Rather paradoxically, the personal and intellectual roots of Sir Isaiah Berlin, an influential contributor to liberal political theory and Western political thought, stem from East-European autocra...

The ethics committee of the University of São Paulo Medical College Hospital and Clinics has authorized partial liver transplantation from living donors. The request for this type of transplantation was brought to the committee by a team of professors of surgery operating at the university, headed by Dr. Silvano Raia. Their request and justification are presented here, with discussion following.

Living donation provides important access to organ transplantation, which is the optimal therapy for patients with end-stage liver or kidney failure. Paired exchanges have facilitated thousands of kidney transplants and enable transplantation when the donor and recipient are incompatible. However, frequently willing and otherwise healthy donors have contraindications to the donation of the organ that their recipient needs. Trans-organ paired exchanges would enable a donor associated with a kidney recipient to donate a lobe of liver and a donor (...) associated with a liver recipient to donate a kidney. This article explores some of the ethical concerns that trans-organ exchange might encounter including unbalanced donor risks, the validity of informed consent, and effects on deceased organ donation. (shrink)

Splitting livers allows two people to receive a liver transplant from one donated adult liver, but the risks to the adult recipient are greater than if they had received the equivalent whole liver. It has been suggested, therefore, that splitting livers harms adult recipients. Without liver splitting, however, there would be few livers available for children, and paediatric waiting time and waiting list mortality would significantly increase. In this paper, we argue that although splitting livers makes (...) adults worse off, this should be considered sub-optimal benefit rather than harm. We explore justifications for sub-optimally benefitting adults in this way and consider alternatives to the current approach. We argue that splitting livers masks the more fundamental problem of low paediatric donation rates and that increasing the number of paediatric donations would improve the situation for both adult and paediatric liver patients. (shrink)

This paper discusses the views of 17 healthcare practitioners involved with transplantation on the ethics of live liver donations . Donations between emotionally related donor and recipients increased the acceptability of an LLD compared with those between strangers. Most healthcare professionals disapproved of altruistic stranger donations, considering them to entail an unacceptable degree of risk taking. Participants tended to emphasise the need to balance the harms of proceeding against those of not proceeding, rather than calculating the harm-to-benefits ratio of (...) donor versus recipient. Participants’ views suggested that a complex process of negotiation is required, which respects the autonomy of donor, recipient and HCP. Although they considered that, of the three, donor autonomy is of primary importance, they also placed considerable weight on their own autonomy. Our participants suggest that their opinions about acceptable risk taking were more objective than those of the recipient or donor and were therefore given greater weight. However, it was clear that more subjective values were also influential. Processes used in live kidney donation were thought to be a good model for LLD, but our participants stressed that there is a danger that patients may underestimate the risks involved in LLD if it is too closely associated with LKD. (shrink)

Background and aims: Liver transplantation provides an opportunity of survival for patients with liver failure, however, this procedure is known to be psychologically and physically fatiguing for patients and their informal caregivers. The aim of this study was to investigate how perceived social support and the distribution of dependency were associated with the psychological wellbeing of patients waiting for liver transplantation and their caregivers, as a dyad. Methods: The present was a cross sectional study. 95 participants were (...) recruited at a hospital in Northern Italy, during the psychological evaluation for inclusion in the transplantation list: 51 patients (19 with alcohol-related illness), and 44 family caregivers. Both patients and caregivers filled in a Symptom Checklist and Kelly's Dependency Grids. Patients also compiled the Medical Outcomes Study Social-Support Survey, and caregivers the Family Strain Questionnaire Short- Form. Results: Caregivers reported important levels of strain, also strongly related to a worsening of their own and patients’ symptoms Patients with alcohol-related pathologies had a narrower social network, which corresponded to an increase in family strain. On the sample as a whole, regression analyses showed that perceived social support and dependency measures did not predict patients’ and caregivers’ symptoms. Nevertheless, cluster analysis identified a group of caregivers who distributed their dependency more and experienced lower levels of depression, anxiety and strain. Conclusions: These results suggest the usefulness of a dyadic approach in the research, prevention and care of liver diseases. A deeper comprehension of the functioning of dyads will help practitioners in the identification of situations at risk. (shrink)

