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Thursday, May 1, 2008

First, Do No Harm

posted by on May 1 at 22:04 PM

Unless the patient used medical marijuana—in which case, hey, feel free to murder the poor bastard.

A musician who was denied a liver transplant because he used marijuana with medical approval under Washington state law to ease the symptoms of advanced hepatitis C died Thursday.

The death of Timothy Garon, 56, at Bailey-Boushay House, an intensive care nursing center was confirmed to The Associated Press by his lawyer…. Dr. Brad Roter, the physician who authorized Garon to smoke pot to alleviate for nausea and abdominal pain and to stimulate his appetite, said he did not know it would be such a hurdle if Garon were to need a transplant.

Garon died a week after his doctor told him a University of Washington Medical Center committee had again denied him a spot on the liver transplant list because of his use of marijuana, although it was authorized under Washington state law.

The sadists at the University of Washington Medical Center—and Swedish Medical Center—didn’t just deny this guy a transplant. They really seemed to get off on torturing this dying man. Check out these details from the PI report:

He had been in the hospice for two months and previously was rejected for a transplant at Swedish Medical Center for the same reason he later got from the university hospital.

Swedish said he would be considered if he avoided pot for six months and the university hospital offered to reconsider if he enrolled in a 60-day drug treatment program, but doctors said his liver disease was too advanced for him to last that long. The university hospital committee agreed to reconsider anyway, then denied him again.

Here is Dom’s previous post about this medical travesty. And here again are those numbers…

UW Division of Transplant: (206) 598-6700

The fax number: (206) 598-0628

The chief of the division is Jorge D. Reyes:

The director is Kay Wicks:

The full directory for transplant staff is over here.

RSS icon Comments

Posted by umvue | May 1, 2008 10:26 PM

Dan, this is fucking unbelievable. Just what you'd expect from the land of Mission Accomplished.

Posted by Karlheinz Arschbomber | May 1, 2008 10:28 PM

Da link no work right...

Currently 16,367 waiting for a liver. Many will die.

I hypothesize that everyone will die, eventually, and still you didn't do all you could do to save them.

Posted by umvue | May 1, 2008 10:30 PM

Just a second. Your transplant doctor tells you to stop eating fried foods, smoking or drinking alcohol (all of them legal) or you won't get a transplant and you ignore them. the answer is simple. you don't get the transplant.

Now, if you want to suggest that the doctor who prescribed him the pot be held liable (for prescribing a contraindicated substance) then you might have a point.

Posted by ho' know | May 1, 2008 10:43 PM

I bet the guy after him on the list is pretty happy with the way this played out.

There are an awful lot more people who want liver transplants than there are livers available, so there is some justification to limiting transplants to only those people whose behavior is the most liver-friendly. For example, you are required to pretty much not drink any alcohol at all if you want to stay on the list. I didn't know about the pot rule, but given the alcohol rule, it's not surprising.

Posted by David Wright | May 1, 2008 10:52 PM

Normally I would agree that this is terrible, but in this case I have to disagree. There are way more people on the transplant list than there are donors, and one way hospitals decide who gets a liver is based on whether the recipient will take care of it by abstaining from drugs and alcohol. That's probably what was going on here.

Posted by zef81 | May 1, 2008 10:52 PM

i received this from UW after sending them an e-mail:

Thanks for raising some of the questions that you did in your e-mail. We can't speak specifically about Mr. Garon's case due to patient privacy laws. Although medical marijuana may be an issue in rare cases, it is never the sole determinant in arriving at medical decisions about candidates for organ transplants, and whether a patient is listed. UW Medical Center follows an extensive evaluation process to determine whether organ transplant candidates should be listed. Patients with a reasonable chance of survival and a good outcome, given a variety of factors, are listed.

