is a shortage of organs and thousands die each year because of it, should we more severely limit who is eligible for a transplant?
Please comment here or email your comments to me at bob@baronson.org.
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Hi Bob,
I work for the busiest liver transplant program in the nation. I think your blogs are insightful and your efforts to increase organ donation are wonderful. As for the question, should alcoholics get liver transplants, yes, under the right circumstances. The liver transplant evaluation process is incredibly extensive. No stone is left unturned from a medical or a social standpoint. Most centers have strict guidelines not only on absinence but also formal treatment and ongoing aftercare such as AA. If someone is willing to go through this very difficult process to better their lives, then they deserve a second chance.
Transplant centers struggle with the charge to save as many people as possible. Never is a decision made lightly and without hours of discussion involving a huge multidisciplinary team. I think people need to know this…if they make the decision to be a donor or to donate a family members organs, they need to know that as a center, we make every effort to use that organ in the most responsible way possible. If many people could see this process from the inside, I think their decision to donate would be an easy one.
Kristin:
Thank you for your comments they are especially appreciated because of your obvious expertise and concern. I hope everyone who reads this blog also reads your comments. At some future date I may want to publish them in their entirety as a separate blog.
thanks again
bob
Bob:
That is a very hard question to answer. I had a liver transplant 2 1/2 years ago and was told not to drink any alcohol at all several years before translant and again after transplant. Basicly I was given the idea that if I drank before, it would show up in my blood tests and I would be backed up on the list and after transplant, if I was to go into rejection because of drinking, I would probably not get another chance. Mind you this was not in writing but kind of insunated.
There are not enough organs to go around now and they should be given to the person that takes care of themselves before and after.
Thats the opinion I have.
Thank you, Bob for all the work you do.
Jim
When a anyone wants to donate a kidney, they do so based upon how it will be used. My brother, who was very helpful and became my Power Of Attorney, did not want to donate a kidney to me. Why? I did not want to ask. I felt it was a private matter and sometimes it is just better off not knowing why.
If a potenial recepient shows no desire or attempt to better their life before a transplant, chances are good they will be the same after the transplant.
Instead, if there is an attitude of thankfulness and a willingness to change, they should be considered.
I would like to see a “lease” agreement signed with each organ transplanted. It would state that if the transplanted organ is abused or put at risk, the agreement can be revoked and the organ taken out and given to someone else. Harsh? Perhaps but just signing something like that would indeed give them incentive to take care of themselves!
I worked at a busy transplant center 17 years ago. I worked the night shift, and that is when people would come in after getting the call that they were getting a liver transplant. We had people come in to the hospital for their transplant that were drunk. Yes, drunk, and it happened more than a few times.
The first time it happened, we took a blood alcohol test of the patient. The next morning, the surgical staff gathered the night shift nurses together, and told us to never do that again, that the patient would be transplanted regardless. The Residents called it TUI- “transplanted under the influence”.
We had a mother and son that were both alcoholics get transplanted (liver) within a few months of each other. They lived together and had little other support- I don’t know what happened to them.
Another lady that was an alcoholic did not go back to drinking, but got addicted to Benadryl. She had numerous long stays at the hospital. I remember one of the Doctors ripping through her belongings looking for her stash of Benadryl.
We also had a young man get a liver transplant- he went back to drinking and destroyed his liver. He got a second transplant, went back to drinking, and then died.
After this happened, the transplant team made it a policy that all those with drinking problems go to rehab after their transplant. I’m not sure what they required before the transplant.
Depends on whether or not this is a serious recovering alcoholic. And those perimenters are simple…time in recovery. I truly hate to be that way. I do. But TOO MANY PEOPLE need these organs. People who did not willingly and purposefully poison themselves over time. I would need to see that a candidate is serious. That they take their recovery seriously. They make bipolars who are poisoned by lithium go thru the these tests, what makes an alcoholic so SPECIAL. In fact, they are not. They are just a little more socially acceptable.
So many thoughtful, interesting comments. but — I’m not hearing anyone address the larger issue of destructive behavior. what about the obese person who has diabetes that destroys his/her kidneys? What about the anorexic who through her behavior is destroying her entire body? Should these people be denied transplants, too? I’d sure like to hear comments on this broader issue.
bob
Just passing by.Btw, you website have great content!
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I am still pondering over this…when Mickey Mantle got his liver I do remember being angry about it I feel the same about obese people that do not even try to change their life habits, I know women that have diabetes and are what is considered very over weight, but they don’t seem to change their eating habits, I think a recovering alcoholic should be given a new chance if they have changed their life style…I guess I feel there are so many that need transplants, just because you are a movie star, baseball hero etc. the mechanic or the factory worker should have the same opportunity, I think Kristin’s reply was very good, but I wonder sometimes how some people get there transplants and others don’t, I admit I am suspicious about it…..
I also work at a transplant center and have seen many different people get transplants. Some were recovering alcoholics/drug abusers who truly changed their lives for the better and it showed. And then there are those who slip thru the cracks and continue drinking up until and after the transplant. I have seen patients who reported doing drugs 1-2 days prior to transplant, still receive a transplant. I have seen patients receive transplants after intentional overdoses. I have also gone into patient’s rooms and found empty vodka bottles. I feel that the six months of soberity should be longer, and that pre-transplant recipients should go thru rehab as part of the listing process. I also think they should been regularly seen by psych, as you said, alcohol is an illness, to help them change their behaviors and thinking related to alcohol as well as offer support.
I have seen patients with long histories of alcohol and drug abuse, most of which with hep b and c receive transplants, when patients with liver cancer or some strange disease die waiting, only to have the hep resurface and destroy the new liver. I try my best to objectively care for my patients, but sometimes it can be difficult and your mind starts wandering and thinking “is it fair?”