Is it possible to invoke the use of moral responsibility as part of the selection criteria in the allocation of livers for transplant? Criticism has been applied to the difficulties inherent in including such a criterion and also the effect that employing such a judgement might have upon the relationship between the physician and patient. However, these criticisms rely on speculation and conjecture and do not relate to all the arguments put forward in favour of applying moral responsibility. None of (...) the present arguments against using moral responsibility in the allocation of livers for transplant are good enough to warrant its dismissal. (shrink)

Many believe that it is morally wrong to give lower priority for a liver transplant to alcoholics with end-stage liver disease than to patients whose disease is not alcohol-related. Presumably, alcoholism is a disease that results from factors beyond one's control and therefore one cannot be causally or morally responsible for alcoholism or the liver failure that results from it. Moreover, giving lower priority to alcoholics unfairly singles them out for the moral vice of heavy drinking. I (...) argue that the etiology of alcoholism may involve enough control for the alcoholic to be responsible for his condition and accordingly have a weaker claim to receive a new liver than someone who acquires the disease through no fault of his own. In addition, I show why it is more plausible to reframe the question of priority in terms of control and responsibility rather than virtue and vice. Given that medical resources like livers are scarce, some people may justifiably be given lower priority than others in receiving these resources. (shrink)

Liver transplantation (LT) activities during the COVID-19 pandemic have been curtailed in many countries. The impact of various policies restricting LT on outcomes of potential LT candidates is unclear. We studied all patients on the nationwide LT waitlists in Hong Kong and Singapore between January 2016 and May 2020. We used continuous time Markov chains to model the effects of different scenarios and varying durations of disruption on LT candidates.

Split liver transplantation (SLT) provides an opportunity to divide a donor liver, offering transplants to two small patients (one or both could be a child) rather than keeping it whole and providing a transplant to a single larger adult patient. In this article, we attempt to address the following question that is identified by the Organ Procurement and Transplant Network and United Network for Organ Sharing: ‘Should a large liver always be split if medically safe?’ This article (...) aims to defend an answer—‘not always’—and clarify under what circumstances SLT is ethically desirable. Our answer will show why a more dynamic approach is needed to the ethics of SLT. First, we discuss a case that does not need a dynamic approach. Then, we explain what is meant by a dynamic approach and why it is needed. (shrink)

In a provocative 1991 paper, Alvin Moss and Mark Siegler argued that it may be fair to give individuals with alcohol-related end-stage liver disease lower priority for a liver transplant than those who develop end-stage liver disease from other factors. Like other organs, there is a substantial gap between the available livers for transplantation and the number of people who need liver transplants. Yet, unlike those with end-stage renal disease, who can survive for some time on (...) dialysis before receiving a kidney transplant, those with liver failure will die without a liver transplant. (shrink)

Caffeine, a known CNS stimulant is given as an adjunct component in most abused drugs which could be fatal with repeated administration in many circumstances. This paper presents a study to investigate the effect of repeated administration of caffeine at high dose on rat liver, and discusses ethical and policy issues of caffeine use. Long Evans rats were treated with pure caffeine solution in distilled water through intragastric route once daily for consecutive 56 days. Three groups of rats recognized (...) as low dose, high dose and control group received 6mg caffeine / kg BW, 12mg caffeine / kg BW and distilled water, respectively. Rat plasma was examined for liver transaminases and alkaline phosphatases concentrations which were significantly increased in plasma as compared to the control. Both rat plasma and liver homogenate were subjected to estimate malondialdehyde, advanced oxidation protein product, nitric oxide, antioxidant enzyme catalase, glutathione and superoxide dismutase activity. MDA, AOPP, NO levels increased and SOD activity decreased significantly in both plasma and liver as compared to those of control where as CAT and GSH activity remain unchanged. Rat liver tissues were studied histochemically with Hematoxylin and Eosin, and Picro Sirius Red staining. Significantly increased infiltration of inflammatory cells and progressive deposition of collagen fibre were visible in liver tissue of caffeine treated both dose groups as compared to the control. Long term administration of caffeine at higher dose, significantly contributes to liver inflammation and consequent fibrogenesis. This raises significant ethical and policy issues. (shrink)

