The „Standards of Care“ in Chronic C Hepatitis: Ethical Dilemma

Case: Mary, 27yrs, lawyer, mother of two, went to see her GP for fatigue and generalized weakness. No history of alcohol abuse or drug use. Her mother died with liver cirrhosis. The blood tests revealed VHC-antibodies and elevated ALT and she was referred to our unit for further investigations. Physical examination was normal, no hematologic abnormalities, VHC RNA=1.200.000 copies/ml, genotype 1b, upper GI endoscopy and abdominal ultrasound were normal. A liver biopsy was performed which showed mild histological disease (METAVIR stage F1). According to our „standards of care“ no antiviral treatment was recommended, and she was reassured that the prognosis was good, and advised to wait for better treatments; meanwhile, she would have laboratory monitoring. She did not accept our recommendation and argued that she was „well informed about better chances of response while was younger and with milder disease“, and we have the moral duty „to give me a chance“ as she was frightened to have the same „fate as my mother“.

Discussion: Treatment with pegylated interferon in combination with ribavirin gives a rate of sustained virological response (SVR) of 45% for chronic C hepatitis genotype 1. It has been shown that patients with SVR can be considered cured of the infection. Ethically, all patients with chronic C hepatitis should receive treatment; however, no health care system could support the enormous financial burden required by such attitude. To date, patients with stage F2, F3 fibrosis has the best potential risk/benefit ratio and are the best candidates for treatment according with almost all guidelines (European, North American). However, patients with milder histologic changes (METAVIR stage 1) appear to respond even better than patients with more advanced fibrosis. A variety of factors that correlate with the SVR have been noted; among them, female sex and younger age. Some informed patients about treatment efficacy may insist to receive curative treatment even if they have minimal liver damage, as Mary has. The international guidelines are just recommendations intended to assist doctors in arriving at reasoned patient care decision, and although they should be followed in most cases, they are designed to be flexible rather than inflexible „standards of care“. The decision to treat or not should be left to the doctor based on the circumstances of an individual patient.

Conclusions: Ultimately, Mary had received the treatment and she was cured of the infection.