WEBVTT - Need a new Liver? Drinkers to the back of the Line. 0:00:02.240 --> 0:00:05.200 I was in a room, a completely white room with 0:00:05.280 --> 0:00:09.039 a brown desk, and there was a older gentleman there 0:00:09.039 --> 0:00:10.879 in a sense, and there was a contract. There was 0:00:10.920 --> 0:00:14.200 like this piece of paper and a pen, and these 0:00:14.200 --> 0:00:17.520 words were specifically uttered to me. You can either choose 0:00:17.560 --> 0:00:20.880 not to accept this and just pass peacefully and not 0:00:20.920 --> 0:00:24.279 worry about anything, or if you take this gift, you'll 0:00:24.280 --> 0:00:26.840 be in the worst pain that you've ever experienced in 0:00:26.880 --> 0:00:31.440 your entire life. And I remember sitting there and just 0:00:31.520 --> 0:00:35.960 being stubborn like I am, And I said, oh, well, 0:00:36.240 --> 0:00:37.440 I think I know about pain. 0:00:38.920 --> 0:00:43.400 Jamie Imhoff was almost certainly dreaming. Who was she bargaining with? 0:00:43.920 --> 0:00:46.199 Was it God? As her life hung in the balance, 0:00:46.960 --> 0:00:50.000 she was heavily sedated in the hospital, drifting in and 0:00:50.040 --> 0:00:53.760 out of consciousness. A month earlier, she'd collapse on the 0:00:53.800 --> 0:00:58.200 floor of her apartment, her body contorting from intense cramps. 0:01:00.000 --> 0:01:03.560 Off to Jamie's collapse, doctors at her Baltimore hospital put 0:01:03.600 --> 0:01:09.720 her on life support. Her diagnosis multiple organ failure. Most importantly, 0:01:10.040 --> 0:01:13.280 her liver had stopped working. She was only thirty eight 0:01:13.400 --> 0:01:13.880 years old. 0:01:14.760 --> 0:01:17.520 They called my family right away, and pretty much to 0:01:17.520 --> 0:01:20.440 all my family, I was unsabable and to come out 0:01:20.480 --> 0:01:22.960 here and plan to book the funeral. 0:01:23.880 --> 0:01:27.360 Acute liver failure is a rare but life threatening condition. 0:01:28.280 --> 0:01:31.240 In Jamie's case, it was very obvious what had cause 0:01:31.360 --> 0:01:32.880 all that damage. 0:01:33.440 --> 0:01:36.160 A typical day of drinking at the time I collapsed 0:01:36.240 --> 0:01:40.319 started around early morning, maybe seven am eight am. I 0:01:40.360 --> 0:01:43.319 always had a bottle of Arka next to my bed 0:01:43.440 --> 0:01:45.160 when I woke up. If I did not take that 0:01:45.280 --> 0:01:48.559 initial first drink, I couldn't function, and then from there 0:01:48.680 --> 0:01:51.120 the rest of the day would be maintained on a 0:01:51.160 --> 0:01:56.560 certain level of alcohol in my body until. 0:01:56.400 --> 0:01:57.040 I went to bed. 0:01:57.240 --> 0:01:59.160 But at that point there was no pleasure in doing stuff. 0:01:59.160 --> 0:02:01.440 This was literally what we call maintenance drinking. 0:02:02.360 --> 0:02:05.400 Jamie was aware she had a problem with drinking. She'd 0:02:05.440 --> 0:02:07.840 been to rehab and managed to get sober for a 0:02:07.840 --> 0:02:11.360 few months at a time, but she worked as a 0:02:11.360 --> 0:02:14.799 bar manager. When life got stressful, she went right back 0:02:14.840 --> 0:02:17.800 to old habits, and that's how she ended up in 0:02:17.840 --> 0:02:21.840 the hospital. At this point, her only chance at survival 0:02:21.919 --> 0:02:25.840 was a liver transplant, but because alcohol use is what 0:02:25.960 --> 0:02:29.720 destroyed her liver, the doctors told Jamie's family she wasn't 0:02:29.760 --> 0:02:33.720 eligible for a transplant, not for another six months. 0:02:34.520 --> 0:02:38.680 My family. Upon hearing the news, they were not very happy. 