Widow of alcoholic denied liver transplant fights ‘six months sober’ policy

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http://news.nationalpost.com/2015/01/22/widow-of-alcoholic-denied-liver-transplant-fights-six-months-sober-policy/

Widow of alcoholic denied liver transplant fights ‘six months sober’ policy
Tom Blackwell

Mark Selkirk was by many accounts a prince of a man — generous, a doting grandfather and ready to deliver after Toronto’s mayor asked his fibreglass company to make hundreds of moose sculptures for a major street-art project.

But he was also an alcoholic, and when Mr. Selkirk was diagnosed with severe liver disease, doctors said he would have to be sober for six months before being eligible for a life-saving transplant — even if his wife donated part of her organ.

Two weeks later, the 53-year-old businessman was dead.

Now his widow is on a mission to have the widely used six-month abstinence rule overturned, calling it discrimination against people with a disability, and not justified by the science. Debra Selkirk believes the rule is at least partly influenced by the stigma around alcoholism.

By comparison, many patients whose poor diet and lifestyle lead to the need for liver and kidney transplants are typically not subject to similar abstinence requirements. And until recently, at least, hepatitis C patients have had worse outcomes than drinkers, the virus always infecting the replacement organ, sometimes causing it to fail.

“This is a written policy that categorically denies treatment to a whole group of people who suffer from a disability,” Ms. Selkirk maintains. “They killed my husband. I’m angry.”

A human-rights complaint she launched was struck down by an Ontario judge last month for being filed too late. But the Toronto woman is now preparing to launch a constitutional challenge of the policy, as well as setting up a website to promote the cause, and even protesting outside the hospital where her husband died.

A nascent debate is taking place in the transplant world, too, with one recent journal article arguing the issue triggers “fundamental ethical questions” about who should have access to scarce organs.

Still, most doctors and ethicists in the field defend the six-month rule as an imperfect but necessary tool to lessen the risk of a return to drinking that could damage a “precious resource.”

They note it also applies to abusers of illegal drugs, and that patients with medical conditions like advanced cancer or morbid obesity are barred from transplants. Such criteria are made necessary by the severe shortage of organs and long wait lists, not to mention the risk faced by living donors, transplant experts note.

“There is nothing more frustrating than for our entire team to put all the effort into transplanting someone, and then have them go right back to drinking again,” said James Burton, head of the liver transplant program at Denver’s University of Colorado Hospital.

And while health professionals say their approach is informed only by good medicine, some worry that easing restrictions for alcoholics could deter the public from donating organs.

Ms. Selkirk says her husband was an “amazing” man, dedicated to volunteer work and his family, despite his life-long drinking problem.

“He was a model friend to look up to,” Mark Grimes, a city councillor, told the Toronto Star after the entrepreneur’s death in 2010.

Mr. Selkirk’s greatest claim to fame, though, came when his company acquired the contract to produce life-size moose sculptures that would be decorated by various artists and distributed around the city in 2000.

Ten years later — jaundiced, fatigued and nauseated — he was diagnosed with acute alcoholic hepatitis, inflammation of the liver.

Mr. Selkirk had been abstinent for six weeks, but was told he would have to stay dry for six months to be considered for the transplant he desperately needed. When his wife volunteered part of her organ — the couple appeared to be a match — doctors said they wouldn’t even “waste” money on surgery, according to Ms. Selkirk.

He ended up among the 2,800 alcoholic liver disease sufferers who die yearly in Canada.

One key reason for the six-month policy is that some forms of the illness can actually be reversed with abstinence, meaning a new organ is not needed at all, said Charles Scudamore, a liver transplant surgeon with the B.C. Transplant Society.

“You might transplant in error … and deny someone else.”

The other fear is of a damaging drinking relapse. A hospital wants to be confident that any recipient is “going to take care of the organ,” said Linda Wright, head of bioethics at University Health Network, the Toronto hospital group where Mr. Selkirk was treated. “We have some respect owed to the organ donor, as well as the donor family.”

But the evidence of what happens to alcoholics who do get transplants is muddy.

About 6% return to some amount of drinking and 2.5% to heavy drinking every year after transplant, concluded a review of previous studies published by University of Pittsburgh researchers in 2008. But being abstinent for more than six months has only a “modest” impact on success, they concluded.
What’s more, even some drinkers who fall off the wagon after transplantation, “still do pretty well,” Charles Rosen, head of transplantation at the Mayo Clinic in Rochester, Minn., acknowledged Thursday. “We don’t like to advertise that.”

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Note this is an example of transplant center practice, each one deciding its own, not OPTN policy.

[Clark]

http://news.nationalpost.com/2015/01/30/robyn-urback-six-month-sobriety-rule-for-liver-transplants-is-harsh-but-necessary/

Robyn Urback: Six-month sobriety rule for liver transplants is harsh, but necessary

The story of Mark Selkirk’s death is an indisputable tragedy. The 52-year-old father, grandfather and husband was a successful businessman and community organizer whose fiberglass business was behind a public arts project that made moose sculptures ubiquitous around Toronto. Mr. Selkirk was also an alcoholic and in desperate need of a new liver when, in late 2010, he was diagnosed with acute alcoholic hepatitis. The problem was that Mr. Selkirk had only been sober six weeks, and in order to qualify for a transplant — from either a living or deceased donor — he would have had to have been sober for at least six months. Mr. Selkirk died two weeks after his diagnosis.

