Tuesday, July 21, 2009

Death of a 22-year old

A man in London has died of alcohol-induced liver failure at the age of 22. You may have seen reports of it in the news. Gary Reinbach died less than 48 hours after his mother had highlighted her son's plight at the weekend. Already some people are using it as a stick to beat the Obama health plan. This is what happens, they say, when the government gets involved in healthcare. This begs the question as to whether or not the government is already involved in the US health care – it is of course heavily involved, spending more on health as a proportion of GDP than the British government spends on the NHS.

However, in this case, no-one in government was remotely involved; these were clinical decisions made by the doctors involved, based on agreed guidelines within the medical profession.

More than 8,000 Britons are awaiting an organ transplant, 259 of whom require livers. More than 400 people died on the waiting list last year. There is undoubtedly a shortage of liver donors. Why? Partly because there are fewer people dying in road accidents, but also because since the outrageous fuss made by the Press some years ago over the Alder Hey scandal of retained organs (see my previous article on Morbid Anatomy), relatives are more reluctant to offer up parts of their dead and dying kin for transplant. In Spain, where consent for organ donation is presumed, they do it better.

So criticism of the government for not introducing a more transplant-favorable regime might be in order, but since supply of livers does not meet the demand there has to be rationing. How should they be rationed? It could be by price. Only rich people get transplants? Not acceptable in the UK; I don’t know about the US. At the moment it is by utility. Those with the greatest need who can make the best use of a transplant should be first in line. On the whole alcoholics are not good candidates for transplants. All they do is ruin the new liver with alcohol. Of course, some are redeemable, but alcoholics are notorious liars. Therefore doctors have introduced a test to see whether they are suitable recipients. Can they stay clean for 6 months out of hospital? If they can they are put on the list for a liver. For the truth is that if someone gets a liver transplant, someone else on the waiting list won’t and will die of their disease. A famous case involved the footballer George Best. He was perhaps the best footballer of his generation, but success went to his head and he drank himself into liver failure. He passed the test of being clean for six months and got his transplant. But having received his new organ he proceeded to ruin it with alcoholic binges. You can see why doctors don’t trust alcoholics.

Moralists might declare that if the disease is self inflicted they should be at the end of the line. We don’t make those judgments in the UK. The list is made up according to who would be likely to benefit.

Poor Gary Reinbach never stood a chance. He started drinking at the age of 11 when his parents’ marriage broke up and by 13 he was binge drinking. The roots of his troubles lie with a lax attitude to family break up and an even laxer attitude to under age drinking.

Binge drinking among young people has led to a sharp rise in deaths from cirrhosis of the liver in the 25-34 age group and hospital admissions among young people have been increasing. In 2007-8 the London Ambulance Service NHS Trust dealt with 8,126 alcohol-related calls for 11 to 21-year-olds, a 27% increase on 2004-5.
The regulation of alcoholic drinks has been heavily influenced by the Portman Institute, a front organization for the alcohol manufacturers. The government is highly reliant on taxes on alcohol. They ignore recommendations from the Chief Medical Officer. This is where I hold them culpable. If the same strict policing of alcohol availability were available in the UK as is present in the USA or better still in Canada, problems like that of Gary Reinbach would not exist.


Burke said...

I would like to ask you about a hypothetical ethical situation, doc.

Suppose a man with a family is dying, and suppose his family will be left destitute without his support. Suppose further that there is a rich man who badly needs a liver and who is willing to pay him a large sum of money for his liver. Suppose the dying man wishes to sell his liver so his family will have money to live on after he dies.

Why should it not be legal for the rich man to buy the dying man's liver?

Why should there be laws against the sale of body parts?

It's my impression that both the Religious Right and the Collectivist Left oppose the selling and buying of bodily organs--the religious, because it's against their religious beliefs, and leftists, because they regard people as social assets whose lives and parts are owned by the "collective," to be disposed of "in the public interest."

