A healthcare/philosophical question

[Art Shirk]

I didn't watch, nor do intend to watch, Sicko, so I am not sure if this has been discussed to length in some Michael Moore thread, or the like but...
I have a friend who just told me that her father-in-law was diagnosed with stage 4 cancer in the liver. This is a man who has drank heavily for decades, knowing full well what he was doing to himself and those around him. He is now in his mid-sixties.

Apparently, he has been moved to the "top of the list" for a new liver. This is all second-hand, and I have no intimate knowledge of the healthcare system, but I assume his urgent status and short-cut is based almost wholly upon his life expectancy. Is this the correct variable to focus on?

What factors should be considered for priority? Who should get to decide what they are (this may be more obvious)? Is this a discussion that is already occurring? Should it?

Personally, I can't help but think this is unjust, but the can of worms alternative seems to involve a potentially overreaching and paternalistic system to decide who lives and who dies based upon a person's individual life choices.

The man/woman who treats his/her body like a temple and has years to contribute may be pitted against the man/woman who dismisses the value of life for years. The second person seems to win.

[Cliff Huckable]

I didn't watch, nor do intend to watch, Sicko, so I am not sure if this has been discussed to length in some Michael Moore thread, or the like but...
I have a friend who just told me that her father-in-law was diagnosed with stage 4 cancer in the liver. This is a man who has drank heavily for decades, knowing full well what he was doing to himself and those around him. He is now in his mid-sixties.

Apparently, he has been moved to the "top of the list" for a new liver. This is all second-hand, and I have no intimate knowledge of the healthcare system, but I assume his urgent status and short-cut is based almost wholly upon his life expectancy. Is this the correct variable to focus on?

What factors should be considered for priority? Who should get to decide what they are (this may be more obvious)? Is this a discussion that is already occurring? Should it?

Personally, I can't help but think this is unjust, but the can of worms alternative seems to involve a potentially overreaching and paternalistic system to decide who lives and who dies based upon a person's individual life choices.

The man/woman who treats his/her body like a temple and has years to contribute may be pitted against the man/woman who dismisses the value of life for years. The second person seems to win.

the system decides who lives and who dies based on

$

If you disagree, and I doubt you do, there's loads to read - but the Texas Advanced Directives Act is the most nauseating example...George W's very un-Christian contribution to dehumanization.

[Jim S]

1. It's unjust

2. Nobody with stage IV liver cancer gets a liver transplant. Nobody.

[timnormandin]

Liver cancer is not caused by excessive drinking per se.

[Jim S]

Liver cancer is not caused by excessive drinking per se.

It is most definitely associated with it. Hepatocellular carcinoma risk is increased with excessive and frequent alchohol intake. The risk is greater with some forms of viral hepatitis for sure, but alcohol does increase the chance compared to those who don't drink.

[Adolf Allerbush]

the system decides who lives and who dies based on

$

If you disagree, and I doubt you do, there's loads to read - but the Texas Advanced Directives Act is the most nauseating example...George W's very un-Christian contribution to dehumanization.

I'm sure you're right but there are instances where this isn't the case. Take Walter Payton for example.

Nevermind...his was inoperable

[davep]

I had a roomate a few years back who did just what you're asking: decide who gets liver transplants. She had some kind of a psych/social worker background, and she interviewed potential liver recipients and their families to see if they had the support they needed to survive after their transplant, and (if the liver failure was caused by substance abuse) determined if they had quit drinking/drugs, whether they were likely to relapse and destroy the new liver, etc.

So in principle the guy you described would be eligable if he had quit drinking. I don't think they hold it against you if you caused your own liver failure, they only try to assess the risk that it'll fail again.

I think her just was just a 'yes, eligable' or 'no, ineligable' call, and I'm not sure how they decide the waiting list order after that.

[timnormandin]

It is most definitely associated with it. Hepatocellular carcinoma risk is increased with excessive and frequent alchohol intake.

