Saturday, January 5, 2008

Feathers, Harpoons, Livers, & Transplants

REFLECTING ON: Ethical issues of transplanting a new liver into a "recovered" alcoholic. Martha's name is real and written with her permission.

In post-conference on Friday, a fellow MEPN ruffled my feathers. You see, in our clinical rotations, we were discussing the hospital policy to transplant new livers into “recovered” alcoholics and the ethical issues contained therein. When somebody informed me that the hospital's policy required a transplantee to be sober for a mere 3 months, I stated aloud, “That just doesn’t sit right with me.” There were some murmurings of agreement and some quiet dissent.

The feather ruffler, Martha, then coolly dealt her reply, “Oh those alcoholics, they don’t deserve livers, do they?”

Ire now raised, I took the bait, “That’s exactly what I’m saying.”

With what I perceived to be silent judgment, Martha looked me coolly, and said, “I know.”

Discussion ensued amongst the other students, but my mind was fixated on Martha’s words; they had jarred me. I was mad at the implication that my judgment of alcoholics was inappropriate or unfounded. I remained silent though. You see, one of the few things that I’ve learned in my thirty years is that when I am full of emotion, I try to keep my cards to myself for fear of revealing a bad hand. I don’t enjoy becoming overheated; it’s a sure-fire recipe for saying ridiculous things and becoming illogical.

As the discussion continued, Martha solidified her seat in court, “And those queers, should we give them livers too?”

Fine Martha. I see your point. Where do we draw the ethical line regarding who is eligible for a transplant and who is not? A fair point: we need to maintain objectivity or else slip down that slope of judgment that can ultimately lead to prejudice and discrimination. And although I concede this point, it was presented with the delicacy of a harpoon thrower. Of course, perhaps I need a harpoon now and then so that I can re-examine issues like these. So, in all honesty, thank you for the harpoon, and for the record, I do believe that gay people do deserve livers.

Alcoholics though? I just don’t know.

Where I take issue with most alcoholics is theirs is an affliction of the mind. While the non-addicted brain maintains its status as an efficient conductor of the organ systems that supply and maintain life, the addict’s mind will gladly sell the piano that it feebly pounds out chopsticks on in order to continue its own selfish, self-annihilation. Replacing the liver is a like putting a tiny band-aid on a huge gash that will continue to expand, ooze, and bleed until the actual cause is effectively managed and treated. The perpetrator of this deep cut is not the liver; it is the mind, and all of the complex and ever evolving layers and patterns that it alternates influencing and being influenced by. I maintain, as in triage, the most serious and life-threatening problems should be treated first. Since the origins of an alcoholic’s liver failure are routed in their addiction, a mental illness, the mind should therefore be prioritized for treatment. And although I am open to it, I have never witnessed a recovery from addiction in just 3 short months.

I ask, what is the point of extending a person’s life that is hell-bent on drinking him or herself to death? Unless that individual shows sincere and real progress towards treating their addiction, their true disease, fixing a diseased liver merely buys them time in the off-chance that they have an epiphany—and what is the likelihood that a person will suddenly shift to a pattern of making healthy decisions after a lifetime of making it’s bad ones? It’s like waiting for lightening to strike.

And in the meantime, while we’re waiting for lightening to strike, what do we actually witness? In my experience working at a group home for emotionally disturbed boys, most of whom were the products of parents that were abusive addicts, I watched how alcoholism continually disappoints, hurts, and self-destructs. One child, Steven, comes to mind. At 14, Steven appeared as if he was in early grade school. His physical and mental stature had been severely retarded by his mother’s drinking. His face and head revealed all the classic physical manifestations of Fetal Alcohol Syndrome: small head, low, misshapen ears, an unnaturally flat face, almost no jaw, thin lips, and incredibly small eyes. Steven read at maybe a 2nd grade level on a good day but cursed like a sailor when he was angry, which was almost all the time. When he got mad, he would often run away in a manner that resembled what a second grader would do: run three or four blocks, and then return home. Until he began to express suicidal ideation, the staff at the facility where I worked would let him run, knowing full well that he would soon return. One day, after Brent Steven expressed committing suicide, I was chasing him during one of his efforts at going AWOL. When I caught up with him, I just stood beside him. I had learned early on that grabbing someone that wants to leave is a sure way of making them dislike you. So I just stood, and then walked beside him, away from the group home. Steven was clearly frustrated—his brow was furrowed and he walked with fists at his sides. Then he stopped and looked up at me. I looked down and asked the kind of question that you only ask after you’ve chased a kid a hundred times, “Why don’t you ever just go for it? Why do you always stop?” Steven turned around and began returning home. We walked side-by-side. He walked silently for a bit, and then answered my question, “If I only just had a piece of paper, that I could draw a map on, then maybe I could draw a map and figure out how to get out of here.”