It appears to me that refusing to allow people to use their resources to live in such cases both literally and morally murder.

What do you think?

Terry Hamblin said...

I don't personally have any problem with somebody selling his liver after he has died, but I do think it would be wrong for hime to commit suicide by transplant. In India it is legal and quite common to sell their skeleton after they have died for the use of medical students.

There is no real difference between this and selling blood. The moral principles involved are the same, but in fact selling blood has unforseen consequences - people lie if hey are desperate and consequently we have donors giving more than is safe and the spread of infectious diseases by blood since the blood banks are also motivated by money also lie.

Watch the movie "Dirty Pretty Things" by Stephen Daldry to see the possible consequences of a market in organs.

Anonymous said...

The issue of alcoholism and it's cost to any society is a very complicated matter.

While in training at a large county hospital in the US I encountered virtually every imaginable permutation of the complications of alcoholism. I also must admit that these alcoholics served as an amazing learning platform for the teaching of medical diagnostic skills, skills required for acute medical care (such as intubation, central line placement, chest tube insertion, etc) and also as a means to hone one's skills in dealing with people.

Alcoholism continued to play a major role in disease management in my private practice, though it has never been as prevalent as it was in the indigent population served during my training days.

I have never had an alcoholic succeed in staying sober long enough to protect his new liver and it is unnerving to watch others die from liver disease for want of a transplant.

Having said that, I must admit that i enjoy drinking wine almost every evening and doubt that any governmental prohibition would succeed any more than it did in this country in the 1920s.

For some of life's problems there do not seem to be answers in this world.


Terry Hamblin said...

I don't advocate prohibition, but it is so easy for young people to buy alcohol in the UK. Supermarkets sell it as a loss leader and you often see young shoplifters taking it off teh shelves. Smaller shops do not bother with ID and ID is often faked. Plus you can import it tax-free from France or on booze cruises.

Anonymous said...

Dear Terry,

I am no expert, but seriously doubt that cost/availability makes very much difference. At it's roots lie individual (likely metabolic) tendencies complicating a failing society.


Burke said...

I still wonder, doc, if we would be seeing this were the patient a prominent person, say, a member of the Royal family, a politician or his relative.

I don't for a MINUTE think people of influence will be standing in line with the rest of us here in the US if we enact a socialistic system. I recently read, for example, that Congress is not going to give up the medical plan it has for its members in any of the plans being proposed here now.

Terry Hamblin said...

There are certainly proven links between tobacco consumption and price, and I believe between alcohol consumption and price. As far as availability is concerned, how does an 11 year old get alcohol? It is just to easy to get alcohol compared with the US or Canada.

There probably is a genetic tendency to become an alcoholic. Innuits, Native Americans, Australian Aborigenes, Irish and Scots all seem more prone. But many of these races don't become alcoholics.

Terry Hamblin said...

Even under the NHS people can still elect to have private medicine. If they can get a donor liver from India I dare say they will find someone to transplant it for them. However, I see that the Pope stood in line to get his wrist X-rayed recently.

Goosey said...

At a recent palliative care study day we were warned that there may be a sharp rise in Head and Neck cancers in the next few years due to binge drinking. Sobering stuff if it's right.

Anonymous said...

It is difficult to get alcohol underaged in the US. When I was a kid, some of us (not me) would approach men walking into the liquor store and ask them to buy booze for us. It might take one or two tries, but we never failed.

Now, that is almost impossible. The Alcohol Beverage Control runs stings where they have people who look underage (usually cute girls) ask men to buy alcohol. Then they get caught and face hefty fines and a police record. Few are going to risk that today.

Of course, kids can steal it from their parents. We used to take small amounts from our parent's liquor cabinet, mix it in soda bottles, and drive around drinking. Terrible sounding now, but we never drank enough to be affected.

We replaced the alcohol with water. I often wondered if my dad or mom every noticed their nightly drink didn't seem to pack the same punch as years ago.