0:02:39.000 --> 0:02:42.320 The idea of being denied care didn't make any sense 0:02:42.360 --> 0:02:43.040 to them. 0:02:43.600 --> 0:02:47.080 Jamie's family spent the next several days making phone calls, 0:02:47.680 --> 0:02:51.080 desperate to find a transplant center that would agree to 0:02:51.160 --> 0:02:56.120 save her life, but no luck. Eventually, they gave up 0:02:56.200 --> 0:02:59.960 and started speaking with a chaplain. They wanted his help 0:03:00.120 --> 0:03:02.920 deciding whether or not to let Jamie die. 0:03:03.040 --> 0:03:06.280 The doctors told my family that I could stay on 0:03:06.280 --> 0:03:09.440 life support for a definite period of time, but they 0:03:09.440 --> 0:03:11.920 did not recommend doing so. 0:03:12.040 --> 0:03:15.000 Now, clearly we're hearing from Jamie in the present day. 0:03:15.600 --> 0:03:19.280 She did manage to survive, but how had she come 0:03:19.560 --> 0:03:23.639 so close to dying? Doctors knew the life saving treatment 0:03:23.720 --> 0:03:27.520 she needed a live a transplant, so why wouldn't they 0:03:27.520 --> 0:03:33.240 give it to her? And how is that ethical? I'm 0:03:33.280 --> 0:03:36.880 Laurena Rora Hutchinson. I'm the director of the Ideas Lab 0:03:36.960 --> 0:03:41.760 at the Johns Hopkins Berman Institute of Bioethics. This season, 0:03:41.880 --> 0:03:44.640 I'm going behind the scenes to discover how some of 0:03:44.680 --> 0:03:49.160 the most significant medical innovations have impacted people's lives and 0:03:49.240 --> 0:03:53.560 continue to whether it's saving lives or creating babies. A 0:03:53.600 --> 0:03:57.280 new technology is usually waiting in the wings, along with 0:03:57.360 --> 0:04:03.400 a whole entourage of ethical questions. On today's show, liver transplants. 0:04:04.400 --> 0:04:07.520 They're often the only option to keep people with liver 0:04:07.640 --> 0:04:12.240 failure alive, but since there aren't enough livers to go around, 0:04:12.760 --> 0:04:17.559 transplant centers have to decide what's the most ethical way 0:04:17.640 --> 0:04:21.800 to determine who gets them first, and when and what if. 0:04:21.839 --> 0:04:25.479 Solving for one ethical dilemma creates a whole host of 0:04:25.600 --> 0:04:31.560 new ethical problems for patients and families. From Pushkin Industries 0:04:31.600 --> 0:04:35.599 and the Johns Hopkins Berman Institute of Bioethics, this is 0:04:35.680 --> 0:04:43.800 playing god. To get some perspective on Jamie's story, I 0:04:43.839 --> 0:04:48.000 called up my colleague, bioethicist Jeffrey Kahn. If you're a 0:04:48.000 --> 0:04:52.080 regular listener, you've heard him on our show before. So, Jeff, 0:04:52.120 --> 0:04:55.240 why was it that someone like Jamie, who clearly desperately 0:04:55.240 --> 0:04:57.840 needed a new liver, was initially not going to get 0:04:57.880 --> 0:04:58.560 a transplant. 0:04:59.520 --> 0:05:02.440 It's a good question, Lauren, and to answer it, we 0:05:02.520 --> 0:05:05.200 need to go back to the early days of being 0:05:05.240 --> 0:05:09.839 able to transplant solid organs. Those are kidneys, livers, lungs, hearts, 0:05:10.440 --> 0:05:13.880 and there just aren't enough and never have been enough. 0:05:13.960 --> 0:05:18.919 Donated organs to transplant to everybody who needs one. In 0:05:18.960 --> 0:05:21.440 the case of livers, people who need a liver transplant 0:05:21.480 --> 0:05:24.120 are really, really sick and can only wait for a 0:05:24.200 --> 0:05:28.120 very short time before either being transplanted and surviving or 0:05:28.200 --> 0:05:32.000 not being transplanted and dying. And so people in the 0:05:32.160 --> 0:05:35.800 transplant community and then people from public policy and ethics 0:05:35.880 --> 0:05:40.320 like me got pulled in to help decide how to 0:05:40.440 --> 0:05:42.960 allocate who should get, who should not, who can wait, 0:05:43.400 --> 0:05:47.159 who in the end won't actually receive a donated organ. 0:05:47.480 --> 0:05:50.760 This is a recurring issue in ethics of transplant and 0:05:50.880 --> 0:05:53.359 bioethics generally. When there's not enough of a thing to 0:05:53.440 --> 0:05:56.800 go around, who gets access to it and therefore who 0:05:56.839 --> 0:05:57.120 does not? 0:05:58.360 --> 0:06:00.760 So how is the decision made about who gets the 0:06:00.800 --> 0:06:02.200 priority for these livers? 