As far as not drinking for fear of being taken off the list. I have seen this as well. Patients have been hospitalized for non-liver related instances, and immediately upon admission, alcohol and tox screen. I have seen patients wait-listed from this. In fact, I have seen patients die as a result of not getting a new organ soon enough, because they did not adhere to the 6 month rule.
The point you made against diabetes and alcoholism, I do not feel is the same. How would you then explain type 1 diabetes? Many people with it are very young and it is not a result of eating behaviors/habits. If you are going to compare it to diabetetes, then is would be more along the line of a patient with diabetes and is NOT taking their insulin and as a result has damage to other parts of their body (usually amputations/altered healing).
But before we go down this very grey road, I think what is most important is.. has this person changed their ways, and are they capable of now taking care of their new organ?
I didn’t know drinkers had a choice in the matter, I thought they had to quit drinking even to be considered for the transplant. A friend of mine has Chronic Hep C, cirrhosis, primary liver cancer… and he still came over here with a beer in his hand. He’s only 50. What is that? Why is he drinking? Should he get a transplant? I don’t know. He said they are putting him at the top of the list, but I don’t know if that is true, they still have to check and see if the cancer has spread. I’m really upset. I read that people in this condition who do get a transplant don’t last very long anyway, and if he’s drinking…. ????
My twin sister just received a portion of her daughters liver. Her transplant center was very clear-NO DRINKING. They have a one strike policy. She has been sober for 10 months. I may have agreed before watching my sister almost die from cirrhosis that alcoholics should not be given a liver. However, until you watch someone that you love suffer from this dreadful disease you can’t judge. My sister has shown incredible strength, humility and courage through this entire process. The one word that comes to my mind is gratitude. I’m so thankful to have my sister in my life.
My brother has alcoholic cirrhosis. He is a hard-working father and husband who, by his daughters admission “has always been there”. He only recently understood/admitted his drinking problem, and only about a month ago learned he had end stage cirrhosis. Two and a half years ago he successfully completed a 30 treatment program. He was sober for about a year and a half. He then fell off of the wagon only about 3 months ago to go back into a treatment program. Unfortunately, he had to be rushed to emergency with pancreatitis. He recover pancreatitis, only to remain very sick until his diagnosis of cirrhosis. He has worked at sobriety. He will get the hang of it given the chance. The challenge is that he only has 3 months soriety, and no recent 30 treatment program. His MELD score is somewhere over 20 and he is decompensating rapidly. What I am hearing often is that he did this all to himself and is really not worthy of giving a chance. He certainly does not fit the typically perception of an alcoholic, but I have yet to uncover a transplant team who would even consider him without 6 months and a 30 day treament program. My brother wants a chance to continue his growth in mastering his sobriety. He wants to satify the requirements and in fact hit a homerun iwth sobriety, but he may not live long enough. How does he do a 30 day treament program when he has hardly been able to walk for the last month? I am a breast cancer researcher and I have yet to uncover any primary research indicating any disparity between survival rates of alcoholics to non-alcoholics post-transplantation. I have spoken to friends on other kind of transplant teams and they feel the strong sense of morality in allowing someone onto the waiting list. Minus the alcohol, I know few more moral people than my brother. I am clearly frustrated on how I may fascilitate a truely good person to have the chance they deserve.
Unfortunately people who are chemically dependant are beyond your personal control. They must come to the realization that they are powerless over their drug of choice and it is killing them, Furthermore they must have a very strong desire to live. Usually this cannot be done alone, a treatment program or regular AA attendance are the only medically accxeptable methods for helping addicts whether the drug is alcohol or heroin. The best you can do is urge him to get help or arrange with a professional for an “intervention” which may be the difference between life or death.
bob
Hello Bob your article is amazing! My step father recently discovered that he has stage 4 Cirrhosis and he has 6 months to a year to live. I really just need your advice to be honest. He hasn’t had a drink in 8 months and I believe he will never touch one again. our next step is to see if we can get him on a transplant list. However, I am just terrified that he won’t be a candidate. What do you recommend? Do you know any good sites? Or do you know any good transplant places we could go to? I just really don’t know what to do? Do you think there is any way of saving him?
Everybody deserves a second chance to live but I think that we have to prioritize people who has pathological diseases to get the transplant first than alcoholics. I think it is a choice to become alcoholic. I used to drink alcohol when I was younger (heavy consumption of alcohol) but I was able to stop. It was my choice to stop drinking and it’s been 5 years and I still don’t drink alcohol. It is not fair to give the organ to a person that never took care of him/herself because a lot of people out there that are more deserving.
For cancer patients, depending on how they got it. Again for liver cancer, if they are a chronic smoker then they should be the last one on the list and give it to person who took care of him/herself.
I was gonna donate my organs before but I changed my mind when I asked the Organ donation center if I have a choice to not to give it to alcoholics but she said “no and it is given to people who matched my organ wether they are alcoholic or not.”
sorry Bob but that’s just my opinion.
Many people have a misunderstanding of the difference between heavy drinking and alcoholism. Many heavy drinkers use will power and quit. Alcoholics, however, have a genetic predisposition to addiction. They crave alcohol the way you crave air. I know, I’ve been in recovery for 28 years and every day is a struggle. If you think will power will help an alcoholic or other substance abuser quit using then you also believe that will power will stop diarrhea.
Your choice to not become an organ donor may have doomed many others to death. Did you know that one organ donor can affect or save the lives of up to 60 people? Had others made the same decision as you did then I would have died a little over two years ago. Please rethink your decision.
bob