Thursday, September 17, 2009

The liver patient question

I've asked two people these questions in the comments on my previous healthcare post, but I'm going to go ahead and ask the question here, so if I asked you there, you might was well answer here.

1. If there is a liver patient who refuses to stop drinking, should he or she be given a transplant liver that could go to someone else?

2. Should money be used to pay for that operation that could be used to pay for healthcare for someone else?

Actual doctors or those close to them can correct me on this one, but my impression is that if you won't stop drinking, there's no well in hell the US is going to give you a transplant liver that could go to someone who has stopped drinking or who never drank in the first place.*

Anyway, how do your views on those questions reconcile with your views on my previous proposal for having a personal responsibility element to what heathcare the government will pay for?


EDIT: I took out the snark about how in Britain alcoholics only get liver transplants when they are rich and famous because further looking into the matter revealed that it wasn't true. Well, that the UK gave a liver to a famous athlete who drank himself to death soon afterwards was fully true, but the fact is that the UK puts a great many livers into alcoholics. Meanwhile, if this UK citizen who hasn't had a drink in 15 years doesn't get a liver transplant before his tumors get much bigger, then he will be taken off the transplant list because if you have too much cancer in your body then you are no longer considered a reasonable candidate for tranplant.

If your belief that people should be given the same care regardless of how they take care of themselves rests on an assumption that organs, doctors' time, money to pay for health care and hospital beds are infinite, you are very much mistaken.

EDIT II:

Well, if you were worried about the man who wrote the Guardian article I linked to above, you can stop. Frank Deasy's liver failed today. He died on the transplant list. By some estimates, 1/4 of the donated livers in the UK go into alcoholics.

Great system they've got there.

CC

*Yes, you can get it by flying to a third-world-country and essentially buying it but rich people in countries with nationalized health care do that too.

21 comments:

Bill Baar said...

You forgot Geographic Favoritism which is key to allocating livers and most organs I think.

It's the result of Government intervention and a good example of why less Government in health care a good thing.

It is very very tough for Government to change as technology makes regulations obsolete. In this case the immediacy of transplanting which once made geography a key concern.

The other piece are MELD scores which rate the patients dying of liver disease within 3 months. You can find them here.

Chalicechick said...

Bill, you're looking at what happens once people are on the list.

People who won't stop drinking are not put on the list.

Note how the same website you link to lists "Active alcohol or substance abuse" as a contraindication to liver transplant here.

And says on the same page:

All patients referred to California Pacific Medical Center undergo careful evaluation by a hepatologist, psychiatrist and social worker with attention to indicators for continued sobriety and compliance with the post-transplant long-term follow up. In particular, previous social stability, employment record, psychiatric status and length of sobriety are evaluated. For patients with the diagnosis of alcohol dependence or abuse, the referring physician will ask the patient to sign an alcohol contract and participate in alcohol recovery while awaiting transplantation. Only patients having psychosocial factors predicting long-term sobriety are accepted for transplantation.

Which I think pretty clearly indicates that you don't even have a shot of making it on the list if the people who evaluate your case believe you are psychologically incapable of not drinking.

CC

PG said...

Addressing the actual topic of the post (scarcity and distribution of organs and money), the difference between refusing a liver to someone with ongoing alcohol addiction, and refusing medical treatment to someone with ongoing alcohol addiction, is that livers are a radically scarce resource. As I explained to Bill in another thread when he tried to extrapolate from Ezekiel Emanuel's analysis of UNOS to what that would mean for health care generally, different analyses apply depending on how scarce the resource is.

The liver you give to Raging Alcoholic is a liver you cannot give to Sober Sunday School Teacher. In contrast, medical resources generally are not so scarce. American society devotes much more money to health care than other countries do, and there's no cap on how much we can spend. Therefore your getting a triple bypass today, even if you've shown no signs of quitting your bad diet, smoking, etc. that caused you to need surgery in the first place, doesn't inherently deprive me of being able to get a triple bypass as well. At least within the American system, you can't directly buy a liver.* You can buy a bypass operation by paying cash even if your insurer doesn't want to grant you one. If someone who can't/won't control his behavior chooses to buy a bypass operation instead of buying a house, it ain't none of my nevermind.

