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WHEN 28-year-old Jerika Whitefield’s mitral valve was damaged by endocarditis, she needed life-saving surgery to repair it.
Before performing the surgery, doctors in her native Tennessee gave her a blunt warning: if she repeated the behaviour that had caused the infection in her heart, they would not save her again.
Whitefield, mother of three young children and a survivor of childhood abuse, had begun taking prescription opioids for endometriosis as a teenager, according to The New York Times.
In 2015, she went through a period of postpartum depression and began injecting crushed opioid pills and occasionally methamphetamine. One of those injections introduced the infection that nearly cost her life.
Increasing rates of opioid and methamphetamine addiction, especially in disadvantaged areas such as rural Tennessee, have led to an explosion of injection-related endocarditis, Knoxville cardiothoracic surgeon Dr Thomas Pollard told The New York Times.
Dr Pollard is a vocal advocate for improved addiction services but, like Jerika Whitefield’s doctors, he has made the decision not to perform a second operation on patients whose endocarditis returns as a result of continued drug misuse.
He is haunted by the case of a 25-year-old man whose heart valve he had replaced, only to see him return a few months later with two badly infected valves, including the new one, and a positive test for illegal drugs. Dr Pollard refused to operate a second time and the man died in hospice care.
The doctors interviewed by The New York Times acknowledged that financial issues can factor into a decision not to treat.
In the US, where many of the most disadvantaged individuals may not have access to health insurance, the costs can end up falling back on the hospital. Treatment for endocarditis can cost more than US$150 000, Dr Pollard told The New York Times.
Australia’s universal health insurance means that the issues are not quite as stark here, but the question of who “deserves” treatment can still be a live one.
Faced with a shortage of donor organs, many of us would instinctively feel that a non-smoker should get priority over an individual who smokes for a new lung, or an abstainer over a person with alcoholism for a new liver.
Australian guidelines are firm on this point, saying that “the fact that an individual may require a transplant due to lifestyle choices they may have made in the past is ethically irrelevant”.
But it isn’t always that simple. The guidelines go on: “However, ongoing substance abuse – including excessive alcohol consumption, cigarette smoking and illicit drug use – are generally considered contraindications to transplantation. These lifestyle factors increase the risk of poor transplant outcomes”.
For example, patients in need of a liver transplant as a result of alcohol consumption are generally required to be sober for 6 months before they will be accepted on to the transplant waiting list, the guidelines say. Their risk of recidivism will also need to be assessed.
It seems inevitable that some of those patients will die before they can complete the 6 months of abstinence. This has certainly happened in the US, where similar rules apply.
The guidelines do allow some latitude, but it’s worth considering how much such restrictions are influenced by our judgment of people struggling with substance misuse, and our reluctance to see addiction as a disease rather than a failing of character.
Would our moral outrage be triggered in the same way by somebody whose devotion to skiing led them to keep hitting the slopes, despite repeated injuries and against medical advice?
Where medical resources are scarce, as they are with donated organs, we obviously want them to go to those most likely to benefit, but working out just who that is will never be easy.
There’s no foolproof way to assess somebody’s risk of recidivism and, just because somebody has relapsed before, that doesn’t mean they will again.
I’m grateful that we don’t live under the American system, where lack of insurance can be the deciding factor, but we do face some of the same ethical dilemmas, especially when you consider the shortage of addiction services in many areas.
Jane McCredie is a health and science writer and editor, based in Sydney. You can find her on Twitter at @janemccredie.
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Arguments of economic rationalism justifying prejudicial treatment should make any health professional extremely uncomfortable. If addiction really is a “chronic, relapsing condition, with a strong genetic loading, in which lifestyle factors are significant, and which treatment can ameliorate”, then it is quite similar to type two diabetes. I wonder if the same “ethical dilemmas” are raised when treating patients with diabetes who fail to make significant lifestyle changes? Do we face an “ethical dilemma” when treating people suffering alcohol-related injuries who present to ED? Should we attempt to determine culpability before treating people suffering road trauma, to ensure only the ‘deserving’ victims are treated?