The Liver Transplant Committee looks at all health care issues to comprehensively evaluate the patient from a medical and psychosocial standpoint. In addition, the committee looks at a number of other issues, including behavioral concerns such as a history of substance abuse or dependency. If such a history exists, then the Committee looks at the period of abstinence the candidate has demonstrated to date, efforts made to maintain this abstinence, and the potential to abuse again. The Committee also factors in the patient’s long-term history of social stability and ongoing medical compliance, as these are the best predictors to maintain graft survival following transplant.

Currently, in a given year, there are approximately 98,000 patients waiting for organs in the U.S. and only 6,000 donors available. Because of this scarcity of organs, the listing process is often rigorous. Those patients who have done -- and continue to do --everything they need to ensure a healthy lifestyle pre-and post-transplant will have the best chance of a good outcome. Please feel free to share this information with friends and colleagues. As you note below, there is more to the story than what is currently running in papers and online.

Posted by kh | May 1, 2008 10:56 PM

While the no-pot rule is justifiable, the fact that this guy wasn't informed of it, and that his doctor prescribed pot to him, isn't. There is probably a malpractice claim against his doctor in there, and certainly the transplant network should be giving those on the waiting list a clear list of DOs and DON'Ts.

Almost all pain-reliving drugs damage the liver, so in a bad situation like that you have to make a difficult choice: do you give up on the transplant and take the drugs to ease your passing, or do you endure the pain and hope you get a transplant in time.

Posted by David Wright | May 1, 2008 11:02 PM

It's not about whether he is using the marijuana for medical purposes or not. Patients with compromised immune systems who smoke marijuana are at risk for Aspergillosis, a serious fungal disease that can cause "fungus balls" in your lungs and eventually kill you. The medications that he would be on include Tacrolimus, Prednisone, Cyclospine or MMF. These drugs can cause severe immune supression and make you susceptible to the worst diseases that are out there, somewhat similar to what you might see in an HIV patient. It's serious stuff. We had a guy in the last few months at the local hospital that was not really immunosupressed (as far as we know), came in with a lung cavity caused by aspergillus. He ended up dying after the cavity eroded into one of his lung blood vessels. Not pretty. Liver transplants are a big deal and require patients to adhere to the most stringent guidelines. Let's play devil's advocate and assume that he go the liver and continues to smoke marijuana. He ends up getting Aspergillosis and dies. The liver that he got is in a sense wasted because it could have gone to someone else who had less risk. I've seen patients that are ex-addicts that continue to be on Methadone (for addiction issues) get livers. It wasn't the marijuana drug issue, but rather the risk for infection with continued use.

Don't get me wrong, the transplant issue is fairly tricky and there are many things that are not fair. For example, minorities and lower-income people are less likely to receive organs. I think UW was correct about this one though.

Posted by residentMD | May 1, 2008 11:21 PM

@ 5 and 8) You wrote "there is some justification to limiting transplants to only those people whose behavior is the most liver-friendly" and "the no-pot rule is justifiable."

Where are the facts you base this on? The popular consensus is that pot does not damage the liver. In fact, one study indicates cannabis use for Hep-C patients "may offer symptomatic and virological benefit to some patients undergoing HCV treatment."

If there is some conclusive evidence on which on which the doctors have made their decision, then they should cite that. But they haven't. What they've actually said is that pot is SOOOO addictive that Mr. Garon would keep smoking it (along with a rare but harmful mold on some of it) and his body would reject the transplant.

Regardless of why Mr. Garon's liver is in this state, marijuana is one of the drugs his doctor recommended under state law. Nobody broke the law and what he needed was a new liver. The UW is denied it based on the implausible scenario that pot is so addictive that he would smoke it at the risk of death. Both claims -- that he caused himself harm because of pot, and that he wouldn't be able to stop -- are absurd and offensive.

Posted by Dominic Holden | May 1, 2008 11:26 PM

Dan -- Thanks to you and Dom for bringing attention to this travesty. I want you to know that your posts have generated much conversation in the national harm reduction community and that many people from around the country (including lawyers and medical ethics professionals) were appalled by this situation and wrote very strong letters to the UW.

