Doctors know that playing God goes with the job

It is right that surgeons deciding who should receive transplants should consider social factors, says Jeremy Laurance
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The Independent Online
Some years ago my father had a coronary bypass operation for heart disease. The first question the surgeon asked when assessing him was, "How old is your youngest child?" The unstated message was that patients with young families to care for would get priority. My father, who then had a nine-year-old daughter, got his operation in four weeks although he had been told the waiting list was four months.

That seemed to me then - in1981 - and seems to me now a humane way to proceed. Of course I am biased. For all I know someone else on the waiting list died because the surgeon, the most eminent in his field at the time, helped my father to jump the queue.

Michelle Paul, the 15-year-old Aberdeen girl who suffered liver failure after taking half an Ecstasy tablet, was denied a liver transplant because someone else was judged to be in greater need. Yesterday, Aberdeen's Sheriff's court ruled that the decision was made on medical, not moral, grounds. The transplant surgeon, Dr Hilary Sanfey, and her colleagues at Edinburgh Royal Infirmary had told the court that Michelle had suffered irreversible brain damage.

But Dr Sanfey admitted that social problems such as drug taking had to be taken into account when considering which patients were suitable for transplant. Success is not achieved when the transplanted patient, with newly inserted organ, is discharged from hospital. There follows a strict lifelong regime of drugs and medical tests that must be followed rigorously if the organ is to last. Doctors have to make a judgement about whether the patient is capable of following such a regime. Is that a medical or a moral decision?

There is intense debate about these matters within transplant units - and beyond them. Sir David Carter, the chief medical officer of Scotland and former director of the liver unit at Edinburgh Royal Infirmary to which Michelle Paul was admitted, said last year that a background of drug or alcohol abuse in a patient "coloured the thinking" of surgeons assessing them. Alcoholics would be required to stop drinking for at least six months before their case for a transplant would be considered, he said.

Sir David was asked if this did not amount to playing God. His response was instructive: "I think that's inevitable if you practise medicine. We are making clinical decisions that affect life and death all the time. Part of the calculation of risks and benefits involves the setting to which the patient returns and the ability they have to cope medically and socially with the pressures."

Few doctors are prepared to speak as frankly as Sir David but all know that social judgements frequently intrude into medical decisions. Doctors have a responsibility to use limited NHS resources to the best effect. Sometimes, as in my father's case, a decision whether or not to treat (or how soon) has ramifications beyond the immediate patient.

The judgement becomes clearly moral when doctors attempt to assess the social worth of patients rather than limiting themselves strictly to calculating the benefit treatment can bring. This was the charge levelled by Michelle's grandmother, Margaret Pirie, who asked the doctors who had refused her grand-daughter a transplant why the former Rangers and England soccer star, Jim Baxter, whom she described as an "ex-alcoholic football player", had been entitled to two liver transplants. Mrs Pirie claimed, in effect, that the doctors had rejected Michelle because she was a drug user with no social standing who had brought her problems on herself. The refusal of treatment on such grounds is clearly unacceptable.

A related row erupted in 1993 over the case of Harry Elphick, a 47-year- old smoker who was told by consultants at Wythenshawe hospital, Manchester, that they would not conduct a test to determine whether he needed heart surgery unless he quit his 25-a-day habit. He reluctantly complied but died before he could see doctors again.

Such cases have worried the profession. A BMA survey in 1993 found that one in four junior doctors said smokers and drinkers should get lower priority for treatment, prompting the association to warn doctors not to deny patients treatment solely because of their lifestyle, and to resist pressure to treat "low risk, high benefit" patients to obtain the best value for money. The only consideration for the doctor should be whether the patient was likely to benefit from the treatment, it said.

The BMA is right to insist that doctors strive to ensure that patients are in the best condition to obtain the maximum benefit from treatment. On that basis, doctors have successfully argued that social issues such as smoking are indistinguishable from medical ones. When resources are limited it is also right that they should choose who is to be treated (or how soon) on the basis of clinical need and the chances of success. Livers are in short supply and it would be a derogation of the doctor's duty to ignore circumstances which could affect the outcome of treatment.

Whether such considerations should include the impact of treatment on the wider family, as in my father's case, is more controversial. Some argue that such decisions are too important to be left to doctors. The answer to them is that they are too important to be ignored.