Now his widow, Debra Selkirk, is pushing to have the six-month rule changed. Ms. Selkirk says she was willing and potentially able to donate part of her liver to her husband, but was denied the opportunity for what she calls discrimination against alcoholics. “This is a written policy that categorically denies treatment to a whole group of people who suffer from a disability,” she told the National Post. “They killed my husband. I’m angry.”

Ms. Selkirk has reason to be frustrated. Like everything else, the system is imperfect; while drug users and alcoholics must adhere to strict regulations to qualify for an organ, there are no hard and fast rules on those for whom poor diet and lifestyle have contributed to organ failure (though the morbidly obese typically do not qualify for transplant). What’s more, the statistics on alcoholic recidivism after transplant show only modest improvement among those who were sober for six months or longer prior to undergoing the operation. And by Ms. Selkirk donating a part of her own liver, rather than a liver from a deceased donor, her husband’s transplant would not have pulled from the public pool of ever-scarce organs. Those points in mind, its no wonder Ms. Selkirk is angry.

Part of the issue that ensnared the Selkirk family is that regardless of whether the recipient is receiving an organ from a live donor (such as a wife, a brother, a son, etc.) or a deceased donor (such as a car crash victim with no brain activity) the requirements for eligibility are the same. In other words, it didn’t matter if the donor liver came from his wife or from an anonymous, deceased donor — Mr. Selkirk had to be sober for six months, period. What’s more, according to the University Health Network, the assessment of a potential living donor — to check organ compatibility, psychological concerns, overall health and so forth — doesn’t actually begin until the recipient has met the eligibility requirements for receiving a deceased donation. That means, in some cases, waiting for the patient to actually get sick enough to qualify for the general registry before even starting to assess the compatibility of a living friend or family member.


For patients who know that they will eventually need a transplant, that wait can be excruciating. It’s why many have called for separate eligibility requirements for patients receiving organs from live donors — as potentially was the case with Mr. Selkirk — and those receiving deceased donations.

That distinction may have helped her husband, but it’s not what Ms. Selkirk is now calling for. Rather, she is preparing to launch a constitutional challenge to abolish the six-month sobriety rule for liver transplant recipients altogether, on the grounds that it discriminates against alcoholics.

[Clark]

http://www.cbc.ca/news/canada/toronto/liver-transplant-ethics-should-alcoholics-be-sober-first-1.2934786

Liver transplant ethics: Should alcoholics be sober first?
Toronto woman whose husband died in 2010 plans to launch charter challenge

Should alcoholics be required to stop drinking for six months before they are eligible for a liver transplant in Ontario?

The issue has been raised by the widow of Mark Selkirk, a Toronto man well known as the person behind the moose sculptures that once appeared across the city.

Selkirk was also a lifelong alcoholic. In 2010, he was diagnosed with acute alcoholic hepatitis and told by doctors he would die without a liver transplant.

In Ontario, patients who need a new liver must abstain from drinking for six months before they are eligible for a transplant. Selkirk died two weeks after his diagnosis.

His widow, Debra Selkirk, is planning a constitutional challenge of the six-month policy. She intends to use the Charter of Rights and Freedoms to argue that the policy discriminates against patients who suffer from alcoholism and uses a moral judgment to deny patients a life-saving treatment.

"I believe that if doctors have a patient whose life they can save and they have a donor who's willing to give, that they have an obligation [to save their life]," she said in an interview on CBC Radio's  As It Happens.

Selkirk believes Ontario's six-month abstinence policy contravenes the charter and Canadians' right to universal access to health care.

She theorizes that if lifestyle choices were taken into account for all procedures, it would be seen by many as inhumane.

"Perhaps we should have a rating system for every disease and everything that comes into our hospital," she argues.

"If someone comes into the hospital bleeding to death and you're a gang member ... I say to him, OK, I'm going to look at my list ... 'Gang related.' We make them wait three hours [according to our lifestyle policy]. If you bleed to death in the meantime, oh well, you're a bad person.

"That's not what universal health care is. Universal health care is save every life you can."

Dr. Gary Levy, the former director of the Multi-Organ Transplant Program at University Health Network who now heads the living donor liver program there, said the policy is in place mainly because livers are a scarce and finite resource. He is not involved in Selkirk's case.

In an interview on CBC Radio's Metro Morning on Wednesday, Levy said last year more than 100 people died while waiting for a transplant.

"We have a shortage of suitable organs, we don’t have enough to meet the need," he said. "We have a responsibility to ensure the organs are used wisely."

Levy said studies have shown that alcoholics awaiting a liver transplant and who are able to abstain from drinking for six months have a very low rate of returning to drinking.

He said if a liver is donated to a patient who damages the new organ by continuing to drink "we don't have one death, we have two deaths."

Levy also denied suggestions that the six-month waiting period is about saving the cost of the transplant surgery.

"We've never denied an individual in our centre because of dollars and cents," he said. "Where a need exists and where people meet the criteria, we move quickly to provide them the service."

Selkirk plans to push ahead with her challenge, saying the current policy treats alcoholism as a "character flaw" instead of a medical condition.

She said the provincial government, which earns revenue from alcohol sales, has a responsibility to make sure everyone gets the medical treatment they need.

"We have an alcohol problem and it's not right to let people die because we don't want to address these problems," she said. "It's not for them to make moral judgment calls."