A Question of Ethics

[Twiggidy]

Injecting Drugs Can Ruin a Heart. How Many Second Chances Should a User Get?

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[Twiggidy]

I mean I guess if an alcoholic is on the list for a liver and drinks they can be booted from the list so Im thinking this isnt much different.

 

[anbuitachi]

I mean I guess if an alcoholic is on the list for a liver and drinks they can be booted from the list so Im thinking this isnt much different.

Similarly, I've seen cases where we emergently transplanted a liver for patient who tried to suicide by acetaminophen overdose. I've also seen patients get second liver after the 1st one rejected due to non compliance with immunosuppressants. I never understood why since the initial workup for people who need a liver is very comprehensive including presence of social support, and psych history. Should non compliant patients even get a 2nd chance??

 

[Psai]

It's not our decision. I think that everyone should get one chance but any relapse should mean no more care. Basing liver transplants on MELD score makes no sense. If the patienttrashed their old liver, then again with their new liver due to noncompliance why even give them a third? Let someone else get a shot at that point.

Then again, we are biased as we tend to see the people who don't take care of themselves. The good ones just follow up in clinic and never end up dying slowly of heart failure in the ICU because they infected their prosthetic valve again.

 

[Robotic Wis-Hipple]

I think it’s reasonable to get a second chance, but it’s clearly a huge cost to the system and if the addiction isn’t treated and followed up what is the point.

I personally have done a couple cases of prosthetic valve endo so 3rd open heart and one 3rd time redo (4th open procedure) for recurrent prosthetic valve endo which I think is clearly past the line. But it’s a surgical question/decision imo.

 

[Hamhock]

Should diabetics (DM2) get another CABG?
The difference here, of course -- in favor of IE patients -- is that we have amazing treatments, social support, home health support, and community organizations all directed at diabetes.
We have relatively zilch for addiction. It's tough to say they are "non-compliant" (which is another whole discussion) when there are no treatments available to be "compliant" with.
HH

 

[MTGas2B]

There are only so many livers available for transplant. There has to be a way to allocate. The “supply” of valve replacements doesn’t face the same limits. Makes the ethical comparisons different, IMHO.


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[Twiggidy]

There are only so many livers available for transplant. There has to be a way to allocate. The “supply” of valve replacements doesn’t face the same limits. Makes the ethical comparisons different, IMHO.


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This is a great point. I understand whole heartedly the risks of 2nd, 3rd, and 4th redo operations. That's the medical side. I also the understand the financial strain that this puts on the system. I just think there's a bit of a slippery slope if a surgeon is like, "You have an infected valve and we gave you 1 (or two) chance so now you get to die because I don't want to deal with you."

Should diabetics (DM2) get another CABG?
The difference here, of course -- in favor of IE patients -- is that we have amazing treatments, social support, home health support, and community organizations all directed at diabetes.
We have relatively zilch for addiction. It's tough to say they are "non-compliant" (which is another whole discussion) when there are no treatments available to be "compliant" with.
HH

That's interesting too. We give a pass to people who can't stay away from the fried foods but not the ones who cant stay away from the meth. Both I'd argue are addictions (which is what Whole 30 claims).

 

[MirrorTodd]

Their first chance was their original organ. IMO the new organ WAS their second chance. Idiots wanna keep doing drugs and **** up their second chance...well thats sad for them, but a waste of a very limited resource to give them a third chance.

 

[pgg]

Most injury and disease is self-inflicted. We shouldn't be rationing resources based on who deserves it. We should be rationing resources based on futility. It's more than just a semantic difference.

A lot of end-of-life care is futile and should be inexpensive and palliative, rather than expensive and heroic.

If there's a gray area, it's patients like this whose ongoing self-abuse or lack of care might transform reasonable care that would normally extend or enhance life into futile care. Realistic assessment of an individual's prognosis and outcome, including factors like the patient's mental health, housing status, ability and willingness to receive followup care ... all of these are important when choosing a treatment based on risks & benefits.