Jim, I said "per se". There are many types liver cancers. I personally know of two people who have died from liver cancer and drank not one little bit. I'm not trying to be a dick, and I'm not arguing that excessive boozing--though this board often takes delight in it--is safe. I'm saying that we don't know if the man in question destroyed his own liver.

[Tri-Ungulate]

1. It's unjust

2. Nobody with stage IV liver cancer gets a liver transplant. Nobody.

1. True.
2. Precisely.

[deliberate]

I support universal healthcare paying for it with a sin-tax on alcohol, tobacco, and preprocessed (fatty) foods. This way the people that need the most healthcare pay the most for it over their lifetime.

[Jer]

Also a tax on people who stress too much. and work too much. and stress others out too much. And people with genetic predispositions for high blood pressure, obesity, cancer, violence, and stupidity.

[Trackhead]

I'm going to go to McDonalds for every meal, for the next 15 years. Then I'm gonna get all you hard working, healthy living, tax payers to pay for my Gastric Bypass.

I'll thank you ahead of time.

[nick > jesus]

if you are going to look at this as a "good for humanity" and "good for the planet" standpoint the most morally right thing to do would be to give no one heath care

[Tri-Ungulate]

I'm going to go to McDonalds for every meal, for the next 15 years. Then I'm gonna get all you hard working, healthy living, tax payers to pay for my Gastric Bypass.

I'll thank you ahead of time.

I'm gonna do this thing called Extreeeeam Backcountry Skiing as much as I can, for the next 15 years. Then when I do a Superman headfirst into a rock, I'm gonna get all you hard working, healthy living, tax payers to pay for my subdural hematoma evacuation.

I'll thank you ahead of time.

[Cyber Cop]

Also a tax on people who stress too much. and work too much. and stress others out too much. And people with genetic predispositions for high blood pressure, obesity, cancer, violence, and stupidity.

So you're going to pay for our healthcare. sweet.

[Trackhead]

I'm gonna do this thing called Extreeeeam Backcountry Skiing as much as I can, for the next 15 years. Then when I do a Superman headfirst into a rock, I'm gonna get all you hard working, healthy living, tax payers to pay for my subdural hematoma evacuation.

I'll thank you ahead of time.

Not sure how good your evacuation will go, considering you'll be in line, behind me. But I'm sure the government will get that bugger out right around the time you herniate.

See, I'll be occupying most of the resources with my post operative complications.

Disclaimer:The idea of socialized medicine bothers me, perhaps from my skewed daily perspective on the abuse of what current social programs we have. Hence, my sarcasm. I'm all for socialized medicine, in theory, but I have my doubts. And I feel those who would bend over backwards for a comprehensive social program should also take a moment to consider other perspectives that they don't encounter in their daily lives.

[Adolf Allerbush]

Disclaimer:The idea of socialized medicine bothers me, perhaps from my skewed daily perspective on the abuse of what current social programs we have. Hence, my sarcasm. I'm all for socialized medicine, in theory, but I have my doubts. And I feel those who would bend over backwards for a comprehensive social program should also take a moment to consider other perspectives that they don't encounter in their daily lives.

I'm skeptical as well but as the wealthiest country in the world I think it's pathetic that there are impoverished people out there that struggle to get health care in our current system. I'm not sure what the answer is but something needs to be done.

[Trackhead]

I'm not sure what the answer is but something needs to be done.

It's too complex for me to come up with any reasonable solutions.

Currently, from what I see, this is who has socialized medicine in America.

1. Elderly: At a qualifying age, they get some level of medicare coverage. Many near retirement individuals delay retirement ONLY because they can't afford private healthcare, and medicare isn't active for them yet. Bummer.
2. Military: Tri-U would know better than I. But even our military is getting screwed with benefit cuts. So you can serve your country for pennies, but you still get screwed in the end.
3. Low Income: Qualifying based on income. Many who are pretty damn poor still don't qualify for medicaid. But unfortunately, many who do blatantly abuse it every day by seeking non-emergent health care in Emergency Rooms instead of making appointments with family physicians.