In response to some of the folks posting here, there are at least two peer reviewed articles in medical journals on the benefits of marijuana for patients with Hep C. And Hep C fucking on the list of conditions for medical marijuana.

These folks did not make a decision based on science (otherwise they would fucking cite it in their mealy mouthed replies). They made a conscious decision to let someone die.

Posted by gnossos | May 1, 2008 11:35 PM

The strict and harsh rules are pretty common at transplant centers across the US. I'm very sympathetic to people involved in stories like this, having lost my 20-year partner last year during a 3+ year wait on the list for a new kidney.

Do we know with certainty he "didn't know" about the pot thing? They're pretty darn thorough in the pre-list interviews about that stuff.

Posted by Wolf | May 1, 2008 11:44 PM

10 & 11, this has nothing to do with Hep C and marijuana. I have a few patients that smoke marijuana, prescribed medically and OTC (; and most MD's have no problem with it. It's really the issue about the risk of aspergillus. I'll admit, the exact risk is not known, but there have been many cases:$=relatedarticles&dbfrom=pubmed

Posted by residentMD | May 1, 2008 11:45 PM

Dominic, I was basing my previous comments on general knowledge that most serious pain relivers are bad for your liver. I am perfectly happy to be corrected by you that pot is not, and to be corrected by residentMD that the primary issue here is aspergillus.

Now in return for my gracious admission of error, I'd like you to step back for a moment and examine your own writing on this subject. In your reporting on this, both you and Dan have left out and/or played down some rather pertinent information: that liver supply is a tiny fraction of demand, and that as a result transplant patients are required to forgo many perfectly legal and indeed common behaviors in order to remain optimal transplantees.

Why have you and Dan left out this rather pertinent information? Because by doing so your can quickly lead your readers to the conclusion that the only possible explanation for this man's rejection is a transplant board composed of evil corporate, establishment types who hate potheads. And therewith you gain another poster victim for use in your culture war against evil corporate, establishment types who hate potheads.

On the other hand, someone presented with the rather pertinent information might, just might, consider the alternative possiblity that the guy was rejected because his pot-smoking made him a less optimal transplantee than many other, equally desperate candidates. They might demand that you show them hard evidence that the transplant board rejected him because they hate potheads, like maybe board members who agitate against pot, or records showing that other transplant boards overwhelming accept potheads for liver transplants. You know, the kind of evidence that actual journalists go and dig up.

So, does your purposeful omission of the rather pertinent information make you two candidates for the "stupid, fucking hack of the day" award?

Posted by David Wright | May 2, 2008 12:19 AM

this is appalling.

Posted by Mike | May 2, 2008 2:52 AM

How is Aspergillus spread?

Since Aspergillus is so common in the environment, most people breathe in Aspergillus spores every day. It is probably impossible to completely avoid breathing in some Aspergillus spores. For people with healthy immune systems, this does not cause harm, and the immune system is able to get rid of the spores. But for people with compromised immune systems, breathing in Aspergillus spores, especially breathing in a lot of spores (such as in a very dusty environment) can lead to infection. Studies have shown that invasive aspergillosis can occur during building renovation or construction. Outbreaks of Aspergillus skin infections have been traced to contaminated biomedical devices.

How can Aspergillus infections be prevented?

It is almost impossible to avoid all exposure to this fungus. It is present in the environment. However, for persons who are very immunocompromised, some measures that may be helpful include: avoidance of dusty environments and activities where dust exposure is likely (such as construction zones), wearing N95 masks when traveling near dusty environments, and avoidance of activities such as gardening and lawn work. Other air quality improvement measures such as HEPA filtration may be used in healthcare settings, and prophylactic antifungal medication may in some circumstances be prescribed by your doctor.