* You can game the UNOS system by establishing residences in multiple states, thus getting on multiple waiting lists, and having a jet to fly you to whichever is the first to offer the organ you need.

Bill Baar said...

Alcohol use plays a big factor your health status, in your ability to survive the surgery; and in the case of MELD scores: survive three months.

It's your health status that decides though, not your vices.

Note poor health stauts would make you unsuitable for the surgery even if there were an abundance of donor organs.

Providers should not do futile procedures regardless of scarcity or abundance. That does not serve the patient.

Chalicechick said...

(((It's your health status that decides though, not your vices.)))

Actually, I'd say that when the treatment center you chose to use for an example writes:

Only patients having psychosocial factors predicting long-term sobriety are accepted for transplantation

I think they are very clearly saying that your vices can keep you from even getting on the list.

CC

Bill Baar said...

If there is a liver patient who refuses to stop drinking, should he or she be given a transplant liver that could go to someone else?

Your MELD score decides. Your Health Status as predictor of your three month survival rate.

What you promise to do in the future should not decide.

Whether or not anyone else is available instead should not be a factor.

You have a MELD score predicting you will not in all likelihood survive three months, then no transplant, regardless of how many livers available.

It would be futile surgery.

2. Should money be used to pay for that operation that could be used to pay for healthcare for someone else?

The passive voice is a killer here. Who's money? Who's decision?

My friend donated one of his Kidneys to his brother up at U of W. He made the decision based on his own calculus. Not every brother would do this.

Should he have been coerced to donate if he had said no?

Should he have been told to donate instead to someone else if his brother had a poor MELD score?

Who's supposed to be empowered to make these decisions is critical.

So who do you have in mind making this decision? I can make it for my own kidney, but can you make it for me?

Chalicechick said...

Well, you can feel free to write this hospital and try to convince them to change their policy.

CC

The Dancin' Hippie said...

I wouldn't support approving the transplant due to the fact that the patient has a medical condition, alcoholism, that indicates that the transplant would not be successful long term. Likewise, I would support approving a liver transplant with someone with advanced lung cancer for the same reason.

But I would support a type two diabetic getting a foot amputation to save their life even if they remain obese.

That doesn't mean that I don't think people should be unaccountable for their behaviors. For example, the insurance program available to small business in Rhode Island requires participants to have an annual physical where risk factors are evaluated: primarily weight and smoking. Patients identified as having high risk behaviors are are given 6 months to address their risk behaviors by receiving insurance paid, doctor recommended treatment (smoking treatment or nutritionist consult + wellness center visists). If the patient fails to comply with the doctors treatment recommendation, their personal insurance premium goes up.

I support this type of system because it recognizes that the conditions are disease processes and focuses on treatment. It places the disincentive for the behavior early in the disease progression allowing for cure of the initial condition, and if the patient doesn't follow doctor advice, the system gets extra revenue on the assumption that it will pay it out later.

--DH

Chalicechick said...

((((Patients identified as having high risk behaviors are are given 6 months to address their risk behaviors by receiving insurance paid, doctor recommended treatment (smoking treatment or nutritionist consult + wellness center visists). If the patient fails to comply with the doctors treatment recommendation, their personal insurance premium goes up.))))

That seems reasonable to me, though given that I think the general gist of Universal Healthcare is that people don't have much in the way of insurance premiums, I was taking the money out another place.

CC

Chalicechick said...

((((Therefore your getting a triple bypass today, even if you've shown no signs of quitting your bad diet, smoking, etc. that caused you to need surgery in the first place, doesn't inherently deprive me of being able to get a triple bypass as well.)))