The uninsured are middle income, often self employed who can't afford private healthcare, but are paying for the existing social programs and gaining no benefit. They are the ones with huge hospital bills, collection agencies after them, etc.

So I'm babbling. I don't know the answer. Maybe someone can enlighten me with sound facts.

[AKPogue]

Trackhead I agree with you that I think that some kind of healthcare for everyone would be great. But everything that I have seen the government run has sucked. I haven't seen anything that really works well that is run by the government. That includes the Military Healthcare Tricare. I have been on both ends as far as working in the military healthcare system and been a patient. It sucks.

Really don't have an answer for what to do on this.

[zion zig zag]

Disclaimer:The idea of socialized medicine bothers me, perhaps from my skewed daily perspective on the abuse of what current social programs we have. Hence, my sarcasm. I'm all for socialized medicine, in theory, but I have my doubts. And I feel those who would bend over backwards for a comprehensive social program should also take a moment to consider other perspectives that they don't encounter in their daily lives.

I just don't see it, the abuse I mean. Everyone in the er, especially those that come in an ambulance, need urgent care.

[Jim S]

But everything that I have seen the government run has sucked. I haven't seen anything that really works well that is run by the government. That includes the Military Healthcare Tricare. I have been on both ends as far as working in the military healthcare system and been a patient. It sucks.

Thank you.

[Benny Profane]

Grow up to play center field for the New York Yankees and hit a lot of home runs and be the Great White Hope in the time of Willie Mays and Hank Aaron. That'll get you preferential treatment later in life, even if you had a double vodka for breakfast to start every day.

[bucbanzai]

Google is your friend.....

http://www.miracosta.edu/home/lmoon/allocate.html

There are many complex, ethical issues related to the allocation of human organs. This is one of the scarcest of medical resources. How can organs be fairly and equitably allocated? Who keeps the list, and what are the criteria? Are there non-medical criteria? Should there be?

There is not one waitlist, but many. The United Network for Organ Sharing now unifies the lists and suggests allocation criteria, but each transplantation center keeps its own list and makes its own criteria, generally based on the UNOS criteria. There is some justification for each transplantation center keeping its own list, as people who live closest to the transplantation center have the best chance of putting a useable organ to use. Cold ischemia time, the time from the start of perfusion to the reconnection in a new person, varies depending on the organ, but is generally quite short. Organs also tend to deteriorate within the body the longer someone is braindead. So, when an organ donor is identified as brain dead, it is important that the appropriate recipient also be identified quickly.

Organ transplantation centers try to have criteria that are solely medical, but this is very difficult in practice. If someone is indigent or homeless, the chances that she or he will be able to survive after a transplant are very low. Transplants require long recovery periods, and once recovered a transplant patient must continue to take large dosages of powerful immunosuppressants for the rest of their lives. In addition, most suffer repeated bouts with organ rejection and must be hospitalized and treated each time. Proper nutrition and a daily schedule that allows for rest, shelter, and regular medical care is needed for an individual to be a good candidate for transplant surgery. Thus, the non-medical becomes medical all too easily.

Worries about allocation take two main forms. Some are worried that the criteria for allocation are unfair, because the rich and famous seem to "jump" the waitlist. Others worry that allocating organs to those who have destroyed their own organs through misuse (e.g. alcoholics who need liver transplants) and/or allowing prisoners to receive donated organs is both an injury to those who need organs but cannot receive them because their places on the waiting list are not high enough, and a disincentive to donate, knowing that your organs may go to someone who is somehow responsible for his/her own organ deterioration.

