AMA Journal of Ethics^®

Case

Mr. F was a veteran construction worker living with his wife and two children when, in 1989, he developed severe back pain and rapid onset of paresthesias, pain, and limited mobility in his lower extremities. He was diagnosed with a primary spinal epidural non-Hodgkin’s lymphoma (NHL) and underwent laminectomy to relieve spinal compression. But the nerve damage was severe and Mr. F continued to experience peripheral neurological deficits, including persistent pain.

Mr. F’s pain was managed on methadone, which has the advantages of being a long lasting agent as well as inexpensive. His chronic pain prevented him from returning to work, and the family’s only source of income was his Social Security disability check, which was frequently not enough to cover all of their expenses. Mr. F’s NHL recurred in 1998 as a localized cranial tumor (“the size of an orange”). After undergoing a partial skull excision with follow-up chemotherapy, Mr. F began experiencing depression; financial strains forced him to sacrifice or space out his pain medication refills. During these gaps, he started to rely on alcohol to treat his pain. Methadone accentuates the effects of sedative hypnotics, such as alcohol, so Mr. F quickly developed dependence. The financial stress combined with alcohol use led to his wife’s leaving him, and, with only his disability for income, he became homeless.

Over the next 4 to 5 years, Mr. F moved among local shelters. Many shelters prohibit or enforce strict limitation on use of narcotic pain medications, and drove Mr. F to use high levels of alcohol as he attempted, in effect, to achieve the sedation of alcohol+methadone). In 2004, Mr. F was diagnosed with severe cirrhosis secondary to viral (B/C) and alcoholic hepatitis. In 2006, variceal rupture led to his first GI bleed, and he has been in the hospital ED six times since for upper and lower GI bleeds and many additional times for alcohol intoxication.

During one of his encounters for persistent upper and lower GI bleeding, Mr. F was admitted to the ICU with a severely low hematocrit and hypotension. Bleeding could only be controlled with local injections of epinephrine throughout the GI tract. The evening after admission, Mr. F developed refractory tachycardia requiring electrical cardioversion. The resident on call remarked that the patient’s only hope was a liver transplant, even though he “obviously” was not eligible. The resident spent the rest of the night calling area hospitals pleading with them to consider Mr. F for a TIPS procedure.

During one of his encounters for persistent upper and lower GI bleeding, Mr. F was admitted to the ICU with a severely low hematocrit and hypotension. Bleeding could only be controlled with local injections of epinephrine throughout the GI tract. The evening after admission, Mr. F developed refractory tachycardia requiring electrical cardioversion. The resident on call remarked that the patient’s only hope was a liver transplant, even though he “obviously” was not eligible. The resident spent the rest of the night calling area hospitals pleading with them to consider Mr. F for a TIPS procedure.

Commentary 1

We can approach these three questions about Mr. F's care through the lenses of justice, utility, and recidivism. The principle of justice forces us to ask who is responsible for Mr. F's current state of health; utility focuses on the effectiveness of decision making and resources being allocated now, and what we know about recidivism in those who abuse alcohol cautions us to think even more carefully about future resource allocation [1, 2].

In the early 1990s, there was widespread belief that alcoholics should have lower priority for transplantation than patients with “non-self-induced” causes of liver disease. The implication was that alcoholics were responsible for their selfdestructive behavior and, hence, for their disease [3]. This attitude is expressed by the ED staff each time Mr. F presents with alcohol intoxication. Considering Mr. F’s history, however, this perspective does not seem just. His alcoholism is secondary to inconsistent pain management, which was influenced by his financial and social position. His use of alcohol as pain control can be further reduced to the complications from NHL, which Mr. F cannot fairly be held personally responsible for. Was his illness “bad luck?” If it was simply bad luck, then does that give us the right to give up on him now? Moreover, if he were personally responsible, would we have the right to give up on him now? Or is medicine a practice in which compassion tempers justice?

On the other hand, chronic peripheral pain is a known complication of prolonged spinal stenosis, and there is no guarantee that a liver transplant would reverse his symptoms. Once Mr. F’s pain caused social and financial problems, management of his situation exceeded the bounds of a 15-minute primary care visit. Furthermore, Mr. F relied on the ED for medical care. Rarely can an ED physician, who is pressured to triage and treat as many people as possible, set aside time to connect a patient like Mr. F with his family, the various shelters, and other social services to assure appropriate pain management.

Rather than looking at the past and attempting to establish responsibility as a means of guiding care and resource allocation, maybe it is more appropriate to focus on current decision making. According to the residents who followed Mr. F, a liver transplant was not even an option. But 7-year post-transplant survival rates of patients with alcoholic liver disease (60 percent) is comparable to (slightly better www.virtualmentor.org Virtual Mentor, January 2009—Vol 11 27 than) those of patients transplanted for other causes (76 percent biliary cirrhosis; 57 percent hepatitis C; 49 percent hepatitis B; and 27 percent hepatocellular carcinoma) [4]. Mr. F also carries diagnoses of “non-active” viral hepatitis C (determined by quantitative DNA analysis) as well as a recurrent non-hepatic malignancy treated with two rounds of chemotherapy. Alcoholism has no effect on viral replication [5] and he does not have any signs of NHL recurrence, so these factors should be considered independently of his alcohol. Considering his diagnostic prognoses, should not a liver transplant be an option?

Many of the arguments against allocating care to certain groups in society focus on the principle of recidivism, or the likelihood of repeating self-destructive acts. While alcoholic recidivism does occur it has been shown not to affect compliance to treatment or graft outcome [6]. Neither a liver transplant nor a TIPS procedure will affect Mr. F’s severe paresthesias, the pain in his lower extremities, or his ineffective pain management. It is not surprising that he continues to consume alcohol. Should this abuse preclude his access to limited and costly resources when, to be fair, he is in this situation because adequate resources were never made available to effectively treat his primary problem of lower extremity pain. At that point, he was not abusing alcohol or participating in any other known self-destructive acts. Why was the health care system unable despite his countless visits to the ED to effectively treat his pain? Did anyone try? Was Mr. F evaluated for surgical pain control intervention? Was he referred to a chronic pain clinic?

A liver transplant is not an option for Mr. F, and TIPS is not a cure—it is simply a band-aid. It will stop the bleeding, but at the cost of increasing his risk of alcohol toxicity because alcohol is effectively shunted through the liver and to the body (particularly the brain). More importantly, the TIPS will not reduce his pain. Justice, utility, and recidivism—many will use these approaches to inappropriately justify Mr. F’s care, but a true examination of his predicament highlights the lack of accountability on the patient’s part and on the part of health care professionals over the years—and it will cost Mr. F his life.