0:06:03.040 --> 0:06:08.560 Every organ has a somewhat different system. For kidneys, there's 0:06:08.960 --> 0:06:11.880 a waiting list, and that's because we can ask people 0:06:11.920 --> 0:06:15.320 to wait and be on a technology called dialysis until 0:06:15.400 --> 0:06:19.160 their number gets called. For livers, it's a different story. 0:06:19.680 --> 0:06:23.080 It's a weightless but it's really a scored weightless. So 0:06:23.160 --> 0:06:25.599 the higher your score, the sicker you are, and therefore 0:06:25.600 --> 0:06:29.080 the higher on the priority list you get. 0:06:29.200 --> 0:06:32.080 And so how does the system treat people like Jamie 0:06:32.080 --> 0:06:34.159 who need a new liver because of a history of 0:06:34.200 --> 0:06:35.520 harmful alcohol use. 0:06:36.440 --> 0:06:40.480 The issue of needing a liver transplant after abuse of 0:06:40.600 --> 0:06:46.400 alcohol or overuse of alcohol created an additional layer of 0:06:46.800 --> 0:06:49.800 ethical dilemma. So on top of the question about what 0:06:49.839 --> 0:06:52.039 do we do when we don't have enough livers for 0:06:52.080 --> 0:06:55.560 all the people who need a liver transplant, layered over 0:06:55.600 --> 0:06:59.480 that is the idea that the reason that the person 0:06:59.640 --> 0:07:03.919 needs a liver transplant owes to their behavior. And so 0:07:04.520 --> 0:07:07.760 the question then is, well, what's to prevent them if 0:07:07.760 --> 0:07:10.880 they get a transplant from doing the same thing that 0:07:10.920 --> 0:07:13.280 they did to cause the need for the first transplant? 0:07:13.280 --> 0:07:17.600 And so that's a kind of societal utilitarian question, is 0:07:17.640 --> 0:07:21.400 this the best way to allocate this very scarce resource? 0:07:22.080 --> 0:07:25.520 And the question about behavior and responsibility is not a 0:07:25.560 --> 0:07:30.240 trivial question in the context of liver transplant because alcohol 0:07:30.280 --> 0:07:33.400 related liver disease is now the number one reason that 0:07:33.840 --> 0:07:36.840 adults in the US need a liver transplant, and these 0:07:36.880 --> 0:07:39.440 patients tend to be really, really sick by the time 0:07:39.480 --> 0:07:43.280 they end up coming to the doctor and seeking treatment, 0:07:43.360 --> 0:07:46.240 and so they become top of the list's highest priority 0:07:46.360 --> 0:07:49.600 when they show up, and that creates or could create 0:07:49.640 --> 0:07:55.120 some really understandable resentment. Wait, why is it that this 0:07:55.240 --> 0:07:59.320 person who undertook this behavior did this to themselves? Why 0:07:59.360 --> 0:08:03.360 should they get a liver transplant before somebody with cancer 0:08:03.480 --> 0:08:06.040 or some child that may have been born with a 0:08:06.120 --> 0:08:10.600 disease that's certainly not within their control, But isn't harmful? 0:08:10.640 --> 0:08:12.920 Alcohol use also considered a disease. 0:08:13.880 --> 0:08:17.720 It is, And as we do more research about addiction 0:08:18.080 --> 0:08:22.880 and behavior, I think it's becoming more clear that there's 0:08:23.000 --> 0:08:28.840 a disease aspect, there's also some behavioral and controllable aspects, 0:08:28.880 --> 0:08:31.720 but that it's very complicated. There are genetic components, there 0:08:31.760 --> 0:08:37.240 are environmental components, there are socioeconomic components, and so these 0:08:37.240 --> 0:08:40.520 are complicated areas where it doesn't make sense to just 0:08:40.559 --> 0:08:43.120 sort of point to someone and say they're responsible for 0:08:43.240 --> 0:08:45.640 the bad health effects of their behavior. 