Posted by anotherresidentMD | May 2, 2008 3:40 AM

I was basing my previous comments on general knowledge that most serious pain relivers are bad for your liver. I am perfectly happy to be corrected by you that pot is not... Let's see your evidence that pot Is. Otherwise all I'm seeing here, and in the center's pusillanimous boilerplate response, is that the issue was he didn't Just Say No. IF you can read, then look at how the goddamned response email focuses on "substance abuse". They were enforcing the anti-drug laws...condemning that man for violating them...not making a medical decision.

Looks to me like you're trying to help them fabricate a better excuse:

...the primary issue here is aspergillus.

Read the response again pal. The primary issue as far as they were concerned was substance abuse. That man was using marijuana under a doctor's orders, and their response to his death was about substance abuse and abstinence. That wasn't medicine, it was Kulturkampf.

Posted by Bruce Garrett | May 2, 2008 4:28 AM

One other thing about the comments here that there are tons of people on the waiting lists for liver transplants. Dan is right, these slimeballs were torturing that man. If his use of marijuana offended them so much they were willing to let him die rather then treat him, given his condition all they had to do was say "Well yes Mr. Garon...we'll just put you right down for a new liver...however there are currently 16,367 people on the list..." and then just waited it out, which given the man's condition wouldn't have been long. But no...that's not the way hate works. It's no good if the wicked don't know why they're being punished. Garon had to know he was being condemned to die because he was a pot smoker, or the morality play isn't effective.

I expect they'll start ratcheting up the rhetoric now about how it wasn't so much "substance abuse" as "oh golly...we were So worried about aspergillus infection..."...or some other even better cover story. I watched something like that happen some years ago here in Baltimore when Maryland Shock Trauma denied a gay man his dying lover's bedside even though he had a durable power of attorney. First it was he wasn't family. Then when they started getting flack for it, the story turned into they lost the medical directives and power of attorney paperwork. And finally when they got sued it was the emergency room was too busy, which worked for the jury that acquitted them.

Posted by Bruce Garrett | May 2, 2008 4:59 AM

I agree with David Wright wholeheartedly. I do think in these situations it is a lot easier to blame the evil doctors than to realize and think about the situation they are in. The primary problem here is the lack of donor livers, and the desire to maximize how much good each one does, even though arbitrary rules. I'm not inside those doctor's heads, but I seriously doubt BS political factors played a role in their decision. Anyone who sees this as a cut and dry case of doctors "torturing" or "Killing" someone is a complete idiot.

Posted by Josh | May 2, 2008 7:15 AM

"The concern is that patients who have been using it will not be able to stop," Reyes said."

@17, nowhere did Dr. Reyes, state that it was about addiction. If he used marijuana before and then got a transplant, he is likely to continue doing it. Not because he is addicted, but because he was in the habit of using it for pain. If he continues smoking after the transplant, he is going to be at risk for bad infections. I do not believe that the hospital has a PC anti-marijuana crusade going and punishing him. We as residents are allowed to prescribe medical marijuana at the hospitals that we work at including Harborview UW and all their affiliated clinics. If the university was anti-marijuana then we would not be allowed to prescribe. I already addressed the punishing for his mistakes or addiction issue. At UW they transplant people that are on Methadone, which in a sense, is still like being addicted to Heroin (but not as messy).

Posted by residentMD | May 2, 2008 7:37 AM

Dan, it is fine to put down the contact numbers of the program director and the transplant division contact number. It is NOT ok to put down the number for all the members of the transplant team.

Why? Because these are the people who arrange immediate transplants and also care for people having post-transplant infections and failure. These people need to be reached IMMEDIATELY by patients, ER doctors caring for critically ill patients, organ donor banks, etc. By opening up their network to spam hate-calls by the pro-weed crowd, you are going to completely jam up the critical communication network that people's lives literally depend on. How the hell would you feel if you had a critically ill family member and you couldn't reach her specialist because some idiot invited thousands of crank calls and swamped their voice mail system? For someone who just went through what you did, I can't fucking believe you've done this. Really stupid of you.

