Why alcoholics aren't allowed to receive liver transplants

An Ontario woman is challenging the constitutionality of a rule that precludes alcoholics from receiving liver transplants until they have been sober for six months. But Dr. Constantine Karvellas says the question of organ allocation is just a matter of making best use of a scarce resource.
A medical team performs an organ transplant. (Submitted by Houston Methodist Hospital)

In 2010, Mark Selkirk was diagnosed with acute alcoholic hepatitis. He needed a new liver, but would not be eligible to receive a transplant until he was six months sober. 

Selkirk died two weeks after his diagnosis, and his widow is now challenging that six-month sobriety requirement in court. She argues the widely-followed policy discriminates against alcoholics and violates their right to life, liberty, and security of the person. 

But according to Dr. Constantine Karvellas, relaxing the criteria for liver transplants just isn't an option. 
He is an assistant professor of medicine at the University of Alberta and a critical care physician involved in his hospital's liver transplant program. 

The full interview is available in the audio player above. The following portions have been edited for clarity and length.

Why do you think recovering alcoholics should be required to stay sober for six months before they can receive a liver transplant?

We need to be aware of some statistics. One is that we know that there are approximately 5,000 patients who die each year from complications from cirrhosis in our hospitals. And with the current seven liver transplant centres that we have and donor rates, we only have capacity to perform approximately 450 transplants a year. So that's approximately one in ten. And in public healthcare, one of the challenges that we face is to maximize healthcare outcomes. What that essentially comes down to is maximizing the number of patient life-years post transplant with those 450 transplants. We know that there's good evidence to suggest that if patients are not abstinent six months prior to transplant then rates of recidivism go up... and this often leads to consequences, not only with the liver transplant graft itself, but also with non-compliance, with taking immuno-suppression, which leads to worse outcomes post-transplant. 

It must be incredibly difficult to make these kinds of decisions. Talk us through the factors that transplant committees consider when they're trying to decide who gets a liver that could save their life. 

One of the most important things is that these decisions are not made by individuals, they're made by multi-disciplinary transplant committees composed of medical specialists, surgical specialists, social workers, infectious disease doctors, psychiatrists... The challenge you have as an individual practitioner is that your responsibility is to your patient. However, committees themselves are responsible to the greater good.

So there are really three questions that one needs to answer. The first is the medical need -- so, essentially, you have medical complications of cirrhosis or chronic liver disease implying that based on our best estimates of prognosis that there's a less than 50 per cent chance of being alive at one year with your current disease state. The second question that comes up is that we need to ensure that there are not medical reasons that would preclude a favourable outcome with liver transplant. These are primarily problems with the heart and with the lungs. So if you have advanced-stage emphysema or you've had multiple heart attacks, you won't do well with an operation. The final thing is where the alcohol issue comes up. There are psychosocial issues that may come up in transplant. That's where the six month alcohol rule comes up for patients with alcohol as the primary cause of their liver disease. But the main issue that comes in when we look at these psychosocial issues is, does the patient have the ability to comply with the medical regimen that they will be taking post-transplant? People need to remember that they're not getting a new liver, they're getting somebody else's liver, and that needs to be managed. 

Click the blue button above to listen to the full interview.


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