None of this is really even controversial for transplants. The first thing that came up on Google when I searched for transplant elgibility criteria was Tampa General Hospital's kidney page, which lists disqualifying factors (bold mine):

• Active malignancy (cancer)
• Active abuse of drugs, alcohol, or other substances
• Severe cardiac and / or peripheral vascular disease that cannot be corrected, such as severe cardiomyopathy with an ejection fraction of less than 25 percent
• Lack of insurance coverage or an inability to cover the expenses involved with a kidney transplant and the subsequent care
• Inadequate support system of family, friends, or others to help provide care
• Documented history of non-compliance with medical regimens or medications without reasonable justification
• Severe pulmonary hypertension that cannot be controlled or treated
• Body Mass Index (BMI) higher than 40
• Active or uncontrolled psychiatric disorders

Transplants are a little different because there's a waitlist / bottleneck to care stemming from availability of organs; as pointed out earlier by MTGas2B, this limit doesn't really apply to valves or other treatments. However, the bolded transplant-disqualifying issues above certainly influence outcome for ALL treatments for ALL conditions (self-inflicted or not) and a rational, compassionate healthcare system can and should factor them into the decision to offer or not offer a particular treatment to someone.


These will always be subjective decisions, but I would argue that weighing utility vs futility is a more objective and moral approach than drawing a line between deserving and undeserving. We're doctors, not priests.

 

[Psai]

There are only so many livers available for transplant. There has to be a way to allocate. The “supply” of valve replacements doesn’t face the same limits. Makes the ethical comparisons different, IMHO.


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The valves cost money. OR materials and time cost money. OR staffing, physician skills and medications cost money. In an era of cost containment, I don't see why we need to sacrifice our firstborn for some iv tylenol but spending hundreds of thousands on futile care is just fine.

Also social support can be deceiving. Whenever someone lands in the hospital, you see the relatives come out of the woodwork hundreds of miles away being all "doctor please do everything for my mother". Then when they're discharged, no one is around anymore.

 

[NightNight]

You go to work everyday specifically to fight AGAINST Darwinism.....it’s unfortunate but it is what it is.

 

[chocomorsel]

Injecting Drugs Can Ruin a Heart. How Many Second Chances Should a User Get?

Read the article earlier today and was impressed about letting the 25 year old die in hospice. I mean that surgeon refused to operate, and the patient didn't insist on fishing for someone who would. I think we need to set our collective feet down and realize that healthcare costs time, money and human resources that are not infinite and learn to say no to patients at times.

We can't save everyone from themselves. They want to live the high life, they need to realize there are consequences.

 

[chocomorsel]

Similarly, I've seen cases where we emergently transplanted a liver for patient who tried to suicide by acetaminophen overdose. I've also seen patients get second liver after the 1st one rejected due to non compliance with immunosuppressants. I never understood why since the initial workup for people who need a liver is very comprehensive including presence of social support, and psych history. Should non compliant patients even get a 2nd chance??

No. Not unless there is a surplus of organs. And we all know that there is not.

 

[chocomorsel]

This is a great point. I understand whole heartedly the risks of 2nd, 3rd, and 4th redo operations. That's the medical side. I also the understand the financial strain that this puts on the system. I just think there's a bit of a slippery slope if a surgeon is like, "You have an infected valve and we gave you 1 (or two) chance so now you get to die because I don't want to deal with you."



That's interesting too. We give a pass to people who can't stay away from the fried foods but not the ones who cant stay away from the meth. Both I'd argue are addictions (which is what Whole 30 claims).

No. It's not "now you get to die because I don't want to deal with you" but "Now you get to die, because you decided drugs were more important than your life".

We have to let grown competent adults make responsible decisions. If they want to remain irresponsible, then they need to realize that the consequences are sometimes life ending/altering. I bet if they had to pay for that liver/heart/valve etc themselves they would think twice about shooting up. But because someone else takes care of the bill, they don't realize how lucky and blessed they are to even get a first chance, let a lone a second.

How many people in Third world countries die every day due to no fault of their own? Who get a virus and die and never get a chance at a new valve because they can't afford it or can't make it to the nearest hospital in time?

Entitlemeniais is rampant in this country. Just because you weren't responsible, does not mean that I have to

 

[chocomorsel]

@pgg,

Why do you agree with someone with active/uncontrolled mental illness being denied a transplant?
If you ask me, that's going against the American with Disabilities Act.

Do mentally ill people not deserve good care simply because they are mentally ill?

They could totally have a good support system at home and the finances to be taken care of and be supported.

What a discriminatory practice for that university. I wonder if it would hold up in court if someone decided to fight it. It sounds like complete BS to me.

 

[GravelRider]

I’ve been apart of a few liver transplant meetings during the course of my training and I actually think it is one of the best systems we have in determining utility for a procedure that we absolutely have to ration. A patient’s ability to pay, to comply, their social support structure, their risk of relapse, and various other factors are all considered before the decision to place a patient on the transplant list is made. It is not until the patient is actually on the list that the MELD score comes into play. Do they always get it right? Nope, but it’s the best we’ve got and more often than not, they do a pretty good job.