Second, Dan, the transplant team doesn't make this policy. These are nurse practitioners, residents, surgeons, etc. who are way too fucking busy to honestly care if someone takes a toke. The policy exists for three reasons:

Grant money, risk factors, and lawsuits.

Some PR person wrote that boiler plate... but at the end of the day it's the GOVERNMENT that classifies marijuana use as equivalent to all other substance use. So what, you say? Well, as a transplant center, try getting grant money to run your program if you don't follow their dumb-ass rules. Once you start publicly saying that weed doesn't really count the way other drugs do, your funding, your research, and ultimately your patients are shit out of luck.

Second - gosh, I wonder how that guy got hep C. Any chance he had a history of IV drug use? Does he have a history of other addictions, like booze? It's worth asking, and it might be worth demanding some proof that they can make changes before giving them a treasured liver. We don't know the details about this guy, and you can bet that his family is putting their own spin on things.

Lawsuits - if this guy gets that liver, and then tokes his way to aspergillosis while little Jimmy down the hall with NO behavioral risk factors croaks, the family is going to fucking sue the shit out of everyone. And why not? Jimmy was just as sick and had no risk factors. He should have gotten the liver because he had the best chance of surviving. The hospital has to be as tough as possible to dodge this bullet.

Posted by Yeek | May 2, 2008 8:23 AM

#21/others: Nobody's saying he was entitled to a liver transplant or that he was the best candidate for a liver. We're saying it's stupid that he wasn't even considered because he was a medical marijuana "drug addict" who needed a "60-day drug treatment program" first. That isn't spin, that's what the UW liver transplant team told the press.

Posted by poppy | May 2, 2008 9:17 AM

The #1 problem with this whole debate is that we are hearing only one side of the story - that from the patient's media campaign.

It's extremely likely that there were other negative factors - beyond the pot - which played into the "no transplant" decision, which the patient's camp conveniently left out and which the hospital is not allowed to reveal because of unbendable confidentiality rules.

No one has ever said that "he wasn't even considered for transplant" because of the medical marijuana. Only that what was probably a very stong psychological dependence on marijuana was one of the factors.

So before you get so outraged about this and seriously interfere with the transplant team's ability to provide needed care to other patients by flooding their voice mails with hate, please keep in mind that there's got to be more to this story than we know about.

That is, there are very likely other serious reasons why this guy would have been at very high risk of fucking up a transplanted liver that none of us will ever know about.

Posted by Other Side of the Coin We Don't See | May 2, 2008 10:17 AM

Yes pot is the safest illegal drug that we know of. But many people (including many people with prescriptions for medical marijuana) still suffer bad effects from using it too much (i.e. abusing it) - we've all known pot heads who used it too much and did harm to themselves.

How do we know that this guy wasn't one of those people? Potentially with many other skeletons in his closet, which the transplant committee happened to find out about?

Posted by all things in moderation | May 2, 2008 10:28 AM

I find two flaws with the comments I've read so far:

1) Of course people get denied transplants for perfectly legal behaviors. But this guy wasn't continuing to eat fatty or salty foods after being advised against it by doctors. According to the story, he was taking doctor-prescribed medical marijuana in order to treat the symptoms of the Hep C that lead him to need the transplant.

The issue isn't whether or not the behavior he engaged in is legal. The point is that he's being punished for following a course of treatment prescribed by his doctor because some other doctors disagree with it.

2) I also keep telling myself there's got to be more to this story... but UWMC has a perfectly decent press corps. If there's reason to justify this, then why don't we hear them telling their side of the story?

Posted by Mickymse | May 2, 2008 10:52 AM

open market for organs now!

Posted by Bellevue Ave | May 2, 2008 11:26 AM
Posted by lopez | May 2, 2008 11:30 AM

UWMC has done their best to "tell their side of the story". But due to very strict confidentiality, they're not allowed to even appear to be defending this decision. It was not - and should not - be public. Yes, this guy's gone public with his grevience. But that doesn't mean that he's signed over his rights to have his medical records be kept private.

