Editorials

Psychosocial factors in selection for liver transplantation

Need to be explicitly assessed and managed

George Masterton , consultant psychiatrist. 
Department of Psychological Medicine, Royal Infirmary of Edinburgh, Edinburgh EH3 9YW

The findings of an opinion poll commissioned to examine liver transplant selection preferences among the general public, general practitioners, and gastroenterologists were published in the BMJ last year.¹ Vignettes of eight potential candidates were given; four livers were available. The constituencies agreed the bottom of the pecking order - a prisoner, preceded by a man with alcoholic liver disease - but if only two candidates were to be chosen, those selected by the specialists (a teenager with an impulsive paracetamol overdose and a woman who had acquired viral hepatitis through drug abuse 20 years before) differed from the public's choices (a baby and a pregnant woman with a cancer that offered little hope of prolonged life). The authors concluded that selection was more emotionally driven for the public, although varying degrees of prejudice is perhaps a more accurate description. In the face of such apparent prejudices not being confined to the public, what can we do to ensure that livers are allocated "fairly"?

The scenario may have been artificial, but it did reflect the reality that demand will increasingly outstrip supply of livers: the latest figures show a 23% increase in the waiting list against no change in the number of transplants during the first quarter of 1999 compared with 1998.² Despite measures to eke out resources such as using living donors and split grafts, the waiting list is set to grow, condemning patients and their families to this awful limbo and leading to more deaths and withdrawals as the wait lengthens.

So if the list is to be contained to a humane length, which patients should be selected? Science is of limited help, the best available evidence coming from cohort follow up studies. Except for patients with malignancy and hepatitis B, who fare worse, and those with primary biliary cirrhosis, who do better, seven year survival rates after elective liver transplantation are similar irrespective of diagnosis.³ There is no justification here for rejecting patients with alcoholic liver disease, who form the most contentious group.

Hence the temptation to resort to value judgments becomes greater, and this will probably be accepted as long as doctors' social biases and the public's concur. When they are perceived to differ, public confidence in the system is compromised - as for example occurred in the Michelle Paul case.⁴  "Why was Michelle denied what Jim Baxter had twice?"⁵ was a newspaper headline which captured the public's concern. The medical reasons behind these unrelated decisions were largely overlooked in favour of a superficial comparison between a pretty teenager pictured in a bridesmaid's dress who had been presented as an innocent victim of Ecstasy and a celebrated football player who was known to drink heavily and thus was considered to have caused his liver disease.

The judgmental approach can be buttressed morally in the 30-40% of transplant candidates whose liver disease is the result of excess alcohol, intravenous drug use, or paracetamol overdose by the doctrine of personal responsibility - in other words you reap what you sow. It may seem natural justice to reject patients whose disease can be construed as self inflicted, but this is an ethically flawed concept,⁶ and prejudice often arises from mistaken assumptions which create misleading stereotypes. Take alcoholic liver disease. In an audit of 50 consecutive patients with alcoholic liver disease admitted to the Scottish liver transplant unit and assessed on the strength of their history and all hospital and primary care records, 26 were diagnosed as harmful users of alcohol (ICD F10.1) - that is, dependence on alcohol had not occurred - and in another eight cases excessive drinking turned out to be, at most, a cofactor. An American group also reported that 26% of 267 patients with apparent alcoholic liver disease being assessed for a transplant had never been alcohol dependent; indeed,13% had had no alcohol problem at all.⁷

Another approach is utilitarianism⁸ - that is, donor organs are used to provide the greatest good for the greatest number; potential recipients have a right to be assessed for a transplant (but not to an organ); and the donors, by proxy their families, have a right to expect best use to be made of their gift (but not to select a candidate). Expected outcome is the crux here, and this should extend beyond mortality to take account of morbidity and quality of life. This approach is reflected, and partially enunciated, in the current system - for example, when asked directly in the opinion poll about selection criteria, gastroenterologists said that medical outcome was the most important factor.¹ Yet these specialists still rated the patient with the poorest prognosis as more suitable than the patients with alcoholic liver disease or a criminal record.

At the fatal accident inquiry into Michelle Paul's death the sheriff recommended, "The whole question of prioritisation or selection of patients for listing for organ transplantation should be discussed."⁴ As a result a colloquium was convened in Edinburgh last December, and guidelines derived mainly from expert opinion are being developed.⁹ The role of psychiatry and psychiatrists in the selection process was identified as a problematic area. At the colloquium the consensus was that liver transplant units selected and managed cases similarly when psychosocial factors were important, yet the psychiatric expertise available ranged from a consultant psychiatrist with regular input to relevant cases and the support of alcohol liaison nurses in one unit to none in several centres.

Moreover, outcome studies do not support the unit's impression of equity. Two British centres have published comparable data on patients with alcoholic liver disease after liver transplants: the prevalence of drinking >200 g a week was 15% in one¹⁰ and 40% in the other; the second unit conceded that their unit did not operate "as explicit selection criteria" as elsewhere, nor did they provide any formal treatment for their patients' alcohol problems before or after transplant.¹¹ It seems common sense to expend as much care and skill in assessing the drinking history as the liver in these transplant candidates - and in the aftercare of the alcohol problem as in care of the graft. A focus for audit with the new guidelines should be to establish whether psychiatric intervention in these aspects improves outcome.

There are two other important grounds for paying close attention to the psychosocial assessment of liver transplant candidates. Firstly, the same principles of selection on medical grounds should apply when mental and behavioural disorders coexist as occurs routinely with concurrent physical disease, because most mental disorders are also associated with increased mortality.¹² Finally, mental disorders still carry stigma, and in a clinical setting where prejudice may occur, or may be perceived to occur, the assessment of patients with psychiatric illness or disability is especially sensitive.

George Masterton , consultant psychiatrist. 

Department of Psychological Medicine, Royal Infirmary of Edinburgh, Edinburgh EH3 9YW

 

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2.	UK Transplant Support Service Authority. Transplant update at the end of April 1999. Bristol: UKTSSA, 1999.
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