Mammograms cost about a hundred bucks apiece. (At least that was what Google told me.)

Another informal Google search indicates that the cost of triple bypasses vary radically. $50,000 is a conservative estimate.

At some point, we will have to make some limitations on what the government pays for. If we can incentivize healthy behavior enough to avoid a triple bypass for one guy, we can pay for 500 mammograms, give or take.

CC

Eve said...

I would support the no-drinking restriction on the liver transplant, but not support the weight-loss-effort restrictions on treatments for diseases that may be linked to obesity.

It is well established that too much alcohol will damage a liver. It is not at all well established that calorie-restriction and increased exercise will lead to permanent, sustainable, healthy weight loss. It is not at all well established that intentional weight loss leads to decreased healthcare costs overall.

This article does a pretty good job of outlining some ways to encourage healthier behaviors throughout society, without resorting to blaming and shaming those who are obese:
http://www.creators.com/liberal/connie-schultz/shame-is-not-a-health-care-strategy.html

The Dancin' Hippie said...

(((...given that I think the general gist of Universal Healthcare is that people don't have much in the way of insurance premiums...)))

I don't think that is the gist of what is being discussed for the USA. That is certainly the case in the UK. I think, but am not sure, that even in Canada there is some premium paid. But I think it is safe to say that single-payer has been removed from the table in the US. Even with the public option, the intent is that people will still have to pay premiums through the exchange. So really, the only people who would not be paying much would be the poor who are given credits on the exchange, assuming that they are unemployed and/or not covered by an employer plan.

So increased premiums wouldn't work for the very poor, but you could still stick them, and everyone else, with a sin tax on tobacco. And ending subsidies for corn and corn syrup products would certainly help on the obesity front.

I'm glad we could come to agreement that we both think personal responsibility is important and a system of incentives/disincentives is critical to the success of any reform. Our difference is on the placement of those incentives/disincentives.

:-)

--DH

PG said...

"At some point, we will have to make some limitations on what the government pays for."

Sure, but that's assuming government *must*( pay for everything, which isn't true in any country of which I know. You can get private insurance or pay out of pocket even in the superscarysocialized NHS in the UK.

There isn't really any "private" or out-of-pocket way to obtain livers. Your getting a liver *inherently* deprives me of a liver. There is a fixed number of livers available. (This, I suppose, is the moment for Bill to say that it's a fixed number only because of that darned government regulation that prevents people from buying and selling livers in a free market.)

We can change what we want to spend money on. Even if we limited health care expenditures to be paid solely by the government, we could do what the Europeans have done and spend less on defense than we do on social programs. There are lots of options when it's just a matter of money. There are fewer options with a radically scarce resource like organs.

Bill Baar said...

This, I suppose, is the moment for Bill to say that it's a fixed number only because of that darned government regulation....

One thing that worries be about Obama Care is the notion something is broken about American Health Care (which I think is Obama code for Medicare is insolvent) and it will mean a cap on Health Care expenditures; with research --the kind of research that would result in artificial organs-- would get defunded.

Obama care would but the breaks on American innovation. The kind of innovation that would create supluses where we have scarcity.

Obama's vision is locked on a fixed pie, and he's going to reallocate based on some calculus of his.

The notion of building and creating wealth and prosperity, surplus and abundance, is really outside his mindset.

Footnote: We never discussed the second question about what is the alternative on spending for someone elses transplant.

Key question there for me is whose money are we spending here? U of W won't do my transplant becaus of drinking (ok), but they'll spend the money to do another's. Ok, whose money? My insurance?

When we start talking about the right-to-care, it begs the question who has the right to coerce who for payment of that care.

John A Arkansawyer said...

Let me complicate your argument: Here's someone who died after being denied a transplant for using a drug. There are other such cases out there. I turned them up without much effort. It looks very much to me like this is based on moralism rather than on a medical basis.

