Sunday, May 04, 2008

The God Squad Redux?

There has been a simple problem with organ transplants, for as long as it has been technologically possible to do so: there are never, ever enough organs. And that leads to the simple, painful, difficult question of how you decide who receives a organ, and who is consigned to death that could have been prevented. And perhaps most importantly, how do you make that decision ethically?

For better or worse, much of the debate on who gets to play god has centered in and around the medical facilities in Seattle. Almost everyone knows the history of Dr. Belding Scriber and the hemodialysis God Squad, with the now-infamous headline “They Decide Who Shall Live and Who Shall Die.” And their criteria for choosing who did receive dialysis is almost painful to consider these days: a married Christian white man with children? Worthy member of society, should be saved! Single convict? Let 'im die.

It's a well-known history, in bioethics and Seattle proper. So it was with some surprise that I read, in the morning's news cycle, that the University of Washington was back in the news with accusations that their transplant committee was playing god. Only this time, they're second-guessing other medical professionals in the process.

The situation itself is simple: a man in need of a liver transplant was prescribed medical marijuana use by his physician to control pain, alleviate nausea, and stimulate his appetite.

The marijuana use, according to a doctor at Harborview Medical Center, would prohibit his paperwork for transplanting being processed. He would have to abstain for six months - a ruling eventually dropped in favour of an offer to reconsider after completion of a 60 day substance abuse program. Sixty days that the patient didn't have. On appeal, the University of Washington Medical Center agreed to consider the case again, and a week ago rejected the man from transplant consideration for a second time.

Medical use of marijuana was approved by Washington voters back in 1998, yet use of illicit substances is often grounds for rejecting someone's place on the transplant list. UNOS leaves the specific criteria to each individual hospital, and the information coming out of Seattle seems to suggest that UW's policy is not automatic rejection, but instructions to abstain for six months to then be reconsidered. (And of course, the medical center itself is not commenting on this case, save to say a range of factors play into every decision made regarding transplant cases).

The problem with this is hopefully simple: if a patient is using marijuana under medical supervision, why should it be considered problematic? Or any more problematic than the use of any other addictive substance (such as most pain medications).

The other problem is less simple. Physicians trying to do right by their patients, trying to alleviate pain and suffering (something that is often difficult to even motivate physicians to do, as continued coverage of the dearth of chronic pain management indicates), are inadvertently creating a situation where their patients are actually being denied further medical treatment based on their current treatment.

Peggy Stewart, a clinical social worker in the UCLA liver transplant center, has a simple solution: create a national eligibility criteria, so that everyone is on the same page, and aware of what will and will not increase their chances at actually being placed on the list.

Or, if I may be so bold as to point out the obvious, don't penalize a patient for following the medical advice of a fully licensed physician.
-Kelly Hills

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