Monday, April 28, 2008

Medical Marijuana discrimination?

Here is a simple, yet, controversial question: If someone has used marijuana - even if used for medical reasons - should this prohibit him or her from being considered to be on a transplant list? Hospitals throughout this great nation struggle with this question every day.

Timothy Garon (pictured above) is a patient at the University of Washington Medical Center. He has end stage Hepatitis C and, according to this Associated Press story, may be in his final days without a liver transplant.
But Garon's been refused a spot on the transplant list, largely because he has used marijuana, even though it was legally approved for medical reasons. "I'm not angry, I'm not mad, I'm just confused," said Garon, lying in his hospital bed a few minutes after a doctor told him the hospital transplant committee's decision Thursday.

With the scarcity of donated organs, transplant committees like the one at the University of Washington Medical Center use tough standards, including whether the candidate has other serious health problems or is likely to drink or do drugs. And with cases like Garon's, they also have to consider — as a dozen states now have medical marijuana laws — if using dope with a doctor's blessing should be held against a dying patient in need of a transplant.
Now, according to the American Liver Foundation, in 2005, approximately 6500 liver transplants were performed in the United States. Also, according to the site, it states that about 17000 Americans are on the liver transplant list. Interestingly enough, the CDC website states that the number of new infections with Hepatitis C has decreased from 240000 in the 1980s to about 19000 in 2006.

The issue of who should and who should not receive a transplant is always controversial. I think the issue of use of marijuana is interesting as I have blogged about it before here, here, and here.

Even though this gentleman's story is very compelling, I'm going to have to side with the hospital on this one. I agree with what was said by Dr. Robert Sade, director of the Institute of Human Values in Health Care at the Medical University of South Carolina. "Marijuana, unlike alcohol, has no direct effect on the liver. It is however a concern ... in that it's a potential indicator of an addictive personality." (And in my book, not a good candidate for a transplant.)


Anonymous said...

I couldn't disagree with the hospital more strongly. The MJ used was under a doctor's care, and unless said doctor is also coming up on state medical board charges for reckless rx negligence, one MUST assume the patient was acting on his doctor's advice directly or implicitly. He should not be disqualified simply because of this. Liver xplant pts are scored, partly based on objective data like INR, Cr, bili, etc. and on subjective data, but the latter is used to determine if there's a compelling psychological (compliance) or social (aftercare) reason to worry if the organ is meeting a dead end best used for someone else. I just can't see how some long-reaching, transitive logic (A=B, B=C, therefore A=C) trumps the otherwise "passing" data. I mean even the quote says, "potential indicator..." Dealing with life/death when all else is a green light, "potential" might as well be "definitive."

Having said that, as a [hopefully future] clinician speaking personally, I'm against the use of medical marijuana for one reason only: it's an inconsistent product pharmacologically and therefore can't be managed with objectively reproducible results. As far as public policy is concerned, however, I am for allowing its use by appropriately trained clinicians (eg, pain specialists having the full arsenal of Schedule II drugs saying MJ would be a viable choice for a pt).

The litmus test for an alcoholic in ESLD is to prove 6 months of sobriety to be eligible for the list. Just 6 months!! Garon's case is so inequitable compared to this.

Neumed said...

I would comment, but I have to go work on my prostate cancer prevention program. :)

Anonymous said...

I also happen to agree with the hospital's decision. It is unfortunate for this man to be suffering and the probability of death imminent, however there are many, many people just like him that are substance free. Thus I understand why they would pass on him and give to someone else whose history is "clean". It's a tough decision and I am glad I do not have to make it!

Anonymous said...

I also agree that this is an extremely tough decision to make and I agree with "asthepumpturns" insofar as I'm glad I don't have to make it either!

My driveby thoughts:

1. The patient was prescribed medical marijuana by his doctor. He should not be penalized (and fatalistically penalized no less) for the decisions his physician made about his care. I agree with what 'enrico' - unless his doctor is being charged with negligence, it doesn't make sense to penalize him for being compliant with his doctor's instructions.

2. There are other narcotics that patients are prescribed for pain control: for example, prescription opiates are almost all Schedule I or II controlled substances and are highly addictive substances. These drugs are routinely prescribed for pain control - even for basic/common procedures like root canals - and b/c of its addictiveness are unfortunately becoming a rapidly popular class of drugs to abuse. So why is one class of prescribed very addictive narcotics more appropriate than another class of prescribed arguably addictive narcotics? From my (admittedly) non-clinician's perspective it seems like a tenuous distinction to make, and I think really it is only being made because of the hospital administration's personal bias against marijuana use and marijuana users.

3. Then again, the patient has a verified history of addiction to speed. Is the administration making their decision based on the speed use or the marijuana use? Or both? The history of addiction to speed is reflective of having an addictive personality, and I can somewhat understand rejecting his request based on that alone. However, he abused speed decades ago - does that mean he suddenly will start again b/c he uses a prescribed narcotic?

In this patient's case - I don't think there is a clearcut answer. But it does set an unfortunate precedent for patients with zero history of drug abuse who are prescribed medical marijuana.

Either way, this is certainly an interesting/ripe medical ethics topic! I look forward to other people's opinions and input.

My Own Woman said...

Asthepumpturns commented, "Thus I understand why they would pass on him and give to someone else whose history is "clean". It's a tough decision and I am glad I do not have to make it!"

I'm still wondering if ANY of us out there who grew up in the late 60's early 70's have a clean "history." Heck, they gave that baseball guy a new liver and he was an alcoholic. I'm thinking that wasn't "clean living" and he wasn't drinking for medicinal purposes. And yes, I do believe that marijuana can have medicial value. Any one person, even the sick and dying, do the best they can with what they have.

To me it's pretty simple, we do things when we are young and stupid and sometimes we don't even realize the full consequences of our actions. It's what we do AFTER we know the consequences that should be considered.

Now, in this particular man's case, the doctor prescribed marijuana for medicinal purposes.
Now, should we refuse him transplants? Ummm...hell no. If it's medicinal, why should we. If it's recreational....maybe a different story.

Anonymous said...

Like so many other aspects of drug policy in this country, this just doesn't make any sense. I'm not going to try and articulate my position here as it would really require an entire post (or even multiple posts) unto themselves.

On a related note, I'm about to start residency in California, so the medical marijuana issue may come up. How does that work? Can I just write a prescription? Do they just take it to the pharmacy? Does anyone know?

Unknown said...

In your article tells that, Timothy Garon is a marijuana addict he is requiring liver transplantation to replace a damaged heart, but whatever the request was rejected because he was as addicted to marijuana and not a drug or alcohol. Because the reason the hospital did not approve it is because he has a level of serious health and drug or alcohol but not marijuana, because each country now have medical marijuana laws. The information is very valuable, thanks.