It's a bit like the soccer player whose story you linked to, who doesn't appear to have damaged his post-transplant liver by drinking to excess. If he is going to drink at a low enough level post-transplant, well, why not give him the liver? (I do agree that someone who isn't going to stop getting smashed and is going to waste that liver shouldn't be getting the transplant.)

kimc said...

"Great system they've got there."

No one has claimed that the system in England is very good. (it's still better than ours though....)

Your statement, Bill, that Obama's plan would stop innovation, is not supported by facts. Medical technology is not influenced by insurance. and medical research has always been done mostly by universities.

Mark Kille said...

CC,

Since you asked me in the comments of the previous post, and I didn't answer, sorry...

I think my broad-principle answer is that I'm okay with (in the sense of pragmatically accept) the idea of assigning priority for specific medical treatments based at least in part on likelihood of success. So if we have 5 livers and 50 people needing livers, then the alcoholics might find themselves at the bottom of the list, and get no liver.

If we have 50 livers and 5 people who need them, though, I'm not comfortable with saying that the 2 non-alcoholics get livers and the 3 alcoholics don't, even though liver transplants are very expensive and the money saved could go back in the "healthcare pot." That seems to be the argument with smoking and drinking and weight (leaving aside the terribly shaky science of fat).

If there is a serious problem with alcohol-caused liver failure or tobacco-caused cancers or corn-syrup-caused diabetes, my preferred solution is not to essentially sentence people to death for making bad choices, but to surcharge and tax the holy bejeesus out of the offending substances in the first place, with the receipts going directly to the specifically relevant treatments.

The hard question I would ask--and my apologies if it has already been asked, I skimmed these comments and don't remember all of the previous ones--is if we are limiting use of resources by the "shoulda known better" standard, will we also deny care to people without valid driver's licenses who sustain injuries while driving anyway? That can be joyriding teens, stubborn seniors, or hardcore DUI-scoffers. Or to anyone who gets an STD except in case of rape or incest? There are many opportunities to conserve resources by not enabling avoidable conditions.

You are right that money and beds are not infinite, any more than livers are. My glib attitude is to look at the defense budget and wonder why we spend so much money on protecting citizens against hypothetical violence while refusing to spend it on treating citizens' actual illnesses. I'm not sure exactly how many liver transplants a single fighter jet could pay for, but I imagine it's probably a good number, and I'm not sure why being a hard-nosed realist about politics and finances can't involve looking at all the other pots out there. As a practical matter, I'm actually perfectly willing to run up the tab on healthcare and then have the debate about highways, agricultural subsidies, state "job creation" tax incentives for corporations, etc. etc.

Chalicechick said...

(((sentence people to death for making bad choices, but to surcharge and tax the holy bejeesus out of the offending substances in the first place, with the receipts going directly to the specifically relevant treatments. )))

That alternative has been proposed. The snag in it that I see is that when I first made the initial suggestion in the other post, several people commented that there are plenty of healthy fat people who would find themselves forced to lose weight.

I said that my vision was that they wouldn't be forced to lose weight unless they had a condition where eat more vegetables and exercising was an important part of the treatment. Truly healthy fat people could continue their lifestyle as they chose.

But while (as a nonsmoker and moderate social drinker) I don't have any problem with taxing alcohol and tobacco, taxing just fast food would be a really regressive tax on the poor. Also the tax-the-cause proposal would be a tax on ALL fat people, ALL smokers and ALL drinkers, which is what people had said they didn't want.

Someone in the comments of the last post had an idea about switching the subsidies around to make sugar cost more and vegetables cost less. I'm ok with that, though.

((( I skimmed these comments and don't remember all of the previous ones--is if we are limiting use of resources by the "shoulda known better" standard, will we also deny care to people without valid driver's licenses who sustain injuries while driving anyway?)))

My original post used "People who are in accidents and aren't wearing seatblets should get less money than people who aren't wearing seatbelts." and I favor that. I liked that example because it is really clear cut.

