Jeremy Laurance: Doctors are there to help patients – not judge them

The ‘transplants for drinkers’ row has divided medical opinion

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I am sure that Don Foster, the Liberal Democrat shadow culture secretary, is a compassionate human being and not the sort to first assess whether a drowning man is deserving of his assistance before throwing him a rope. What then is the explanation for his decision to release figures highlighting the growth in liver transplants that show that one in four now go to people who abuse alcohol?

Of 151 liver transplants carried out in 2007-8, the highest total for a decade, 35 (23 per cent) were performed on alcoholics. Mr Foster's stated intention was to draw attention to Britain's "binge-drinking culture" and the impact that alcohol is having both on the NHS and on the health of the people affected.

"The Government has made endless pronouncements about tackling alcohol misuse but has failed to take any real action. Ministers are sitting on their hands while irresponsible retailers continue to sell alcohol at pocket money prices," he declared.

There can be no quarrel with this claim, which is a self-evident truth. But a politician of Mr Foster's experience can surely not have believed that it would have been enough to project his discovery on to the front pages of the weekend's newspapers.

What made Mr Foster's intervention particularly controversial was the implied criticism, that scarce NHS resources were being used to save the lives of people who were the authors of their own destruction.

That turned a dull set of figures into a row over "transplant organs for drinkers". The mother of a young woman who died in a car crash and whose organs were donated after her death was quoted in one newspaper as saying she found the idea "offensive."

"If there are two people side by side wanting a liver and one is an alcoholic and one isn't, there's no contest – you take the one who is not an alcoholic, they are more entitled," she insisted.

In saying this she was reflecting the opinion of a wide swath of Middle England. The suggestion that some patients may be more deserving than others has divided lay and medical opinion for decades. Should smokers be treated equally with non-smokers? Do obese people deserve sympathy or blame? And what of those who ride motorcycles or climb mountains, knowing that they are dangerous activities?

The difficulty with this approach is obvious. Almost anyone who is ill can, in some measure, be judged to have brought their illness on themselves. That is why the National Institute for Clinical Excellence wisely ruled out discrimination on this ground, in guidance issued more than three years ago. Care must be non-judgmental if it is to be humane.

But there are exceptions. One is when the patient imperils the success of a treatment by continuing with the behaviour that made them ill in the first place. A smoker in need of heart surgery who refuses to give up tobacco puts himself at risk because his habit increases the likelihood of blood clots resulting from the operation, which could kill him. On those grounds, surgery might reasonably be denied.

This is a judgement about the balance of risk and benefit, and is taken with the sole interests of the patient in mind. It is not a judgement about whether he or she is a "deserving" case.

A trickier problem is where the ethical duty to treat all patients according to their need conflicts with the duty to provide equally for all patients. In a health service with a limited budget doctors have a duty to use resources efficiently – and that means not wasting them on a patient unlikely to benefit.

When George Best, who died aged 59 in 2005, was spotted drinking after his liver transplant in 2002 he was rightly criticised. There is a shortage of organs and a transplant involves a huge commitment of NHS resources. There is no better way for anyone lucky enough to have received one to show their gratitude than by looking after it.

But to turn this into an obligation leads into difficult territory. It is one thing to require a smoker to give up in order to prevent clots blocking the fresh blood vessels being stitched to his heart. It is another to order a motorcyclist to sell his machine after he has been put back together by surgeons.

Clinical decision-making must not shade into social engineering or doctors will become even more God-like than they already are.



Jeremy Laurance is the Health Editor of 'The Independent'

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