On the complexity of making clinical decisions…

Stephen Nolan has featured the Gareth Anderson situation again this morning for most of the show. As he notes, the Health Minister is now on his own as far as the other parties are concerned. The DUP wants a review. The SDLP, Sinn Fein and now this morning, the Alliance Party have all called for a similar review. He’s also just responded to Liam Clarke’s article in yesterday’s Sunday Times and has confessed he doesn’t have an organ donor card: given this is a question of scarcity that’s a key consideration here, if you’re in the UK you can register here, in Ireland you can get a donor card here. Below the fold we carry a short piece laying out some of the general medical context to the tragic situation young Mr Anderson faces from a Slugger reader:

One cannot but feel for the plight of Gareth Anderson who is seriously ill in a London Hospital, nor in any way criticise his father, who is considering legal action to try to help save his son.

There seems to be considerable political interest, although Michael McGimpey is surely right in his assertion that he cannot force change to organ transplant rules.

Some of the political interest seems to focus on the fact that normally a six month period of abstinence from alcohol is required prior to accepting a patient onto the transplant waiting list: this length of time appears to be unavailable to Mr. Anderson. Whether or not he will be assessed or accepted remains to be seen.

The current guidelines are here and although the six month abstinence period may not always be required it seems to have been a significant factor in a recent decision not to transplant a young patient.

It must be remembered, however, that whatever happens if he is to receive a liver transplant someone will have to die (to be a donor) and someone else will receive a liver later and hence, they may die. Although there has been some progress in terms of living liver donation this is still a very small minority and is unlikely to be possible in the vast majority of adults in the foreseeable future.

Transplantation units are of course used to making these sorts of judgements which make Solomon’s look easy and they have to make them extremely frequently. According to Prof Gilmore people with a short history seem to do less well when transplanted (see audio piece here). It is also important to mention that even if a patient has had a successful liver transplant, that does not offer a normal life expectancy and maintenance of the donated liver requires long term immunosupression (albeit less potent than for many other donated organs).

Sadly there is currently no equivalent of renal dialysis for liver disease patients and as such the non transplant options for patients with severe liver failure are extremely limited.

The effect of any judicial review or political pressure is of course difficult to gauge though any sudden change in transplantation guidelines forced by putative legal action would undoubtedly throw the whole system into chaos. Although an increase in organ donation would no doubt help in these dreadful situations (50% of families still refuse transplant donation) there is a grim fact that the improvements in trauma and intensive care services have actually resulted in a reduced number of organs available for transplantation.

Of course, sadly, no discussion of liver disease would be complete without noting that it is rising in incidence and this is largely caused by increasing consumption of alcohol and from an earlier age. Very recent data have suggested some decrease in alcohol consumption in the 16-24 year age group but an increase in excessive drinking in Northern Ireland. The causes of increasing alcohol consumption are of course multiple and varied: however, a very major factor is the increasing relative affordability of alcohol.

The Scottish government (Scotland’s problems are worse than any other part of the UK) has begun to attempt to address this issue with the possibility of minimum prices for alcohol though Gordon Brown has rejected this approach for the rest of the UK.

One final point worth making on liver disease has nothing to do with alcohol: paracetamol is an extremely safe and effective medicine used by countless people every day at the appropriate dose. However, in overdose it is can be fatal (again from liver failure) causing about 100 deaths in England and Wales each year and about in Northern Ireland (page 10).

The story of Gareth Anderson is a very real and a very human tragedy. It will no doubt be suggested that whatever the outcome people (especially young people) will stop and think about the dangers of excess alcohol. That is of course a completely naïve hope: in reality young people will continue to get drunk and get themselves into fights and end up in the A+E departments of our hospitals either drunk or injured and every now and again someone will die from the effects of excess alcohol whether acute or chronic, direct or indirect. However, the vast majority of people (even young people) will either by good luck or by a degree of personal responsibility drink alcohol without suffering any major ill effects.

There is a place for legislation and there is also a place for personal responsibility. In addition there is also bad luck, and Gareth seems to have suffered extraordinarily from this.

Mick is founding editor of Slugger. He has written papers on the impacts of the Internet on politics and the wider media and is a regular guest and speaking events across Ireland, the UK and Europe. Twitter: @MickFealty