Medical Ethics & Alcoholic Liver Disease
Alcoholic liver disease (ALD) is the most common form of chronic liver disease in the world. Tackling ALD will require a combination of harm-reductive policy and best practice in medicine. The most advanced stage of ALD is cirrhosis and end-stage liver disease (ESLD), characterised by irreversible damage to the liver. The definitive treatment for ESLD is liver transplantation; however, the limited supply of donor livers has created controversy around the topic of liver transplantation for self-inflicted diseases. For this reason, criteria and scoring systems are used to prioritise those who are most likely to benefit from liver transplantation, which aim to help provide a fair legal and ethical basis for allocating the scarce supply of livers to an ever-growing list of patients.
The British Society of Gastroenterology’s (BSG) criteria for liver transplantation considers referral in liver disease patients who develop any of the following features: hepatic encephalopathy, jaundice, variceal haemorrhage, or ascites. A UK Model for End-Stage Liver Disease (UKELD) score is then calculated to assess suitability for referral – a score >48 indicates a survival advantage with liver transplantation. NICE guidelines recommend referral to alcohol services for those who continue to drink, as engagement with the addiction team is mandatory for liver transplant assessment. Those who have been abstinent for <3-months but engage with addiction services can be referred if there is a risk of disease progression or a high 3-month mortality risk.
Medical ethics refers to the application of rules, principles, theories, and guidelines in a clinical setting. The four principles of medical ethics are: respect for autonomy, beneficence, non-maleficence, and justice. These principles provide a universal framework for decision-making when reflecting on moral issues that arise in a clinical environment. This piece aims to highlight the disparity between the principles of medical ethics and the British Society for Gastroenterology’s criteria for liver transplantation assessment and application.
Beneficence & Non-Maleficence
The concept behind beneficence is to provide treatment that benefits the patient. This means the basis of any decisions made for the patient should revolve around enhancing patient wellbeing. Clinicians have an ethical obligation to provide good treatment to all patients. Non-maleficence is the obligation to not inflict harm on patients. This goes hand-in-hand with beneficence, in that clinicians have an ethical obligation to provide good treatment to all patients and prevent procedures which will cause them harm. The criteria put in place allow us to determine the indication for liver transplantation and the survival benefit of the procedure. If a patient meets the criteria, personal beliefs and opinions should not impact treatment options.
Previously, criteria for liver transplantation included a 6-month abstinence period, which was mandated to reduce recidivism and allow time for liver recovery. Research on this issue is contradictory. There is evidence of reduced recidivism in alcoholics undergoing liver transplantation (27). Studies found a lower rate of relapse in patients who had abstained from alcohol before liver transplantation (16%) compared to those who did not abstain (41%). This suggests the abstinence rule can be used to reduce ethical dilemmas when deciding if a patient deserves a liver, as those who engage with addiction services are less likely to self-inflict damage post-transplantation.
Other studies have found no difference in relapse rate among 118 participants, regardless of abstaining or not, and there is evidence patients with ESLD have a high 3-month mortality rate ranging from 60%-90% within one year. These findings suggest the abstinence rule may cause more harm than benefit in ESLD patients. Based on these studies, in addition to violating the principle of beneficence, the abstinence rule also contradicts the pillar of non-maleficence as the time patients are required to abstain from alcohol is long enough for the disease to progress. This sequentially causes harm to the patient which goes against the principle of non-maleficence.
Autonomy & Justice
Autonomy is the principle that gives all patients the right to make decisions and live according to their values, regardless of whether their choices are deemed to be detrimental to health. By this definition, patients who have capacity should be able to determine what treatment they receive, irrespective of the clinician’s personal beliefs.
Substance-use disorder patients bring about challenges for clinicians when determining capacity. This is due to factors such as symptoms of withdrawal and relapse needing to be considered. It is particularly difficult to measure capacity of alcoholic patients given the cognitive symptoms of alcohol withdrawal, which include confusion, memory loss, and confabulation. For this reason, the autonomy of patients must be compromised to a degree in the cases of substance-use disorder patients. Cognitive symptoms of alcohol withdrawal inhibit a patient’s capacity to make rational and informed decisions resulting in the need for paternalistic action from practitioners in circumstances where patients are deemed unfit to determine what is in their best interest.
Justice is the principle of treating all patients equally, including the equitable distribution of resources. The allocation of resources is an ethical dilemma when it comes to the scarce supply of livers, particularly when treating self-inflicted diseases. Hence, organ allocation is based on urgency and survival benefit, calculated using the UKELD score.
The abstinence rule imposes another ethical dilemma, however, as the requirements of justice changes between alcoholic and non-alcoholic liver disease patients. Justice for ALD patients requires that they will have to abstain from alcohol for at least 3 months, whereas justice for all other liver disease patients requires that they are prioritised based on those with greatest need for transplantation. Justice is maximised when allocating donor livers to indicated patients, as opposed to leaving the decision to a clinician, who may have a biased opinion on transplantation in patients with a self-inflicted disease. A consistent understanding of justice would suggest the only reason alcoholics should be given lower priority for transplantation is through a poor transplant prognosis. This suggests the current criteria leaves room for clinician bias. This means that current criteria may need further development to eliminate clinician bias.
Ethical Implications
Although the current criteria aim to reduce ethical issues when allocating donor livers, in the context of a self-inflicted disease, other ethical dilemmas arise which are not accounted for. These include clinician bias, harm to the patient, and injustice regarding resource distribution.
Transplant centres have a responsibility to ensure candidates are evaluated without the stigma surrounding ALD patients. The ideology of liver transplantation being better suited to patients who do not have a self-inflicted disease, such as primary sclerosing cholangitis, is based on people taking responsibility for their own health. Other diseases, such as non-alcoholic steatohepatitis (NASH) could be argued to have a self-inflicted basis due to excess calorie intake, resulting in metabolic syndrome and subsequent NASH cirrhosis. However, there is much less debate about the ethics of providing liver transplantations for NASH patients compared to the ethics of considering ALD patients for liver transplantation.
Furthermore, studies have shown a genetic basis for alcoholism. This means the belief in ALD being entirely a self-inflicted disease is less valid than initially thought, putting the relevance of abstinence when selecting candidates for liver transplantation into question. Mounting evidence suggesting no improvement in liver function with abstinence in ESLD patients, alongside the risk of disease progression during this period, indicates the need for re-evaluating the BGS’s criteria for liver transplantation. Revision of the criteria should include ways of practising liver transplantation assessment in a more beneficial and just manner for this patient population, with a focus on addressing the issues raised in this piece.