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Tuesday, May 29, 2012

another question about rationing, without an answer

Today I met a man whose liver is failing. He drank way too much alcohol for many years and quit in February when he finally realized his liver was toasted, pickled, scarred, hardened, cirrhotic. He had begun to build up fluid in his belly that had to be drained with a needle because the medicines designed to help reduce it didn't work and made him feel terrible. Because the liver clears toxins created by metabolism, and his didn't, he began to be loopy and tired all the time. Today the fluid had built up again and when over 8 quarts of it was drained from his belly he was too weak to walk and had to stay in the hospital.

The single solution to his problem, barring the invention of a time machine so he can go back and not drink so much, is liver transplantation. He is not insured for a liver transplant. We talked about this and about his prognosis with the technology available to him, which is terrible, while he struggled to keep his eyes open. I am pretty certain he will remember none of the conversation. He made the comment that it is terrible that things like money and insurance determine who will live and who will die. When you put it that way, it is terrible. But it is so very not that simple.

Many physicians are intelligent, motivated and inventive. They see a problem and use their knowledge of anatomy, physiology, pharmacology, plumbing, that sort of thing, to solve it. Amazingly creative solutions arise, many of them wildly complex, expensive and prone to spectacular failure. Liver transplantation is just one example of this. If a liver is failing and needs to be replaced and livers in folks dying of non-liver disease are just fine, why not replace failing livers with unspent, perfectly good used livers? Nearly 6000 liver transplants are performed every year, a very involved and expensive procedure costing nearly a quarter of a million dollars for each patient treated (those numbers vary widely depending on many factors.) The donor liver needs to be matched by blood type and must be removed, preserved, reattached and must withstand the body's immune response. Families of the not-quite-dead must agree to harvesting the organ while the body that holds it is still capable of nourishing it. There are living donors, because livers are quite good at regenerating themselves even after more than half of their volume is removed. These living donors go through a major operation to save someone else, from which it can take months to recover. Some donors die. After transplant, the recipient of the donated liver must take medications that suppress immune function, sometimes for years, in order to avoid rejection.

Getting a liver transplant is a really big deal. Only a fraction of people who are on transplant lists get transplanted and many die waiting for a new liver. The sickest of those waiting get preference. Active drinkers or drug abusers are not candidates, and people whose conditions are very likely to cause death despite a liver transplant are not put on the list. A person must be abstinent from alcohol for at least 6 months and have a good support system to maintain sobriety to be eligible for transplant.

So, I ask, in the case of liver transplant, is it terrible that something like money and insurance coverage helps make the decision about who will have the opportunity for a cure for liver failure? What should make the decision? Should the medical profession have an essay contest? Should we judge each candidate's likelihood of contributing to society? Should we value the unusual, and transplant those with red hair, odd names, unusual syndromes? Should we measure who deserved to get sick and who did not? What about the fact that some people can drink like fish and never get liver disease? Should we absolutely refuse to transplant people whose own actions directly lead to liver failure, like those who overdosed on acetaminophen in a suicide attempt, because we most certainly do transplant these, and they often go to the head of the list because their livers get so sick so fast.

And what about other resource intensive treatments that we invent for dire illnesses? Should we just not invent them because we don't have the resources to offer them to everybody? Should we invent them in scientific studies, then discard them because they are not universally effective or their cost benefit ratio is unfavorable, even though increased familiarity will most certainly lead to modifications that benefit at least some people?

If and when my patient wakes up, we will perhaps discuss it again, and I will listen to what he has to say, and I will not have any truly satisfactory answers.

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