0:08:46.320 --> 0:08:50.600 So what approach have transplant centers come up with allocating 0:08:50.640 --> 0:08:54.320 livers to people with and without a history of alcohol use? 0:08:54.440 --> 0:08:56.760 How is it fair to people with them? 0:08:56.800 --> 0:09:00.160 Without going back now a number of decades to the 0:09:00.280 --> 0:09:04.600 nineteen eighties, transplant centers that do liver transplants in the 0:09:04.720 --> 0:09:08.800 US and really has become a global practice. Have required 0:09:08.840 --> 0:09:12.360 patients with the history of alcohol abuse who need a 0:09:12.360 --> 0:09:15.840 liver transplant to show that they can be sober no 0:09:16.040 --> 0:09:18.719 use of alcohol for at least six months before they're 0:09:18.760 --> 0:09:22.480 eligible for a transplant. That's been named the so called 0:09:22.559 --> 0:09:27.280 six month rule. So, in effect, the rule requires patients 0:09:27.320 --> 0:09:31.000 to go off and cure themselves of one disease alcohol 0:09:31.040 --> 0:09:35.120 abuse before we'll treat them for another disease. That doesn't 0:09:35.160 --> 0:09:38.240 seem fair, but that's the approach that has been implemented. 0:09:38.640 --> 0:09:42.240 There were actually at least three reasons that transplant centers 0:09:42.679 --> 0:09:47.040 and the policy makers around liver transplantation decided that this 0:09:47.280 --> 0:09:50.720 was the right approach. First, there was a thought that 0:09:51.080 --> 0:09:54.520 if patients stopped using alcohol for a period of time, 0:09:54.920 --> 0:09:58.600 their livers might actually come back and heal themselves. The 0:09:58.600 --> 0:10:02.200 second and maybe more important reason for some period of 0:10:02.200 --> 0:10:06.000 sobriety was the view that they're blameworthy, like they brought 0:10:06.000 --> 0:10:08.800 it on themselves, and we shouldn't reward somebody who brought 0:10:08.800 --> 0:10:13.720 something on themselves by giving them access to a life 0:10:13.720 --> 0:10:18.000 saving liver transplant when there are other people who didn't 0:10:18.040 --> 0:10:21.400 behave badly also waiting. You know, we better make sure 0:10:21.520 --> 0:10:23.760 that the people who were going to offer this very 0:10:23.840 --> 0:10:27.880 scarce life saving treatment to are not going to do 0:10:27.920 --> 0:10:30.800 the same thing that required the transplant in the first place. 0:10:31.280 --> 0:10:34.360 And then the third reason is a sort of you know, 0:10:34.400 --> 0:10:37.920 what will the members of society think about donating their 0:10:38.040 --> 0:10:40.240 organs when they see that the people who are getting 0:10:40.360 --> 0:10:44.920 livers are the people who abused alcohol? Will that make 0:10:45.000 --> 0:10:48.439 people less likely to be willing to be organ donors. 0:10:48.679 --> 0:10:52.840 So all of that played into the decision about, you know, 0:10:52.840 --> 0:10:55.760 what to do with somebody like Jamie, how can we 0:10:56.640 --> 0:10:59.840 still think about transplants for them in a way that 0:11:00.080 --> 0:11:01.200 ethically acceptable? 0:11:02.120 --> 0:11:04.560 So what have we learned from having this six month 0:11:04.640 --> 0:11:05.280 rule in place? 0:11:05.800 --> 0:11:07.880 Well, the first thing that we learned is that making 0:11:07.880 --> 0:11:11.160 people wait six months is a death sentence for half 0:11:11.200 --> 0:11:14.079 of them. It turns out that the liver does not 0:11:14.320 --> 0:11:17.959 regenerate when given a chance to be alcohol free. It's 0:11:18.080 --> 0:11:21.640 just that people who have abused alcohol have effectively killed 0:11:21.679 --> 0:11:24.000 their liver, and so making them wait for six months 0:11:24.400 --> 0:11:28.360 is they can't survive it. Also, it turns out research 0:11:28.360 --> 0:11:30.680 has shown that the six month rule is a bad 0:11:30.760 --> 0:11:34.920 predictor of whether someone will stay sober after a transplant 0:11:35.160 --> 0:11:37.840 and it turns out it has no effect on people's 0:11:37.840 --> 0:11:40.480 willingness to donate based on survey research. 0:11:40.920 --> 0:11:43.560 Wow, so people have been dying because of the six 0:11:43.600 --> 0:11:46.440 month rule even though it doesn't really do what it's 0:11:46.480 --> 0:11:48.560 supposed to do effectively. 0:11:48.720 --> 0:11:52.640 Yes, and it's not even a rule, it's a practice. 