The limits of philosophy in liver transplantation

The dual role dilemma of liver transplantation health care professionals

BACKGROUND

Similar to many other countries, in Germany patients with alcohol-related liver disease are obliged to prove their abstinence before being accepted on a waitlist for liver transplantation. Health care professionals (HCPs) must both treat patients and ensure that patients have proven their abstinence. The aim of this exploratory study was to develop a deeper understanding of how HCPs deal with this dual role.

METHODS

The study used semi-structured interviews as the source of data. 11 healthcare professionals from ten of the 22 German transplant centers were interviewed. After transcription, a qualitative content analysis was performed.

RESULTS

We found that these HCPs faced an ethical dilemma, as they must balance the roles of being both a treatment provider (the therapist role) and an assessor (the monitoring role). To solve this dilemma, the strategy seems to be a tendency for the HCPs to take on one dominant role amongst these two roles. HCPs who prefer to take on the therapist role seem to feel burdened by the 6-month abstinence rule and the obligation to monitor their patients. HCPs who prefer to take on the monitoring role tend to have negative assumptions about the patients. HCPs also reported the impression that patients perceive HCPs as more involved in monitoring and less open to the therapeutic role. From this it can be deduced that current regulations and structures lead both to stress for HCPs and to suboptimal therapy for those affected.

CONCLUSIONS

The results showed that current transplantation guidelines can have a negative impact on both patient care and the burdens on the HCPs. From our point of view, there are various changes that could be made to the current clinical practice that would help solve this dilemma. For instance, integrating other assessment criteria that are more closely adapted to the health status trajectory and psychosocial background of the individual patient would be both possible and would lead to improvements in practice.

Ethical issues associated with solid organ transplantation and substance use: a scoping review

While solid organ transplantation for patients with substance use issues has attracted ethical discussion, a typology of the ethics themes has not been articulated in the literature. We conducted a scoping review of peer-reviewed literature on solid organ transplantation and substance use published between January 1997 and April 2016. We aimed to identify and develop a typology of the main ethical themes discussed in this literature and to identify gaps worthy of future research. Seventy articles met inclusion criteria and underwent inductive content analysis. Four main ethical themes were identified: (1) personal responsibility; (2) utility; (3) moral character; and (4) fairness. Each theme had multiple sub-themes and there was substantial overlap between themes. This scoping review identified a disproportionate emphasis in the literature regarding personal responsibility, which was referenced by each of the other themes, and a narrow focus on alcohol and liver. We recommend future research further investigate these connections between ethical themes and focus on ethical issues associated with transplants from organ groups other than liver for patients who use substances other than alcohol.

Drinking in the last chance saloon: luck egalitarianism, alcohol consumption, and the organ transplant waiting list

The scarcity of livers available for transplants forces tough choices upon us. Lives for those not receiving a transplant are likely to be short. One large group of potential recipients needs a new liver because of alcohol consumption, while others suffer for reasons unrelated to their own behaviour. Should the former group receive lower priority when scarce livers are allocated? This discussion connects with one of the most pertinent issues in contemporary political philosophy; the role of personal responsibility in distributive justice. One prominent theory of distributive justice, luck egalitarianism, assesses distributions as just if, and only if, people's relative positions reflect their exercises of responsibility. There is a principled luck egalitarian case for giving lower priority to those who are responsible for their need. Compared to the existing literature favouring such differentiation, luck egalitarianism provides a clearer rationale of fairness, acknowledges the need for individual assessments of responsibility, and requires initiatives both inside and outside of the allocation systems aimed at mitigating the influence from social circumstances. Furthermore, the concrete policies that luck egalitarians can recommend are neither too harsh on those who make imprudent choices nor excessively intrusive towards those whose exercises of responsibility are assessed.

Liver transplantation for alcoholic liver disease

Patients with end-stage alcoholic liver disease should be considered for liver transplantation. A careful pretransplant evaluation must be undertaken to assess for both medical and psychiatric factors that will continue to require attention following transplantation. Although most programs require at least 6 months of ethanol abstinence before consideration of liver transplantation, there is little evidence that this conclusively predicts a reduction in recidivism. Most programs continue to exclude those with alcoholic hepatitis. Postoperatively, attention to psychiatric issues, recidivism, compliance, and assessment for tumors, especially squamous cell carcinomas, should be undertaken.

Developing a Brief Monitoring Procedure for Alcohol-Dependent Liver Graft Recipients

To address the occurrence of deaths in later postoperative years among alcohol-dependent liver graft recipients, the authors developed the Brief Active Focused Follow-Up protocol as an instrument for monitoring alcohol use following liver transplant. In this preliminary study, patient receptiveness to its use was tested and its ability to identify patient drinking was noted. Alcohol-dependent liver transplant recipients (N=24) and alcohol-dependent nontransplant patients (N=25) were asked to rate their receptiveness to the Brief Active Focused Follow-Up in three areas. Subjects used a five-point scale for which 5 indicated the highest positive response. Liver transplant recipients responded positively to the Brief Active Focused Follow-Up, with mean responses of 4.92, 4.08, and 4.63 with regard to clarity, usefulness, and ease of completion, respectively. Nontransplant subjects responded similarly, with mean responses of 4.88, 4.12, and 4.52. The two groups were not significantly different in their receptiveness to the Brief Active Focused Follow-Up interview. The Brief Active Focused Follow-Up identified alcohol use within the last 30 days: 8% (N=2 of 24) in the transplant group, and 56% (N=14 of 25) in the nontransplant group. These results suggest that 1) this manualized, brief monitoring technique is well received by alcohol-dependent liver transplant patients, and 2) the Brief Active Focused Follow-Up's "user friendliness" makes it a potentially appropriate instrument for long-term monitoring of alcohol use among alcohol-dependent liver graft recipients.