He had a serious history of substance abuse. He admitted to the press that he had "shared needles with speed freaks". So. Was UWMC just supposed to take his word for it that "I'm over that now". Any drug addict clinging to life would say this on their death bed. Of course not. The responsible thing is to say that he would need to have a 60-day treatment eval by a substance abuse treatment center.

And I'm sure that this was not the first time he had heard that that is what he should do. If he had been seeking to be listed on the transplant list for months, it is very likely that this had been recommended to him before. And it may be telling that he "never got around to it" until he had less than a week to live.

Posted by just sayin | May 2, 2008 11:40 AM

What if I went to every support group message board in the country for people on transplant wait lists and posted the phone number and email address for every Stranger staffer. Urging them to let their outrage be known at this one-sided journalism and interference with medical care of very sick patients at the university of washington?

Posted by How would it feel | May 2, 2008 12:01 PM

You sound like a writer for Law and Order, Dan.

Did they also "murder" all the people who died on the waitlist? Can't they just grow livers in a petri dish these days?

Posted by w7ngman | May 2, 2008 12:14 PM

"First, do no harm..."

It makes a catchy little headline and all, but I'd like to see someone show us what net harm is done. It's not as if they have a liver, aren't giving it to this guy, and then tossing it in the dumpster.

There are plenty of people waiting for those livers. Someone will get it, and good will be done.

Not saving someone and doing harm to someone are VERY different things, especially when someone else (more deserving or not, that's not related to the issue of doing harm) is being saved INSTEAD.

Again, please point out the net harm.

You can't, Dan. But you can make a sensationalist rant lacking complete information, so there's that.

Posted by lopez | May 2, 2008 12:33 PM

@ 22:
--"it's stupid that he wasn't even considered because he was a medical marijuana "drug addict""--

You're wrong. He was considered by two transplant boards at two hospitals. They didn't blow him off - they reviewed the case and unfortunately gave him an answer he didn't want to hear.

@ 25:
--"According to the story, he was taking doctor-prescribed medical marijuana in order to treat the symptoms of the Hep C that lead him to need the transplant."--

Yes, and that doctor may have innocently made a bad decision that screwed his patients chances. The transplant team is not obligated to do the surgery because of sub-optimal prior medical care that they had nothing to do with. The transplant docs are the experts, and they know best what is a risk factor and what isn't. This isn't a case of a 50-50 disagreement, it's a case of transplant specialists (lots of them) versus a general practitioner.

--"If there's reason to justify this, then why don't we hear them telling their side of the story?"--

By law they are forbidden to mention any aspect of the patient's confidential history that isn't already public knowledge. So, if the patient was told to give up marijuana and refused or lied about it - they can't say it. If the patient was not taking his regular medications and was at huge risk for failing the transplant - they can't say it. If the patient was abusing alcohol or tested positive for cocaine - they can't say it. If he had emphysema and smoking weed was destroying his lungs as well as his liver - they can't say it.

And if they do say it, they can get sued.

Of course, the lawyers, the family, and Dan can say whatever they want, true or not, and can't be punished for it.

So, those overworked doctors do their job, keep their mouths shut, and take abuse from credulous, professionally-outraged fools like Dan who can't be bothered to think twice.

Posted by Yeek | May 2, 2008 2:29 PM

Yeek. You're my hero.

Dan. Love 95% of your stuff. And for an opinionated fucker like me, that's impressive. This is definitely in the other 5%.

Posted by Aaaarrrggh | May 2, 2008 3:56 PM

Check out the correction below from the AP. I suppose it emphasizes the mercurial nature of one-sided stories.

Correction: Medical Marijuana-Death story


SEATTLE -- In a May 1 story about the death of Timothy Garon, The Associated Press reported erroneously that a doctor had told Garon the previous week that he had been denied placement on a liver-transplant list due to his use of medical marijuana. According to Garon's family and lawyer, the doctor did not give a reason for the denial.

Posted by Yeek | May 2, 2008 9:13 PM

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