Now the question wasn’t about liver transplants, but other “less scarce” procedures and how we should ration them. I, for one, do not want to be the one determining who deserves and who doesn’t deserve treatment. That is a massive slippery slope and frankly, I don’t want that responsibility.

Now the matter of utility is a different story because it allows for some objective measures beyond someone deciding whether or not a patient “deserves” care. That is something I can get behind and it is essentially what we do for liver transplants. How we determine utility of various treatments is something that we have to decide as a society and given our track record with end of life care in the ICU, I’m not so sure we are up to the task.

 

[GravelRider]

@pgg,

Why do you agree with someone with active/uncontrolled mental illness being denied a transplant?
If you ask me, that's going against the American with Disabilities Act.

Do mentally ill people not deserve good care simply because they are mentally ill?

They could totally have a good support system at home and the finances to be taken care of and be supported.

What a discriminatory practice for that university. I wonder if it would hold up in court if someone decided to fight it. It sounds like complete BS to me.

Active/uncontrolled mental illness suggests that they don’t have good support systems at home. No one is saying that they can’t be listed, but rather they need to get the mental illness under control before being listed. Once the patient is listed then the MELD score takes over (unless they fall off the list for whatever reason). A liver transplant is a major, multidisciplinary undertaking for a very scarce resource. Giving a liver to someone who is unlikely to take care of it not only results in the potentially faster death of the recipient, but also the person who was next up on the list who didn’t get that liver.

 

[anbuitachi]

Honestly i didn't even know surgeons did this. that they can just deny to operate when the surgery can save the person's life simply based on prior behavior... if they went to court, would the surgeon even win teh case?? On the medicine floor or ICU it seems like if the family want to continue full on treatment, despite high 6 month mortality, can we just say no because he's likely to die within 6 months?

 

[chocomorsel]

Active/uncontrolled mental illness suggests that they don’t have good support systems at home. No one is saying that they can’t be listed, but rather they need to get the mental illness under control before being listed. Once the patient is listed then the MELD score takes over (unless they fall off the list for whatever reason). A liver transplant is a major, multidisciplinary undertaking for a very scarce resource. Giving a liver to someone who is unlikely to take care of it not only results in the potentially faster death of the recipient, but also the person who was next up on the list who didn’t get that liver.

Ok. But let’s assume that they have a support system is what I am getting at.
Let’s not just assume that because they are mentally ill they don’t.
Some mental illness is resistant to treatment or shows minimal improvement.

 

[chocomorsel]

Honestly i didn't even know surgeons did this. that they can just deny to operate when the surgery can save the person's life simply based on prior behavior... if they went to court, would the surgeon even win teh case?? On the medicine floor or ICU it seems like if the family want to continue full on treatment, despite high 6 month mortality, can we just say no because he's likely to die within 6 months?

I look at it as more like, the willingness to continue said risky behavior is overall going to lead to futile care as has been mentioned above.
Now if said person had attempted to enroll in rehab, then maybe this would require further discussion. And that is what the surgeons see.

I bet you Ethics Commitee was involved.

 

[Hamhock]

Honestly i didn't even know surgeons did this. that they can just deny to operate when the surgery can save the person's life simply based on prior behavior... if they went to court, would the surgeon even win teh case?? On the medicine floor or ICU it seems like if the family want to continue full on treatment, despite high 6 month mortality, can we just say no because he's likely to die within 6 months?

We can certainly refuse to provide futile care.
I suspect there was more to that case than the surgeon simply deciding that the risk of recidivism was too high to proceed.
I have seen multiple cases of refusal based on progressive septic shock (even without bad cardiogenic shock) with blood cultures not clearing. In fact, I would bet most surgeons want at least 48h of negative blood cultures before valve replacement (this is true in my limited experience in both quaternary and community centers).
HH

 

[GravelRider]

Ok. But let’s assume that they have a support system is what I am getting at.
Let’s not just assume that because they are mentally ill they don’t.
Some mental illness is resistant to treatment or shows minimal improvement.