Other ones get more complicated, and I suspect you need someone smarter than me writing the laws. But I will give it a shot. May take on the people without drivers licenses who cause car accidents is:

-People without drivers licenses because their license was taken away because of something like failing to pay parking tickets should still be covered as much as any other victim.

-People whose drivers licenses were taken away for something like too many reckless driving and excessive speeding convictions should be covered at a reduced rate.

-People who don't have drivers licenses because they are joyriding teenagers are fully covered because the personal responsibility stuff doesn't kick in until they are 18.


As for STDs, because theoretically they can be transmitted through mouth sores people might not be aware of, but mostly people have died from AIDS they caught from their cheating spouse*, my inclination is to cover them all.

But I do see where you're coming from.

CC

*I'd always heard that this was true of the lady who played Miss Kitty on Gunsmoke, though the wikipedia page is kind of ambiguous on the point since she had cancer, too.

Mark Kille said...

"The snag in it that I see is that when I first made the initial suggestion in the other post, several people commented that there are plenty of healthy fat people who would find themselves forced to lose weight."

I'm not sure why, when what we're charging is inputs rather than outputs? Eat enough whole-grain bread, organic free-range grilled chicken breast, eggplant and corn and peaches and all, and you can maintain your weight quite nicely if that is your desire.

"I said that my vision was that they wouldn't be forced to lose weight unless...exercising was an important part of the treatment."

Exercise actually seems the trickiest one, because what is the bad thing is a lack, not an excess. It's hard to charge for a lack. And exercise independent of weight is actually really important for lots of things--osteoporosis, cholesterol, circulation...

"taxing just fast food would be a really regressive tax on the poor."

I wouldn't tax the product, but the ingredients. Which would get passed on to the consumer, yes, but competition to find healthier alternatives while keeping cost down would be a good thing, for the restaurants and the people. That already happens some, like with replacing the kind of oil stuff is fried in, offering applesauce as a side in kids' meals along with fries, etc.

The brokenness of our food system is kind of a whole thing in its own, though. I wouldn't want to try to address health issues through food supply without looking at why an apple grown at the farm down the street is more expensive than a bag of chips shipped in from 12 states away.

"Also the tax-the-cause proposal would be a tax on ALL fat people, ALL smokers and ALL drinkers, which is what people had said they didn't want."

Ah. I'm perfectly fine with that, actually. If there is a product I enjoy, and part of the social cost of that product being available on the market is that some people abuse it and so get sick, it seems perfectly fair that I should bear some of that cost.

Cerulean said...

This has been one of the awesome-most conversations on the ChaliceBlog recently, and I think CC and many of her commenters made several excellent points.

I've been mulling over my thoughts on the topic (liver transplants), and have come to some sort of conclusion.

I see three obvious ways to decide who gets a liver:

1) The system we currently have, which is akin to a first-come-first-serve waiting queue, modified for organ rejection issues

2) A social triage system by which potential liver recipients are ranked and judged for transplant worthiness, whether the judging is done by subjective or statistical grounds

3) A system where money talks. An exaggerated example would be one where livers are auctioned off to the highest bidder, but the general idea is to give livers to those who can most pay for them. I'd like to think the exorbitant sums paid for livers would go toward research in liver replication technology, but that's not necessarily an inherent requisite of the system.

The more I think about it, the more I believe that our current system, first-come-first-served, is the most impartial and objective way to go about it. Compared to the other two systems, it's not as prone to gaming the system, playing politics with it, or assigning a number to a human life.

(The problem with playing social triage is best illustrated by the saga of Terri Schiavo.)

sdh said...

He said according to your article, in the UK a lot of alcoholics and they are obviously a lot of which require the liver, because it consumes too much alcohol is then their hearts are many who are sick and in urgent need of liver transplant surgery and replaced him with a still intact. Thank you.