To the Editor:
The American Society of Anesthesiologists’ (Schaumberg, Illinois) Committee on Transplant Anesthesia is a voice for liver transplant anesthesiologists and is actively engaged in educational efforts related to both clinical and ethical approaches to donation after circulatory death. It was thus with surprise and some distress that we read a recent piece which perhaps casts a negative light on the profession and the liver transplantation process. It may also create significant adverse sentiment and publicity, particularly with regard to the precious resource of donor families.1
Liver transplant anesthesiologists are involved in the preoperative assessment of liver transplant recipients, which includes objective, data-guided evaluation and listing, including patients with alcoholic liver disease, a recognized indication for liver transplantation.2,3 Outcomes of liver transplantation due to alcoholic liver disease are comparable to those other indications in the absence of relapse. Most institutions have robust algorithms and policies in place requiring assessment by trained mental health professionals, participation in abstinence programs with mandatory signed contracts, and frequent, unscheduled drug and alcohol testing. Failure to meet these goals usually results in temporary delisting until compliance is guaranteed. Some programs have an alternate pathway for liver transplantation patients with abstinence less than 6 months but have additional requirements in place. These include the pursuit of an abstinence program, strong family support, and appropriate patient insight into their disease. These approaches have limited relapses to heavy drinking to about 2.9% over a median follow-up of 6 yr.4 Professional, empathetic care of patients with any substance abuse disorder is a guiding principle of ethical medical practice and is no different for patients with alcoholic liver disease. Although the risk for recidivism remains in any patient with a substance use disorder, to suggest, as this poem does, that an alcoholic could receive a liver transplant so he can continue drinking is an affront to the ethos guiding the transplant team.
Of greater concern is the implication of mismanagement of precious donor organs gifted by grieving families. Donor families should be confident in the medical judgment and ethical practice of the transplant team to best utilize donor organs based on objective criteria and vigorous screening processes. The apparent disregard for the solemnity and sanctity of the donation process, as suggested in this poem, has a significant risk of disengaging and discouraging donor families from allowing a second chance for grateful, sober recipients.
We respect the freedom of expression but are nevertheless disappointed to read this subjective opinion piece in Anesthesiology, a highly respected peer-reviewed journal. We are gravely concerned for the potential damaging implications to the transplant community at large, and in particular donor families who may be unaware of processes in place listing and delisting patients with alcoholic liver disease for liver transplantation.
Dr. Ramsay is a consultant for Masimo Corp. (Irvine, California) Scientific Advisory Board, and has funded research from Masimo Corp. The authors declare no competing interests.