The 1995 case of Mickey Mantle's liver transplant was worrisome to many on both accounts. Mantle, a famous baseball player, was 63 years old, and had spent 43 years as an alcoholic. Although he had been recovering from his alcoholism for a year and a half, his liver was ruined due to both alcoholism and hepatitis C. The hepatitis C was believed to have been contracted from a blood transfusion he received during surgery for a sports-related injury, but may have been contracted during a life-time of drunken womanizing, as well. In addition, he had a tumor in his liver, called a hepatoma, which compressed his bile duct. Although the average wait time on the list to receive a liver in 1995 was three to four months, Mantle received his in a day. However, though the tumor in his liver had not been cancerous, the underside of his liver did have cancerous cells. The transplant went ahead as planned, but the cancer then spread to his lungs, and Mantle died 3 months after his transplant. Critics charged that Mantle was only given a liver so quickly due to his public prominence. Others charged that he should not have been given a liver because of either his alcoholism or his cancer, both of which are reasons not to place someone on the list at some transplant centers.

First, let us address the issue of whether Mantle did, in fact, receive favortism. He did not. His case was treated the same as anyone in the same condition at the same transplant center would have been treated. In fact, the day after his surgery, another liver donor who would have matched Mantle was identified, but there was no one on the center's waitlist to receive the liver, so it was transferred to another center. This center also took patients who were recovering from alcoholism. They did not routinely take patients who had cancer, but no test had shown that Mantle's liver was cancerous prior to its removal, nor could they have shown this, because the cancerous cells were behind the liver, where the testing instruments do not reach.

There is a further question whether someone like Mantle should receive a special place on the waitlist. In fact, since patients can get themselves on more than one waitlist, rich people who can afford to apply in more than one place do have some advantages. They can get their names placed on more than one waitlist, or they can move to the area where people with the conditions they evince are accepted on the waitlist. One might argue that giving a transplant to a famous person would encourage others to donate. Mantle did television commercials encouraging donation. There is also a Mickey Mantle Foundation set up to encourage organ donation. Just as species preservation organizations, like the San Diego Zoological Society argue that they should preserve attractive and interesting species, even when there is not sufficient diversity among the species members or habitat left into which the species could be reintegrated, because that attractive species brings in donations that can further more useful work, Mantle's doctors could argue that giving an organ to a very famous man who had little chance of making years of use of the organ could still be beneficial in raising awareness of organ donation and encouraging people to donate their organs so that others may be saved.

In Mantle's case it is most likely that his liver was deteriorated mostly by Hepatitis C which he most likely contracted through a blood transfusion during knee surgery. However, should people who are alcoholics receive transplants, even when they are in recovery? Many transplant centers take former alcoholics as patients. In the 1970s and 80s they were less likely to do so, because it was believed that alcoholics would have worse survival rates. Since then, in study after study alcoholics have fared as well as or better than those whose livers had been ruined by other means. Since they do not fare any worse than non-alcoholics, the decision not to give a liver transplant to a recovering alcoholic must be a non-medical decision. However, if we are going to give transplants only to those who had no hand in their problems, then we would have to say that people who need heart transplants must not have been work-a-holics, cigarette smokers, or have had poor dietary habits. When someone needed a liver transplant due to hepatitis C, we would have to explore the way in which the hepatitis C was contracted to see whether any choice was involved.

The first principle of allocation is always making the best use of the organ, saving a life that is in immediate danger, yet has a great deal of possibility for long-term survival. More recently, two cases in which organs were accidentally allocated to people who were not the right blood type for the organ have come to light. As there are no statistics kept on this, no one knows how often this has occured. A single waitlist with a single set of criteria might help in insuring that organs are most efficiently allocated.

[Trackhead]

I just don't see it, the abuse I mean. Everyone in the er, especially those that come in an ambulance, need urgent care.

Coming from you, I'll take that as a bwahahahahaha!

See you on your next 3am wake up call for the whaaaambulance.

[haydukelives]

but here the welfare folks know that for them an ambulance costs less than a taxi. for them its free, for you its $100 a mile.