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When alcohol abstinence criteria create ethical dilemmas for the liver transplant team
  1. K A Bramstedt1,
  2. N Jabbour2
  1. 1Department of Bioethics, Cleveland Clinic Foundation, Cleveland Clinic Lerner College of Medicine, Cleveland, OH 44195, USA
  2. 2University of Southern California (USC), Los Angeles, CA, USA
  1. Correspondence to:
 Katrina A Bramstedt
 PhD, Bioethicist, Associate Staff, Department of Bioethics, Cleveland Clinic Foundation, Cleveland Clinic Lerner College of Medicine, 9500 Euclid Ave, JJ-60, Cleveland, OH 44195, USA; txbioethics{at}

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In the setting of transplant medicine, decision making needs to take into account the multiple clinical and psychosocial case variables, rather than turn to arbitrary rules that cannot be scientifically supported

The yearly demand for liver transplants far exceeds the supply of available organs (living and cadaveric donation).1 Additionally, alcoholic cirrhosis has been a controversial indication for transplant as these recipients can be viewed as having caused their own illness—an illness that is preventable by abstaining from alcohol (or using alcohol in moderation). While not categorically denying liver transplantation to those with alcoholic cirrhosis, many hospitals have incorporated a six month alcohol abstinence criterion (“six month rule”)2 in an effort to select optimal candidates. The six month rule has two purposes; namely, allowing the liver a chance to recover in the absence of alcohol (to possibly avoid the need for transplant), and also observation of the patient to verify that he/she remains alcohol free, with the hope of reducing the risk of relapse. Everhart et al,3 determined that 85% of US liver transplant programmes and 43% of third party payers require a defined period of abstinence—for example, three or six months—as part of the waiting list process.

Liver transplantation does not cure alcoholism, as evidenced by the fact that roughly 20% of these patients use alcohol following transplant, with one third exhibiting “repetitive or heavy drinking”.4 Arguments abound as to the scientific merit of a six month abstinence criterion in reducing the risk of alcohol relapse following transplant. Some propose that a minimum of six months abstinence itself predicts a lower relapse rate,5 while others argue that six months is not predictive or that other factors—for example, illicit drug use—in combination with a minimum number of months abstinent is predictive.6,7 Even the United …

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