0:11:52.840 --> 0:11:55.360 It's all the transplant centers adhere to it, but it's 0:11:55.360 --> 0:11:58.920 actually not required. And you know, at the time that 0:11:58.960 --> 0:12:03.640 it was implement it made sense for all the reasons 0:12:03.679 --> 0:12:06.560 that we have discussed to use the few livers that 0:12:06.600 --> 0:12:12.120 became available in the best possible way, and it took 0:12:12.200 --> 0:12:15.480 a while for research to be performed and information to 0:12:15.520 --> 0:12:18.360 come in that would help inform whether that was the 0:12:18.440 --> 0:12:23.840 right policy. But it's really unclear that there wouldn't be 0:12:23.960 --> 0:12:28.679 unintended negative consequences if the six month rule were to 0:12:28.720 --> 0:12:32.720 be completely abandoned. So we really just don't know all 0:12:32.800 --> 0:12:38.240 the implications of stepping away from or completely abandoning the 0:12:38.280 --> 0:12:41.319 six month rule, and that's something that needs more, maybe 0:12:41.360 --> 0:12:44.439 more nuance and more information before we decide what the 0:12:44.520 --> 0:12:45.800 right policy should be. 0:12:47.280 --> 0:12:50.439 After the break, we'll hear from someone who is challenging 0:12:50.480 --> 0:12:54.679 the six month rule. The doctor who gave Jamie Imhoff 0:12:54.800 --> 0:12:56.480 a second chance at life. 0:12:57.000 --> 0:13:00.000 I am in the second chance business, and I believe 0:13:00.040 --> 0:13:04.560 even the ability of people to with multiple chances and 0:13:04.640 --> 0:13:05.920 multiple tries to get it. 0:13:05.920 --> 0:13:09.040 Right playing God will be right back. 0:13:14.240 --> 0:13:17.800 So when I started liver transplants, everybody knew the rules 0:13:18.400 --> 0:13:19.800 and the rules were agreed upon. 0:13:20.679 --> 0:13:24.800 This is Andrew Cameron. He's a liver transplant surgeon at 0:13:24.880 --> 0:13:29.720 Johns Hopkins University. He knows all about the eligibility rules 0:13:29.720 --> 0:13:33.520 for liver transplants. These aren't cut and dry legal rules, 0:13:34.000 --> 0:13:35.719 more like common practices. 0:13:36.160 --> 0:13:40.040 To get a liver transplant after excessive alcohol use, you 0:13:40.120 --> 0:13:45.640 needed to be sober or abstinent for six months. That 0:13:45.760 --> 0:13:48.480 was the rule, and we all accepted it. 0:13:49.080 --> 0:13:52.600 But these days Andrew is doing something almost unheard of 0:13:52.760 --> 0:13:57.080 in the transplant community. At his transplant center in Baltimore, 0:13:57.200 --> 0:14:03.760 he routinely, intentionally systematic breaks the six month rule. The 0:14:03.840 --> 0:14:07.200 first time he broke this rule, or bent it, as 0:14:07.240 --> 0:14:11.360 he says, was fifteen years ago. A patient showed up 0:14:11.440 --> 0:14:15.160 at Johns Hopkins' deathly ill with liver failure and a 0:14:15.240 --> 0:14:16.960 history of heavy alcohol use. 0:14:17.360 --> 0:14:19.160 And I remember our team going to take a look 0:14:19.200 --> 0:14:21.720 at him and saying oh, well, unfortunately this is an 0:14:21.760 --> 0:14:25.040 easy one. He's been drinking recently and so isn't eligible 0:14:25.040 --> 0:14:28.480 for a liver transplant. And we didn't think much more 0:14:28.520 --> 0:14:31.040 of it. But as we were leaving his room, his 0:14:31.120 --> 0:14:34.280 family grabbed us and said, you know you're not going anywhere. 0:14:34.680 --> 0:14:40.280 You know, we are demand that year reconsider. And it 0:14:40.360 --> 0:14:42.200 was pretty tough to argue with him. In fact, it 0:14:42.240 --> 0:14:44.920 was impossible to argue with them, and they made such 0:14:44.920 --> 0:14:48.600 a compelling case that as a team, we got together 0:14:48.680 --> 0:14:51.680 and considered whether we ought to bend the rules in 0:14:51.720 --> 0:14:56.280 this case, and we struggled with that decision, but as 0:14:56.320 --> 0:15:00.160 a team, we decided to bend the rules and we 0:15:00.200 --> 0:15:01.479 went ahead with a transplant. 