The decline in organs donated after brain death has been countered by an increase in organs donated after circulatory death. Organs donated after circulatory death present an increased risk of complications for their eventual recipients when compared with organs donated after brain death, so the likelihood of successful transplantation is decreased. If organ donation is considered to be in the best interests of the patient, interventions that facilitate successful donation and transplantation might be permissible. This paper seeks to establish whether (...) it is ethically permissible to manage the end-of-life care of a dying patient to maximize the chances of successful transplantation, and if so, whether it is permissible to further maximize these chances by managing the potential donor to enable donation after brain death rather than donation after circulatory death. (shrink)

Background: Allocation of scarce organs for transplantation is ethically challenging. Artificial intelligence (AI) has been proposed to assist in liver allocation, however the ethics of this remains unexplored and the view of the public unknown. The aim of this paper was to assess public attitudes on whether AI should be used in liver allocation and how it should be implemented. Methods: We first introduce some potential ethical issues concerning AI in liver allocation, before analysing a pilot survey (...) including online responses from 172 UK laypeople, recruited through Prolific Academic. Findings: Most participants found AI in liver allocation acceptable (69.2%) and would not be less likely to donate their organs if AI was used in allocation (72.7%). Respondents thought AI was more likely to be consistent and less biased compared to humans, although were concerned about the “dehumanisation of healthcare” and whether AI could consider important nuances in allocation decisions. Participants valued accuracy, impartiality, and consistency in a decision-maker, more than interpretability and empathy. Respondents were split on whether AI should be trained on previous decisions or programmed with specific objectives. Whether allocation decisions were made by transplant committee or AI, participants valued consideration of urgency, survival likelihood, life years gained, age, future medication compliance, quality of life, future alcohol use and past alcohol use. On the other hand, the majority thought the following factors were not relevant to prioritisation: past crime, future crime, future societal contribution, social disadvantage, and gender. Conclusions: There are good reasons to use AI in liver allocation, and our sample of participants appeared to support its use. If confirmed, this support would give democratic legitimacy to the use of AI in this context and reduce the risk that donation rates could be affected negatively. Our findings on specific ethical concerns also identify potential expectations and reservations laypeople have regarding AI in this area, which can inform how AI in liver allocation could be best implemented. (shrink)

The United Network for Organ Sharing recently changed the policy by which donor livers are allocated to liver failure patients in the United States. Formerly, all liver failure patients were characterized as status 1 and placed at the top of the transplant list. Under the new policy, only patients with liver failure due to acute illness () are eligible for status 1; patients with liver failure due to chronic liver disease () are characterized as status (...) 2. Since donor organs are allocated first to status 1 patients and then to status 2 patients, the new policy moves all CLF patients down on the waiting list relative to all ALF patients. This means that some livers that would have gone to CLF patients under the old policy will now go to ALF patients. Accordingly, while the new policy will likely increase the number of ALF patients saved, it will also increase the number of deaths among CLF patients waiting for a transplant. (shrink)

The world’s first living donor liver transplant from an HIV-positive mother to her HIV-negative child, performed by our team in Johannesburg, South Africa in 2017, was necessitated by disease profile and health system challenges. In our country, we have a major shortage of donor organs, which compels us to consider innovative solutions to save lives. Simultaneously, the transition of the HIV pandemic, from a death sentence to a chronic illness with excellent survival on treatment required us to rethink our (...) policies regarding HIV infection and living donor liver transplantation. Although HIV infection in the donor is internationally considered an absolute contraindication for transplant to an HIV-negative recipient, there have been a very small number of unintentional transplants from HIV-positive deceased donors to HIV-negative recipients. These transplant recipients do well on antiretroviral medication and their graft survival is not compromised. We have had a number of HIV-positive parents in our setting express a desire to be living liver donors for their critically ill children. Declining these parents as living donors has become increasingly unjustifiable given the very small deceased donor pool in SA; and because many of these parents are virally suppressed and would otherwise fulfil our eligibility criteria as living donors. This paper discusses the evolution of HIV and transplantation in SA, highlights some of the primary ethical considerations for us when embarking on this case and considers the new ethical issues that have arisen since we undertook this transplant. (shrink)

