The increasing discrepancy between the number of people with end-stage liver disease who could benefit from a liver transplant (with in improvement in both quality and quantity of life) and the availability of suitable livers from deceased donors means that not all those who might benefit from the procedure can be offered and receive a graft. Thus, rationing of the available organs has to occur. The often competing objectives of equity, justice, utility, and benefit have to be balanced. Different health care systems have developed appropriate guidelines.
It has been recognized for many years that selected patients with alcoholic liver disease (ALD) are suitable candidates for liver transplantation with excellent outcomes, broadly similar to those grafted for other indications.1 Nonetheless, transplantation of those with ALD has generated a widespread concern among the general public, health care professionals, patients, and potential donors and their families. The reasons for this concern are multifactorial and encompass both judgmental and nonjudgmental issues, including concerns that the liver damage is self-induced and the recipient may return to a pattern of alcohol consumption, leading to graft failure or noncompliance. The actual situation is more complex, and health care professionals have developed guidelines to help select suitable recipients who not only would benefit from the procedure, but would also be at low risk of returning to a damaging pattern of alcohol consumption, whether from a direct effect of alcohol on the graft or indirect effects on extrahepatic organ damage, noncompliance, or other patterns of behavior that lead to death. Despite the observations that a return to some form of alcohol consumption is not uncommon, with current practice, graft loss from a return to alcohol consumption is small, and far less than the effect of recurrent hepatitis C viral infection.
Nonetheless, the views of the public and health care professionals are important, and clinicians involved in the delivery of liver transplantation must recognize the public opinion, even if they disagree with those views. In this article, the surveys of public opinion will be discussed. It must be remembered that public opinion may not necessarily reflect current medical and ethical practice, and in some cases, there may not have been the opportunity to think through the consequences and implications of the responses.