The Tricky Ethics of Transplants for Addicts
Many programs require liver recipients to be six months sober, but that policy may funnel organs away from the people they’re most likely to help.
“How many of you think we should do liver transplants for alcoholics?”
About half the hands were slowly raised, while the other members of the class looked around nervously. These were third-year medical students, and I was giving my monthly lecture on organ transplantation.
“How many of you think the potential recipient should have six months of absolute sobriety before being offered a transplant?”
This time, the majority raised their hands, and a look of confidence could be seen on most of the students’ faces.
“But what if they won’t live six months? What if the patient is a 37-year-old mother of three, or a 26-year-old college graduate who didn’t realize the damage he was doing to his liver? Would you stand over the young man, with his parents watching, and tell him you could save him but you’ve decided he doesn’t deserve it?”
I continued: “How many of you think alcoholism is a disease?” Almost everyone raised his hand.
“What do you think the recurrence rate of this disease is after liver transplantation?”
A few people guessed about 20 percent, which is roughly accurate.
“How many of you think hepatitis C is a disease?”
Everyone.
“And the recurrence rate of that after transplant?”
One hundred percent.
In the early days of liver transplantation, saving patients with alcoholic liver disease was generally considered an inappropriate use of such a limited resource. Yet now that the practice has been supported by data showing that outcomes for these transplants are as good as or better than outcomes for other diagnoses, the policy has changed.
Many programs require candidates to have been abstinent for at least six months. The rule, which has been widely adopted at transplant centers around the country, came from a retrospective study of 43 patients who underwent transplant for alcoholic liver disease. In this analysis, abstinence for less than six months prior to transplant was considered a risk factor for recurrence.
Multiple further studies have been equivocal on the specific length of abstinence required to reduce recidivism, or return to alcohol use post-transplant. To add to the confusion, a recent study from France showed that well-selected patients with a diagnosis of severe acute alcoholic hepatitis did just as well with transplant and had a similar recurrence rate as those who had abstained for six months.
Before he found out he needed a new liver, Herbert Heneman was not your typical corner-of-the-dive-bar alcoholic. Heneman, the Dickson-Bascom professor emeritus of management and human resources at the University of Wisconsin–Madison, grew up in St. Paul, Minnesota. He had a happy childhood and a very supportive family. He describes his parents as somewhat heavy drinkers, particularly his father, but he remembers no health issues, legal problems, or family crises related to alcohol.
After Heneman finished college, he began graduate school and married his high-school sweetheart. Everything was falling into place.
Heneman doesn’t remember a specific time when he suddenly increased his drinking. He doesn’t remember a dramatic liftoff. Alcohol just slowly started to permeate everything he did. He started hiding his drinking from his wife and kids, and drinking alone. He found himself getting sick more often, episodes he described as the flu, or exhaustion, or general weakness. Eventually, his physician told him it was his drinking that was causing his health problems, but Heneman didn’t buy it. He knew he could stop if he wanted to.
On Labor Day 1990, Heneman was hammered at a party—stumbling, sweating, and generally not looking well. A nurse who happened to be there thought he was having a heart attack, and an ambulance was called. En route to the hospital, a blood-alcohol level was taken, and it came back at 0.375. Heneman was placed in detox, and from there he went to a 28-day inpatient rehab program. He was sober for the entire four weeks and told everyone there he was committed to sobriety. He relapsed the first day out.
About two weeks later, Heneman went to detox again. Once he was sober, he agreed to be committed as an inpatient to the McBride Center for the Professional, a branch of the Milwaukee Psychiatric Hospital where patients with successful careers can be treated for their addictions. In a regular rehab facility, it is too easy for people of Heneman’s social status to look at the people around them who are also struggling with addiction, especially if they are from a different walk of life, and say, “I’m not like them. I can control this.”
Even so, at McBride, Heneman resisted. He didn’t really want to participate in the group sessions; he just wanted to read about alcoholism and beat this thing using his own brain.
“On a Sunday morning,” he told me, “I went to a little interdenominational church service that was being held in the hospital. And as I walked in the door, this woman began playing ‘Amazing Grace’ on the piano. And that was my true turning point.” Heneman owned up to his alcoholism and spent three months as an inpatient.
At the same time, he was diagnosed with cirrhosis. After Heneman was released from the psychiatric hospital, he found himself in the office of Münci Kalayoğlu, a transplant specialist. Münci told Heneman that if he was able to stay sober for a year, he would perform the transplant. But there was a catch: “If you ever, after your transplant, go out and drink again,” Münci said, “I’m going to come over to your house with my pocketknife and take back the liver.”
Heneman has grasped the fact that his alcoholism will never be “cured.” It is always lurking, ready to come back with a vengeance. “The other thing that really helps keep me sober is that I was so fortunate to receive a transplant, particularly back then. It would be an absolute dishonor to my donor family for me to go out and drink again and somehow do any damage to my liver.”
After his transplant, Heneman had one brief readmission for a rejection episode. Otherwise, he has had no problems with his transplanted liver for more than 25 years. I asked him how the transplant changed his outlook on life. “I think it changed it much for the better,” he said. “I’ve led a much fuller life than I otherwise would have.”
I asked for Heneman’s thoughts on transplanting patients with acute alcoholic hepatitis, patients who clearly can’t survive a waiting period of sobriety prior to transplant. He said, “My own experience was very much that recovery needs to be a very serious, lifelong commitment, one day at a time, and that people who try to go it alone are not very likely to succeed.”
This post is adapted from Mezrich’s new book, When Death Becomes Life: Notes From a Transplant Surgeon.