Now Steven had been in cars and even hikes that lead him off the facility’s premises a thousand times. It was only in that moment that I became acutely aware of how damaging the alcohol had been to his brain: he couldn’t keep his surrounding or even where he was in his mind for long enough to leave. He wanted to draw a map, one that he could keep in his mind, so that he could escape. In his distorted thinking, he hadn’t thought to consult an already existing map.

So there it is: why I resent and am so unforgiving of alcoholics. How can 3 months of drying out correct for Steven's lifetime of depression and frustration? It can’t. And it’s not fair. It’s not fair to Steven and it’s not fair to someone on the transplant list who, in all honesty, shows a hell of a lot more promise than a 3-month “recovered” alcoholic. Does Steven's mother deserve a new liver? I think not. And though it may sound harsh, I’m fine with that. Why? Because both within my personal and professional life, I’ve seen and felt the wake of mayhem and hurt left behind by alcoholics.

I realize that Steven is a dramatic illustration of the consequences of someone’s addiction. But it is real, and although most that are affected by alcoholism do not bare Steven's physical abnormalities, they are nonetheless affected in a manner that is similar to Steven; they bare internal scars and pain that they will carry with them for the rest of their lives. Call it what you will: a bias, a stereotype, or even prejudice. Judgment based on experience is what I prefer to call wisdom. Oh Jesus Christ I sound like a televangelist. Sorry. Just let me have my televangelist moment though and I will go back to trying to be well adjusted.

Here’s where it starts and ends for me: I’m absolutely willing to give the next recovering alcoholic a fair shake—just not after three months. How can an individual consider himself or herself cured when they’ve spent a much longer period of time slowly poisoning themselves? They’ve proved time and time again that they are not competent to make healthy choices, so why would we prolong that process? I don’t have time in my life to wait for the lightening to strike. Someone who deserves a new liver, in my mind, would be hit by that lightening, bottle it up, and bring it to the god damn hospital and show everyone that they deserve a new liver. That’s just me though.

I’m sure I sound like a pessimist right now. Rest assured, I’m not. I’m a horribly sensitive, bleeding heart optimist. You know how I know? Because despite my animosity towards alcoholics that have caused pain everywhere, I will still do my best, as a student and nurse-to-be, to provide quality nursing care to that alcoholic--even to Steven's mother. Why? Part of me is still invested in the hope that a person can change, even though the odds are against it. Pragmatic optimism? I don’t know what to call it. Most of me, however, just knows it’s the right thing to do.


Anonymous said...
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Anonymous said...

It's a slippery slope once we start playing God and deciding who does and who doesn't 'deserve' what kind of treatment.

What about an morbidly obese diabetic? Does she 'deserve' a new kidney?

Does a smoker 'deserve' a lung transplant?

Would you do CPR on a registered sex offender?

gNAT said...

Thanks for the comment! These are exactly the controversial, "dirty little questions" that circulate in everyone's mind, and everyone seems to have their "button". Alcoholics just happen to be mine.

Yesterday I cared for a belligerent crack addict and confessed kidnapper, and somehow, that didn't affect me as much. Go figure.

Whether there is a button or not, though, everyone does deserve equal's just a matter of overcoming/confronting personal feelings and maintaining our professional obligation. Thanks for reading.

Lawrence said...

Hah - I know Martha and I can see the harpoon throw quite clearly!

How did the med center choose 3 months as the required sobriety time? Have there been studies done? Maybe a 3mo sober alcoholic with a new liver has a profound incentive to stay sober.

How many months of sobriety would you require? Perhaps there is no difference in frequency of relapse between 3 mos, 12 mos, and 24 mos.

Great blog. I am in incoming MEPN - also Crit Care/Trauma - also a man - also with a interest in bioethics.