When a lone sailor encountered difficulty in the southern ocean, we spent millions to rescue him from the consequences of his chosen risk-taking activity. Yet twenty years later he continues to knowingly endanger himself… …should taxpayers demand that resources not be wasted on such “selfish” individuals? http://www.abc.net.au/news/2017-02-25/20-years-after-a-dramatic-mid-ocean-rescue2c-veteran-sailor2c/8303466
Are we to apply this argument to Aboriginal people? This seems like discrimination to me. They smoke more, they have more obesity—but all this can be traced back to the continuing injustices they live under. We have to work at removing the causes (and causes of the causes) of these risks.
I agree with some other commentators, the language in this article is quite stigmatising:
– rather than addict try dependant or a person with an alcohol or drug use problem (see the guidelines for referring to dependence in journalism published by http://aodmediawatch.com.au/guidelines-for-journalists/)
– self inflicted? the case study cites a women abused as a child and then prescribed opioids by a doctor for endometriosis a long term painful condition, despite opioids being recommended and on label for short term pain management only
– what about the other social determinants of health, we see wealthy/famous/sports stars in Australia get treatment/transplants and maintain their harmful lifestyle without the censure that the poor experience in the same circumstance
– only 60% of people seeking treatment can access it in Australia, is there any other health condition so poorly resourced?
Excellent and thought-provoking article. As a doctor with the responsibility of distributing a very limited and finite health resource (donated organs), the call is always going to be a tough one. You don’t have control over the politics and emotion surrounding the provision of addiction services, even though you can lobby and express opinion. All you can really rely on is science. The “reluctance to see addiction as a disease rather than a failing of character” is an important point in any debate on the provision of social and other services to help people out of addiction, but is not relevant to transplant surgery. All that can guide the judgement in the latter case is the science – the risk of graft failure and therefore wastage of the donated organ (from all causes, including addiction relapse), the years of life bought as a result, etc. The decision must be dispassionate and not based on criteria out of the transplant surgeon’s direct control.
I truly have no answer to this problem faced only by affluent societies. The ethical discussion that Jane highlights above is one that only doctors in developed countries face but it really focus on the widening disconnect between socialist inclusive medicine model (Australia) and the mainly fee for service model with its stringently cost limited public system of the USA and also what is happening elsewhere in the world. To treat all people uniformly on humanitarian grounds in our socialist system unfortunately conveniently hides the reality that everything has a price that is always paid by someone else; by the taxpayers (loaded with rapidly increasing taxes) and by the other needy patients through the longer waiting lists they will be forced to face. (e.g. the NHS). Our demand for super medicine seems to be in-elastic and this demand must always be met or political oblivion awaits the politician who tries to control it. We have seen over the last thirty to forty years, starting with the HIV patients, the rapid rise of single illness political advocacy groups (with big pharma enthusiastically following on) supplanting medical advisory bodies and totally driving the political process. The cost of the intervention now appears to be a minor consideration when weighed against political virtue signalling. The concept of QALY is almost never considered. I personally truly do not know how this model can be sustained into the future when now routinely see unbelievably expensive drugs (e.g. hundreds of millions of dollars per year for one drug) are routinely added to the health bill for the benefit of very few people. An uncomfortable but truthful observation I’m afraid. I believe if one is truly an ethical person then one must honestly ask: if we can’t or won’t ration health care dollars in our country, what kind of message does that really send to all the people in the developing world? Metaphorically they are like the ‘little match girl’ and sit outside in the freezing economic cold (often starving) and peer through the window at us with utter disbelief at our somewhat contrived angst and our terminal case of affluenza. We do appear to have an unwelcome appointment with the future at some point when the social/health welfare bill eventually becomes unsustainable and cannot be matched by our country’s economic capability. This true unless you believe in the tooth fairy or the magic pudding.
The title of your article “treating addicts….” betrays something of the stigma and dehumanisation that people who use drugs are subjected to. People who use drugs often have insufficient access to treatment for drug dependence over decades, not to mention lack of support for housing, employment and other basic social determinants of health. “Self-inflicted” is very insufficient term to describe the behaviour of people who are experiencing addiction. Case by case assessment leaves the door open to prejudice and ignorance.
I work in addiction and refer all patients who allow me to. Several do not follow through readily. I accept that the treating specialist will have to make case by case decisions.