The allocation of any scarce health care resource, especially a lifesaving resource, can create profound ethical and legal challenges. Liver transplant allocation currently is based upon urgency, a sickest-first approach, and does not utilize capacity to benefit. While urgency can be described reasonably well with the MELD system, benefit encompasses multiple dimensions of patients’ well-being. Currently, the balance between both principles is ill-defined. This survey with 502 participants examines how urgency and benefit are weighted by different stakeholders. Liver (...) transplant patients favored the sickest-first allocation, although all other groups tended to favor benefit. Criteria of a successful transplantation were a minimum survival of at least 1 year and recovery of functional status to being ambulatory and capable of all self-care. An individual delisting decision was accepted when the 1-year survival probability would fall below 50%. Benefit was found to be a critical variable that may also trigger the willingness to donate organs. The strong interest of stakeholder for successful liver transplants is inadequately translated into current allocation rules. (shrink)

Background The allocation of any scarce health care resource, especially a lifesaving resource, can create profound ethical and legal challenges. Liver transplant allocation currently is based upon urgency, a sickest-first approach, and does not utilize capacity to benefit. While urgency can be described reasonably well with the MELD system, benefit encompasses multiple dimensions of patients’ well-being. Currently, the balance between both principles is ill-defined. Methods This survey with 502 participants examines how urgency and benefit are weighted by different stakeholders. (...) Results Liver transplant patients favored the sickest-first allocation, although all other groups tended to favor benefit. Criteria of a successful transplantation were a minimum survival of at least 1 year and recovery of functional status to being ambulatory and capable of all self-care. An individual delisting decision was accepted when the 1-year survival probability would fall below 50%. Benefit was found to be a critical variable that may also trigger the willingness to donate organs. Conclusions The strong interest of stakeholder for successful liver transplants is inadequately translated into current allocation rules. (shrink)

In this work, a system for the classification of liver dynamic contest- enhanced CT images is presented. The system simultaneously analyzes the images with the same slice location, corresponding to three typical acquisition moments. At first, the texture features are extracted separately for each acquisition mo- ment. Afterwards, they are united in one “multiphase” vector, characterizing a triplet of textures. The work focuses on finding the most appropriate features that characterize a multi-image texture. At the beginning, the features which (...) are unstable and dependent on ROI size are eliminated. Then, a small subset of remaining features is selected in order to guarantee the best possible classification accuracy. In total, 9 extraction methods were used, and 61 features were calculated for each of three acquisition moments. 1511 texture triplets, corresponding to 4 hepatic tissue classes were recognized. As a classifier, an adaptive boosting algorithm with a C4.5 tree was used. Experiments show that a small set of 12 features is able to ensure classification accuracy exceeding 90%, while all of the 183 features provide an accuracy rate of 88.94%. (shrink)

Over eighty years ago, a third, previously unidentified copy of the Anglo-Norman prose chronicle, Le Livere de Reis de Engleterre,was discovered in John Rylands French MS 64. Despite this discovery, and the paucity of witnesses to this chronicle, scholars of LRE generally pass over the version contained in the John Rylands manuscript. Through an examination of the sources and variant readings of LRE, this article argues that this previously overlooked copy of LRE is more authoritative than the other two. The (...) superiority of the John Rylands manuscript enables us to determine best text readings of LRE with improved accuracy. It also allows us to date the chronicle with greater precision than previously possible, and provides grounds for tentatively locating the origins of the chronicle to northeastern England. (shrink)

BackgroundThe German guidelines for liver transplantation stipulate that every patient with alcohol-related liver disease needs to prove evidence of a 6-month abstinence period before they can be admitted to the waiting list for liver transplantation. This internationally widespread abstinence rule has been criticised as it prevents patients at least temporarily from receiving an effective and potentially life-saving therapy. This poses the question of how this abstinence rule is depicted and justified by transplantation professionals.ArgumentsIn case of the 6‑month (...) abstinence rule, guidelines are used as a tool for rationing health care. Four frames of interpretation can be reconstructed from the ethical and medical literature. Each linguistically mediated frame offers a different representation of the 6‑month abstinence rule. According to these different framings, the 6‑month waiting period is depicted (1) as a diagnostic tool to determine the regenerative capacity of the liver, (2) as a prognostic tool to determine the prospects of success of a transplantation, and (3) to determine the drinking behaviour after transplantation. In a further context, the abstinence rule (4) is interpreted as an expression of an obligation to avoid behaviour harmful to health.ConclusionThese four frames provide linguistically mediated patterns of interpretation that are used by different actors to limit the indication for liver transplantation. They give rise to different ethical questions that allow a systematic ethical assessment of the 6‑month abstinence rule. (shrink)

