Allocating livers to substance and alcohol misusers

The success of liver transplantation for the treatment of patients with end-stage liver disease has resulted in a widening gap between the number of potential recipients and the numbers of grafts available. Allocation of these scarce resources to people who have developed liver failure as a consequence of their own and often illegal behaviour has attracted much controversy. For patients with alcoholic liver disease, there is relatively little evidence that many patients return to a damaging pattern of alcohol consumption and, at least in the short term, the outcome is no different compared with patients grafted for other causes of cirrhosis. There are well-validated markers which predict abstinence. For abusers of other substances, there is relatively little experience. Of concern is the variation between the priority-setting by the medical profession and the general public. The latter, who, in the UK, can be considered as providers of the donated organs and pay for the costs of the procedure, tend to rate patients with alcoholic liver disease and who have drug or substance abuse at a lower priority than those who develop liver failure from other causes. These differences need further debate and resolution.