A good support system is a separate criteria from the uncontrolled mental illness. Should we transplant a liver in someone with severe depression who is a constant suicide risk? We’ve all known or heard of stories of people who commit suicide despite wonderful support systems. Unfortunately, if a patient has severe enough depression where suicide is a concern then I would argue that patient shouldn’t be listed for liver transplant. It’s not meant to be discriminatory, but rather to prolong the usefulness of the scarce resource. Between the time spent on the list getting sicker and sicker (to raise that MELD score) and the potentially long recovery afterward, a patient needs a kind of mental fortitude to go through that.

Notice that the definition in that particular transplant center’s criteria did not say mental illness needs to be cured. It leaves room for interpretation and a patient who is demonstrating compliance with psychiatric care has a better chance at being listed than someone who is not compliant with treatments and counseling. It’s sort of a “whole picture” type of thing.

 

[Twiggidy]

Honestly i didn't even know surgeons did this. that they can just deny to operate when the surgery can save the person's life simply based on prior behavior... if they went to court, would the surgeon even win the case?? On the medicine floor or ICU it seems like if the family want to continue full on treatment, despite high 6 month mortality, can we just say no because he's likely to die within 6 months?

That's why this article is very interesting as far as an ethics question. Comparing it to organ transplants wasn't the best comparison on my part.

I look at it as more like, the willingness to continue said risky behavior is overall going to lead to futile care as has been mentioned above.
Now if said person had attempted to enroll in rehab, then maybe this would require further discussion. And that is what the surgeons see.

I bet you Ethics Commitee was involved.

I understand 1000% what you're saying and quite honestly agree with you but as was mentioned about, is it much different than the obese uncontrolled diabetic who won't lose weight and continues to eat garbage and now needs a redo CABG. Of course, there's more involved with graft patentcy than just "lose weight and eat right" but many will argue that sugar, fried foods, etc are just as addictive as drugs but as a society we know "Drugs are bad" and Popeye's is delicious. (don't @ me. it is and i fight every day night to eat it lol) I know I'm reaching to play the devil's advocate but it is quite literally a "fixable" situation and the surgeon refuses to fix it.

 

[pgg]

@pgg,

Why do you agree with someone with active/uncontrolled mental illness being denied a transplant?
If you ask me, that's going against the American with Disabilities Act.

Do mentally ill people not deserve good care simply because they are mentally ill?

They could totally have a good support system at home and the finances to be taken care of and be supported.

What a discriminatory practice for that university. I wonder if it would hold up in court if someone decided to fight it. It sounds like complete BS to me.

Again, there's that word, "deserve" ... and the entire point of my post was that "deserve" has got nothing to do with it.

If you transplant an organ into a person with significant, active, uncontrolled mental illness you are harming that person. They are not going to be able to meticulously comply with ongoing treatment and followup, such as immunosuppression. This is worse than futile care, because you've inflicted all of the pain and risk of the transplant upon them, for essentially no benefit.

Don't look for a reason to be angry; there's enough real discrimination in the world without seeing it where it isn't.

 

[nimbus]

We have to let grown competent adults make responsible decisions. If they want to remain irresponsible, then they need to realize that the consequences are sometimes life ending/altering. I bet if they had to pay for that liver/heart/valve etc themselves they would think twice about shooting up. But because someone else takes care of the bill, they don't realize how lucky and blessed they are to even get a first chance, let a lone a second.

Physically and chronologically they may be adults. But emotionally they are children. And I know some actual 12 year old children who have better coping mechanisms than some adult drug addicts. You are expecting their behavior to be rational and drug addicts are not rational. They are certainly not grown competent adults.

 

[deleted480308]

It’s part of the problem with a govt monopoly on this (or pseudomonopoly as govt sublets this to a particular few) as then the govt sets the rules.

I should be able to donate my organs to a group that gives alcoholics their 9th liver if I want and I should be able to give to a group that says too bad no 2nd liver if you drank your first one away.

Then let the selection criteria for recipients guide the supply and demand of donors, we’ll see if donors really want to donate to the alcoholics 9th liver.

As to cost, all patients should be responsible for their own costs or finding charities to handle it. Teen with bad genetic luck will have an easier time finding donations to fund their transplant and care than 9th liver alcoholic guy.

 

[deleted480308]

Physically and chronologically they may be adults. But emotionally they are children. And I know some actual 12 year old children who have better coping mechanisms than some adult drug addicts. You are expecting their behavior to be rational and drug addicts are not rational. They are certainly not grown competent adults.