0:15:02.080 --> 0:15:04.880 Andrew now runs a program at Johns Hopkins that treats 0:15:04.920 --> 0:15:09.000 people with cases similar to that patient. It was this 0:15:09.120 --> 0:15:12.920 program that helped Jamie get her new liver. Can you 0:15:12.960 --> 0:15:15.040 tell me a bit more about the research that you're 0:15:15.080 --> 0:15:18.640 doing with people with a history of heavy alcohol use 0:15:18.840 --> 0:15:21.080 and their ability to get transplants? 0:15:21.320 --> 0:15:24.040 Sure? So that there was an exciting New England Journal 0:15:24.040 --> 0:15:26.920 paper in which a group of liver transplant centers in 0:15:27.000 --> 0:15:30.560 France transplanted patients like the one I just described and 0:15:30.880 --> 0:15:35.360 in fact, a relatively low percentage of those patients when 0:15:35.400 --> 0:15:39.440 followed carefully, ever, went back to drinking. Now, at Johns Hopkins, 0:15:39.520 --> 0:15:43.600 we decided to start a very similar pilot program, and 0:15:43.880 --> 0:15:49.479 we've now transplanted about one hundred and thirty patients without 0:15:49.640 --> 0:15:53.080 a six month waiting period. And when we compare them 0:15:53.080 --> 0:15:55.600 to a group of patients that got transplanted that Hopkins 0:15:55.640 --> 0:15:57.920 at the same time that did have that six month 0:15:57.960 --> 0:16:03.040 waiting period, there was no hard data that suggested that 0:16:03.040 --> 0:16:04.600 that rule made a lot of sense. 0:16:05.040 --> 0:16:09.120 And so does that mean that any patient with alcohol 0:16:09.160 --> 0:16:11.720 related liver disease is given a transplant? 0:16:12.160 --> 0:16:15.720 Well, thanks for asking that question, because people hear some 0:16:15.840 --> 0:16:19.280 of these stories and say, oh, there's no rules, and 0:16:19.520 --> 0:16:21.840 there are rules. There need to be rules. They just 0:16:21.920 --> 0:16:25.480 not this past fail test, single question have you drank 0:16:25.480 --> 0:16:28.640 in the last six months. Rather, it is a look 0:16:28.680 --> 0:16:33.280 at factors that would meaningfully predict your performance post transplant, 0:16:33.480 --> 0:16:36.600 like do you have insight into your need to change 0:16:36.600 --> 0:16:39.600 your drinking? Do you have a social support network that 0:16:39.680 --> 0:16:43.600 will help you after your transplant? Are you willing to 0:16:43.640 --> 0:16:47.200 participate in programs that would help you stay abstinent after 0:16:47.280 --> 0:16:48.160 your transplant? 0:16:48.960 --> 0:16:51.920 So you talked about insight, and I just want to 0:16:51.920 --> 0:16:55.800 pick up on that, because how do you measure insight? 0:16:56.720 --> 0:16:59.920 It's tough, isn't it. So we all maybe have a 0:17:00.080 --> 0:17:03.000 feel for it. We all maybe can think of times 0:17:03.240 --> 0:17:07.000 in our own lives when something happened that was dramatic 0:17:07.160 --> 0:17:10.439 enough to cause behavior change. So for some folks that 0:17:10.520 --> 0:17:14.199 drink alcohol, that may be getting arrested or a dui. 0:17:14.600 --> 0:17:18.160 It may be a loved one leaving them a divorce 0:17:18.200 --> 0:17:21.480 for example, if they have expressed insight, if they have 0:17:21.560 --> 0:17:25.399 expressed a willingness to participate in programs that will allow 0:17:25.480 --> 0:17:29.480 them to have success after transplant, those are all favorable factors. 0:17:29.760 --> 0:17:34.760 You could imagine almost a group decision by multiple caregivers 0:17:35.000 --> 0:17:39.560 looking at multiple factors that predict performance after transplant and 0:17:39.680 --> 0:17:44.960 making as best we can, and it's not perfect, a logical, fair, 0:17:45.720 --> 0:17:49.200 humane decision about whether this person can get through a 0:17:49.240 --> 0:17:51.359 liver transplant and do well on the back end, if 0:17:51.359 --> 0:17:55.399 the answer is yes or maybe yes, we want to 0:17:55.400 --> 0:17:56.920 go ahead and give them the benefit of the doubt. 