The liver is the human body’s mandatory organ, but detecting liver disease at an early stage is very difficult due to the hiddenness of symptoms. Liver diseases may cause loss of energy or weakness when some irregularities in the working of the liver get visible. Cancer is one of the most common diseases of the liver and also the most fatal of all. Uncontrolled growth of harmful cells is developed inside the liver. If diagnosed (...) late, it may cause death. Treatment of liver diseases at an early stage is, therefore, an important issue as is designing a model to diagnose early disease. Firstly, an appropriate feature should be identified which plays a more significant part in the detection of liver cancer at an early stage. Therefore, it is essential to extract some essential features from thousands of unwanted features. So, these features will be mined using data mining and soft computing techniques. These techniques give optimized results that will be helpful in disease diagnosis at an early stage. In these techniques, we use feature selection methods to reduce the dataset’s feature, which include Filter, Wrapper, and Embedded methods. Different Regression algorithms are then applied to these methods individually to evaluate the result. Regression algorithms include Linear Regression, Ridge Regression, LASSO Regression, Support Vector Regression, Decision Tree Regression, Multilayer Perceptron Regression, and Random Forest Regression. Based on the accuracy and error rates generated by these Regression algorithms, we have evaluated our results. The result shows that Random Forest Regression with the Wrapper Method from all the deployed Regression techniques is the best and gives the highest R2-Score of 0.8923 and lowest MSE of 0.0618. (shrink)

Organ transplantation has increased worldwide while the number of organ donors have not increased similarly. Consequently, the waiting period for transplant candidates is prolonged. Patient narratives have uncovered physical and psychosocial suffering in the transplantation process. However, relatively few studies have explored patients’ experiences in the actual waiting period. This qualitative study was conducted in Norway and aimed to describe patients’ experiences of being accepted as recipients of a new liver and their waiting following this decision. A sample of (...) 21 patients with end‐stage liver disease, placed on the ordinary waiting list for a liver transplant, were interviewed in the hospital before they went home to wait for a compatible liver. Uncertainty related to life and death was a major issue, both in the waiting period and as a response to being put on the waiting list. Another central issue was their overwhelming lack of energy. Patients inferred a linear relationship between lack of energy, physical limitations and mental distress. Despite major advances in medical treatment, little follow‐up was given during the waiting period and most of the patients seemed resigned to the inevitability of their suffering. This raises issues of health personnel responsibility and a need to heighten awareness about patient suffering during the waiting period. (shrink)

ObjectiveThis study aims to investigate anxiety and its influencing factors in patients with drug-induced liver injury (DILI).Materials and MethodsNinety-four patients with DILI were enrolled and evaluated with a self-rating anxiety scale (SAS). According to the anxiety score, they were divided into four groups: the non-anxiety, mild anxiety, moderate anxiety, or severe anxiety groups, and the scores were analyzed based on demographic and biochemical indicators.ResultsOf the 94 patients with DILI, 63 did not have anxiety and 31 had anxiety (32.9%), of (...) which 27 had mild, 3 had moderate, and 1 had severe anxiety. There were no statistically significant differences in gender, age, occupation, and level of education between the groups (F= 1.42,H= 2.361,H= 6.751,H= 1.796, andP> 0.05); anxiety score and degree of anxiety between the types of drugs that led to the liver injury (H= 0.812,H= 1.712, andP> 0.05); anxiety score between the different degrees of liver injury (H= 2.836,H= 4.957,P> 0.05); or length of hospital stay or prognosis between the degrees of anxiety (F= 1.487,H= 0.761,P> 0.05). However, there were statistically significant differences in the degree of anxiety between different degree and types of liver injury (H= 7.981,H= 8.208,P< 0.05).ConclusionPatients with DILI may have anxiety, especially mild anxiety. The occurrence of anxiety in patients with DILI is not related to gender, age, occupation, or level of education but may be related to the degree and type of liver injury. Anxiety has no impact on the length of stay in hospital or the prognosis of the DILI. These findings may contribute to the development of management strategies for patients with DILI. (shrink)