I think “expecting” may not be the right phrasing here as no one should be forcing them to act right. If they make bad decisions the consequences are theirs. I don’t need them to act right but it’s not my obligation to fix if they don’t

 

[Man o War]

Honestly i didn't even know surgeons did this. that they can just deny to operate when the surgery can save the person's life simply based on prior behavior... if they went to court, would the surgeon even win teh case?? On the medicine floor or ICU it seems like if the family want to continue full on treatment, despite high 6 month mortality, can we just say no because he's likely to die within 6 months?

Our surgeons are very selective. A rash of bad outcomes can negatively impact your program, and patient selection is a key part of obtaining good outcomes.
Our surgeons routinely deny people organ transplantation for lifestyle decisions including BMI.
I have found heart and lung transplant surgeons to be much more reasonable and discerning about who they will operate on than orthopedic surgeons. We are putting joints in morbidly obese people with resulting healing issues when we really should be making them lose weight first to optimize results. The NHS has recently started cracking down on this.

 

[GravelRider]

It’s part of the problem with a govt monopoly on this (or pseudomonopoly as govt sublets this to a particular few) as then the govt sets the rules.

I should be able to donate my organs to a group that gives alcoholics their 9th liver if I want and I should be able to give to a group that says too bad no 2nd liver if you drank your first one away.

Then let the selection criteria for recipients guide the supply and demand of donors, we’ll see if donors really want to donate to the alcoholics 9th liver.

As to cost, all patients should be responsible for their own costs or finding charities to handle it. Teen with bad genetic luck will have an easier time finding donations to fund their transplant and care than 9th liver alcoholic guy.

You can do just that with living donor kidney and liver transplants.

 

[chocomorsel]

Physically and chronologically they may be adults. But emotionally they are children. And I know some actual 12 year old children who have better coping mechanisms than some adult drug addicts. You are expecting their behavior to be rational and drug addicts are not rational. They are certainly not grown competent adults.

So does that mean that we treat them as such? As in, don't let them make their own medical decisions because they behave like children? Ask their parents for consent and such?
Whether or not they make good or bad decisions, at the end of the day, unless they are declared mentally incompetent, we should treat them as the not so smart adults that they are.

 

[chocomorsel]

Again, there's that word, "deserve" ... and the entire point of my post was that "deserve" has got nothing to do with it.

If you transplant an organ into a person with significant, active, uncontrolled mental illness you are harming that person. They are not going to be able to meticulously comply with ongoing treatment and followup, such as immunosuppression. This is worse than futile care, because you've inflicted all of the pain and risk of the transplant upon them, for essentially no benefit.

Don't look for a reason to be angry; there's enough real discrimination in the world without seeing it where it isn't.

Ok. We are all entitled to an opinion as I certainly have mine. I can see if they are not able to take care of themselves and are lone.

But you didn't address what I asked as far as they having a good support system and the financial means.

Their disqualifications seem to make assumptions and assume that they are all unable to take care of themselves and have no support.

Their statement simply states,
"Active or uncontrolled psychiatric disorders" And that's it. Seems to paint all mental health patients with the same broad strokes. I didn't look at their website to discern the fine differences if there are any like @GravelRider has stated there are. I am hoping there certainly are.

What about my statements came out as "looking for a reason to be angry?" I was posing some honest questions and giving an honest opinion.

 

[pgg]

Ok. We are all entitled to an opinion as I certainly have mine. I can see if they are not able to take care of themselves and are lone.

But you didn't address what I asked as far as they having a good support system and the financial means.

Their disqualifications seem to make assumptions and assume that they are all unable to take care of themselves and have no support.

Their statement simply states,
"Active or uncontrolled psychiatric disorders" And that's it. Seems to paint all mental health patients with the same broad strokes. I didn't look at their website to discern the fine differences if there are any like @GravelRider has stated there are. I am hoping there certainly are.

What about my statements came out as "looking for a reason to be angry?" I was posing some honest questions and giving an honest opinion.

Tone's hard to convey on the internet ... you just sounded mad about the university's discriminatory BS practice.

Active or uncontrolled psychiatric disorders is kind of vague. I suspect they're not denying people who are receiving stable treatment or those with mild personality disorders, but rather schizophrenia, bipolar, etc.

 

[chocomorsel]

Tone's hard to convey on the internet ... you just sounded mad about the university's discriminatory BS practice.

Active or uncontrolled psychiatric disorders is kind of vague. I suspect they're not denying people who are receiving stable treatment or those with mild personality disorders, but rather schizophrenia, bipolar, etc.

Ok. I will give you that.