0:17:58.119 --> 0:18:01.719 That's great. So I want to talk about Jamie. You know, 0:18:01.800 --> 0:18:06.760 we heard Jamie's story and when she was taken into hospital, 0:18:06.840 --> 0:18:11.080 she was in a coma, and so in that situation, 0:18:11.720 --> 0:18:14.120 how would you determine her insight? 0:18:15.400 --> 0:18:18.639 It's tough, You're right. We didn't have the luxury of 0:18:18.680 --> 0:18:20.719 speaking with her, but we could talk to her family, 0:18:21.200 --> 0:18:24.119 so we couldn't hear it directly from her. But we 0:18:24.240 --> 0:18:28.320 knew that she had tried in the past to achieve 0:18:28.359 --> 0:18:30.760 sobriety and it had success in doing so. And we 0:18:30.840 --> 0:18:35.560 knew that she had some profound life stressors that had 0:18:35.560 --> 0:18:39.399 caused relapse. And that is a common story, and that 0:18:39.560 --> 0:18:43.840 is not a story that we cannot work with after transplant. 0:18:44.240 --> 0:18:48.480 So a lot of things spoke to Jamie's favor enough 0:18:48.520 --> 0:18:51.080 to give her the benefit of the doubt and say, 0:18:51.080 --> 0:18:53.480 this is a young person that we're not ready to 0:18:53.480 --> 0:18:53.960 give up on. 0:18:55.000 --> 0:18:57.399 And could you say a bit more about social support. So, 0:18:57.480 --> 0:19:00.359 for example, if someone doesn't have a partner, does that 0:19:00.440 --> 0:19:03.760 mean that they're kind of like go lower in the list? 0:19:03.880 --> 0:19:07.760 Or a social support is anyone who will help you 0:19:08.040 --> 0:19:10.919 after transplant with the things you need to do to 0:19:11.000 --> 0:19:14.119 take good care of your organ transplant. It could be 0:19:14.359 --> 0:19:18.440 a partner, It could be a family member, it could 0:19:18.480 --> 0:19:23.280 be a friend, it could be somebody from your AA group. 0:19:23.640 --> 0:19:27.000 It is somebody who was willing to help. The kind 0:19:27.000 --> 0:19:30.919 of help you're going to need after transplant is I 0:19:30.960 --> 0:19:32.600 don't feel well. You may have to take me into 0:19:32.600 --> 0:19:35.280 the hospital. I have an appointment tomorrow, I need to 0:19:35.280 --> 0:19:37.560 get my labs checked out. It can also be more 0:19:37.600 --> 0:19:41.600 than that. It can be I'm not feeling great, I'm worried. 0:19:41.640 --> 0:19:43.840 I'm going to have a relapse. Can you help me? 0:19:45.160 --> 0:19:50.240 It would take a person that couldn't identify a single 0:19:50.480 --> 0:19:55.240 soul to help them to get excluded from transplant. And 0:19:56.040 --> 0:20:01.160 even in those scenarios, we have advocates and social workers 0:20:01.320 --> 0:20:05.359 and transplant psychologists that work with our patients to try 0:20:05.560 --> 0:20:09.800 and mobilize somebody. So it's not really about saying yes 0:20:10.119 --> 0:20:14.400 or no. It's about saying, if we do this, how 0:20:14.440 --> 0:20:18.760 can we predict success afterwards? What can we do to 0:20:18.920 --> 0:20:22.760 help you be successful afterwards? And therefore get. 0:20:22.520 --> 0:20:27.200 To yes and yeah, that's great. So how in this 0:20:27.359 --> 0:20:29.320 program do you measure success? 0:20:30.160 --> 0:20:34.359 The gold standard for success after Oregon transplant, as measured 0:20:34.400 --> 0:20:39.200 and reported by the government is one year patient survival, 0:20:39.920 --> 0:20:42.560 and in the large group of patients that we quote 0:20:42.640 --> 0:20:45.680 took a chance on and bent the rules for one 0:20:45.760 --> 0:20:49.440 year later ninety four percent of them were alive and well, 0:20:49.800 --> 0:20:53.600 and that is as high or higher than any other 0:20:53.720 --> 0:20:57.200 indication for liver transplant that you could name. And then 0:20:57.560 --> 0:21:01.760 we measure how many of those folks relapse in terms 0:21:01.800 --> 0:21:07.800 of using alcohol, and probably twenty percent total have any 0:21:07.960 --> 0:21:10.760 relapse at all, as measured even by a single drink. 