Limited Aggregation is the view that when there are competing moral claims that demand our attention, we should sometimes satisfy the largest aggregate of claims, depending on the strength of the claims in question. In recent years, philosophers such as Patrick Tomlin and Alastair Norcross have argued that Limited Aggregation violates a number of rational choice principles such as Transitivity, Separability, and Contraction Consistency. Current versions of Limited Aggregation are what may be called Comparative Approaches because they involve assessing the (...) relative strengths of various claims. In this paper, we offer a non-comparative version of Limited Aggregation, what we call the Threshold Approach. It states that there is a non-relative threshold that separates various claims. We demonstrate that the Threshold Approach does not violate rational choice principles such as Transitivity, Separability, and Contraction Consistency, and we show that potential concerns regarding such a view are surmountable. (shrink)

Medical technology assessment deals with the evaluation of novel or existing health care procedures. This paper addresses the interdependence between factual and normative issues, using the controversies about acceptability and desirability of reduced-size liver transplantations with living donors as example.

The dominant model for bioethical inquiry taught in medical schools is that of principlism. The heritage of this methodology can be traced to the Enlightenment project of generating a universalizable justification for normative morality arising from within the individual, rational agent. This project has been criticized by Alasdair MacIntyre who suggests that its failure has resulted in a fragmented and incoherent contemporary ethical framework characterized by fundamental intractability in moral debate. This incoherence implicates principlist conceptions of bioethics. Medical ethics as (...) practiced, though, is partially in keeping with teleological alternatives to principlism. Nonetheless, the hegemony of principlism threatens to harm the practice of good medicine whenever it is used to provide justification for the sanction or prohibition of practices, despite not being equipped to grant moral authority to such justifications. An example of this failure and its resulting harm is expressed in the growing obsolescence of living donor liver transplantation. (shrink)

When does behavior trigger a lesser claim to medical resources? When does chronic drinking, for example, mean that one has a lesser claim to a liver transplant? Only when one's behavior becomes a callous indifference to others' needs—when one knows the consequences of heavy drinking and knows that by drinking one may end up depriving someone else of a liver.

Some philosophers and physicians have argued that alcoholic patients, who are responsible for their liver failure by virtue of alcoholism, ought to be given lower priority for a transplant when donated livers are being allocated to patients in need of a liver transplant. The primary argument for this proposal, known as the Responsibility Argument, is based on the more general idea that patients who require scarce medical resources should be given lower priority for those resources when they are (...) responsible for needing them and when they are competing with patients who need the same resources through no fault of their own. Since alcoholic patients are responsible for needing a new liver and are in direct competition with other patients who need a new liver through no fault of their own, it follows that alcoholic patients ought to be given lower priority for a transplant. In this article, I argue against the Responsibility Argument by suggesting that in order for it to avoid the force of plausible counter examples, it must be revised to say that patients who are responsible for needing a scarce medical resource due to engaging in behavior that is not socially valuable ought to be given lower priority. I'll then argue that allocating organs according to social value is inconsistent or in tension with liberal neutrality on the good life. Thus, if one is committed to liberal neutrality, one ought to reject the Responsibility Argument. (shrink)

The liver progenitor cell (LPC) has enormous potential for use in cell therapy to treat liver disease. Since liver regenerates readily from pre‐existing hepatocytes, a role for LPCs and, indeed, their existence have been questioned. Research during the last decade has established that LPCs are an important alternative source of cells for liver regeneration. Their utility for cell therapy lies in their ability to generate both hepatocytes and cholangiocytes. However, they are observed in liver diseases (...) that often lead to cancer and there is experimental evidence that implicates LPCs as the source of tumours. This article provides a brief history of the studies that established the functional importance of LPCs in liver disease. It focuses on mouse models that have led to the identification of factors that regulate LPC growth and differentiation and discusses LPCs derived from different sources. Recent promising results from both in vitro and vivo studies suggest that LPCs could be useful for cell therapy. In the context of liver disease, LPCs may indeed be the cell of the future and understandably “our favourite cell”. BioEssays 27:1192–1202, 2005. © 2005 Wiley Periodicals, Inc. (shrink)

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 supportedThe yearly demand for liver transplants far exceeds the supply of available organs .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 . While not categorically denying (...) class='Hi'>liver transplantation to those with alcoholic cirrhosis, many hospitals have incorporated a six month alcohol abstinence criterion 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 , 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 …. (shrink)