Today’s medical news is about a girl who died because she was denied a liver transplant.

One editorialist blasts the denial as a major denial of the girl’s civil rights under the UN mandates that grant everyone a right to free medical care.
And the local attorney plans to file manslaughter charges against the company.

All these stories are from the template: Girl is healthy, girl got sick, if she got the transplant, she’d get well and live happily ever after. But the evil witch Insurance company denied the transplant so she died. Let’s kill the witch.

So she died because an evil insurance company wouldn’t pay $75 thousand to do her tranplant.

The problem?

The girl wasn’t healthy. She had just gotten a bone marrow tranplant from her brother to treat her leukemia. This is a very expensive procedure, since you have to kill off the patient’s own bone marrow before giving the new bone marrow, so you need to keep the person isolated from germs during that time.

Presumably the insurance company paid for this bone marrow tranplant, and the weeks she spent in Intensive care being treated for complications of that transplant.

There are various forms of leukemia, and most respond to chemotherapy, but only in the more lethal forms do you risk curing people by doing a bone marrow transplant.

Bone marrow contains cells that make red blood cells that carry oxygen, and several forms of white blood cells that fight off infection. Leukemia is cancerous overgrowth of the cells that make white blood cells. Bone marrow also makes platelets, that stop bleeding.

In a bone marrow tranplant, you kill off the person’s own bone marrow so you can kill off the cancerous one. You then replace the marrow with either stem cells or a matching bone marrow. This is the only chance to cure some of the more lethal types of leukemia that don’t respond well to chemotherapy.

But the medicines used have a lot of side effects, the chance of infection are real, and the cure rates are far from 100 percent. Medical discussion on this site (reg required) compares different treatments for different types of leukemia.

I’ll leave the exact numbers to the experts: none of my leukemia patients qualified for transplant therapy and the only one that did ended up with an infection, so they sent her home to “be treated” i.e. die closer to home.

So why did this young girl need a liver transplant? Probably from the drugs used to prevent her body from killing off her new bone marrow.
The LATimes gives details:

A leukemia patient, 17-year-old Nataline had been in intensive care at UCLA Medical Center for about three weeks after suffering complications following a successful bone marrow transplant Nov. 21, relatives said. She was covered under the policy of her mother, a real estate agent.

UCLA doctors put her on a list for a liver transplant Dec. 6 and a liver became available four days later, the family said. Her doctors told Cigna in a letter that patients in similar situations had a 65% chance of living six months if they received a liver transplant.

In other words, she was very very sick, still in intensive care following her bone marrow transplant (i.e. not simply in protective isolation) and there was no guarantee that she’d live with treatment, although when treating young patients doctors tend to want to do everything they can to save a life.

Ironically, it is CNNMONEY that has the pessimistic side of the story ignored in other news reports.

Dr. Stuart Knechtle, who heads the liver transplant program at the University of Wisconsin, Madison, says transplantation is not an option for leukemia patients because the immunosuppressant drugs used in such procedures tend to spur the growth of cancer cells (he was not commenting specifically on Nataline’s case).

That was my impression as a doctor. This was a very sick girl. The doctors were trying everything they could to save the young girl’s life, even though chances were slim. Her own doctor’s estimated to the insurance company that she had a 65% chance of living six months…but one wonders where they got that figure.

THIS article goes into all the complications of having acute liver failure. Did this girl have problems with toxins from the damage liver making her brain swell, or causing bleeding? Did the doctors use an artificial liver to clear the toxins? What was the chance of her own liver repairing itself? Was her bone marrow working well enough to risk major surgery? Was the new bone marrow working enough to prevent bleeding and infections from the stress of major surgery? And would the medicines to keep her new liver alive lead to her leukemia coming back?
But I do have problem with this argument:

In a perfect world, Cigna would have funded the transplant and it would have worked, against the odds, to give Natalie a normal life. In the world as we know it, however, a scarce viable liver would have been used in an operation that is most likely futile in the long term, and another patient in need of a transplant — and who might have stood to gain more from it — would have had to wait.

I am leery about that last part, that the liver could be better used for another patient. How do you know that, sir? Are you implying that a 17 year old innocent girl is less valuable than a 40 year old teacher with Hepatitis B liver disease? Or a 60 year old celebrity whose liver was destroyed by booze and drugs?

As a doctor, I’ve spent enough of my time fighting with Insurance companies and Government Health care gatekeepers to loathe the idea that a nurse (as in this case) or what is sometimes worse, a clerk, can deny someone needed medical care.

Yet as a doctor, I am also aware that health care costs make insurance so costly that many people prefer not to buy it, and that countries with universal health care often end up rationing not only extraordinary and possibly futile treatment as in this case but care that in the US would be approved of and paid for without any question.

For example, the BBC reports that GP’s there complain of widespread rationing of medicine

And Dr Michael Dixon, chairman of the NHS Alliance, which represents NHS trusts, added: “Rationing is the great unspoken reality.

“The only people who refuse to mention the ‘r-word’ are the media and the politicians, who continue to want to promise everything for everyone in order to win elections.”

Ah, yes, elections…isn’t someone running for President who intends to make free and abundant universal health care an issue?

And aren’t a lot of the activists publicizing this tragic case those promoting this politician?

Enquiring minds want to know.

Actually, I do support universal health care via private insurance companies, but mainly because it is easier to argue with them than with a government clerk, and also because I’ve worked as a doctor in Federally run hospitals. Any activist who touts Federally run health care as the answer needs to spend some time looking at these facilities before they point fingers at insurance companies.
Medically, the case is tragic, but this is not the black and white case as implied by all those activists.


Nancy Reyes is a retired physician living in the rural Philippines. Her website is Finest Kind Clinic and Fishmarket and she writes medical essays at HeyDoc Xanga Blog.

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