0:21:10.800 --> 0:21:14.040 And what we saw was that when we worked together, 0:21:14.160 --> 0:21:19.400 when we utilized extra resources to help them stay sober, 0:21:19.840 --> 0:21:23.120 even the small group of folks that return to drinking 0:21:23.480 --> 0:21:28.000 were able to ultimately return to abstinence and sobriety with 0:21:28.200 --> 0:21:28.880 extra help. 0:21:30.240 --> 0:21:34.040 So the people close to death store, they're high on 0:21:34.080 --> 0:21:36.679 the priority list, and then there are going to be 0:21:36.760 --> 0:21:39.520 other people on that list, for example, a young person 0:21:40.119 --> 0:21:43.520 with a congenital liver disease who might not be as 0:21:43.560 --> 0:21:46.159 close to death's door, but they're still waiting on that 0:21:46.200 --> 0:21:49.720 list for a liver transplant. Someone might ask you, why 0:21:49.800 --> 0:21:52.800 would someone like Jamie with a history of heavy alcohol 0:21:53.000 --> 0:21:57.280 use get that liver before their loved one who's also 0:21:57.359 --> 0:21:58.320 on the waiting list. 0:21:59.119 --> 0:22:04.200 These are very difficult questions. So far, society has decided 0:22:04.680 --> 0:22:07.800 that the people that can't wait need to go first, 0:22:07.840 --> 0:22:10.560 and that the people that can wait ought to wait 0:22:10.640 --> 0:22:14.399 until it's their turn. A better system would be if 0:22:14.400 --> 0:22:17.320 we had enough organs to go around for everybody. That's 0:22:17.400 --> 0:22:21.280 not the way it is now. So as you suggest 0:22:21.680 --> 0:22:24.960 somebody who's born with a congenital anomaly, we would of 0:22:25.000 --> 0:22:27.960 course say, oh, well, this isn't your fault. You need 0:22:28.000 --> 0:22:30.160 to go to the front of the line. In this case, 0:22:30.160 --> 0:22:32.359 we were looking at folks that had a claim to 0:22:32.359 --> 0:22:34.359 the front of the line, and we were saying, but 0:22:35.240 --> 0:22:37.320 you did it to yourself, you can't go to the 0:22:37.359 --> 0:22:40.520 head of line. That was the only case in which 0:22:40.560 --> 0:22:44.760 we excluded folks from the recognition that they needed an 0:22:44.760 --> 0:22:49.000 emergent surgery to save their life. And that's probably not 0:22:49.200 --> 0:22:53.360 a modern way of looking at something like alcohol used disorder. 0:22:53.600 --> 0:22:57.640 That's treating it more as a character flaw than a disease. 0:22:58.280 --> 0:23:00.199 You know, I think I have the advantage in this 0:23:00.280 --> 0:23:04.800 discussion of having met these people. They're real people, they are, 0:23:04.920 --> 0:23:09.760 they have families, they have they're they're indistinguishable from folks 0:23:09.840 --> 0:23:13.920 that are listening to this conversation. And it just occurred 0:23:13.920 --> 0:23:16.840 to all of us that a second chance is something 0:23:16.880 --> 0:23:18.920 we all probably are going to need at some point 0:23:19.040 --> 0:23:21.560 in our lives. And if the rules of the game 0:23:21.680 --> 0:23:24.800 are stacked against you or were never made clear or unfair. 0:23:25.000 --> 0:23:27.760 That's just that's just not fair play. And we have 0:23:27.920 --> 0:23:32.480 been able to see how well people can do when 0:23:32.520 --> 0:23:35.800 given a second chance. So I guess I would ask 0:23:35.920 --> 0:23:41.520 people to withhold judgment maybe, and and imagine if it 0:23:41.600 --> 0:23:45.560 was your brother, if it was your your partner, if 0:23:45.600 --> 0:23:50.040 it was your kid that needed a life saving transplant, 0:23:50.960 --> 0:23:54.000 if there was a way for doctors to save your 0:23:54.119 --> 0:23:57.800 kid's life, and somebody tried to say we could, but 0:23:57.880 --> 0:24:00.480 we're just not going to. You wouldn't stay and for it. 0:24:01.320 --> 0:24:03.439 You wouldn't stand for it, and we're not standing for 0:24:03.520 --> 0:24:03.880 it either. 0:24:04.440 --> 0:24:08.680 Okay, So yeah, you've convinced me. And I'm just wondering 0:24:09.119 --> 0:24:14.360