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Ethical Impasses in the Care of Patients With Hepatitis C

TO THE EDITOR: The report by Geppert et al. (Psychosomatics 2005; 46:392–401) represents an initial step toward tackling the immense ethical dilemmas facing clinicians caring for the 4 million Americans with hepatitis C virus (HCV) infection.¹ Two paramount issues, however, were largely unaddressed in this report; the first involves the role of an individualized, multidisciplinary risk–benefit assessment of patients being evaluated for HCV treatment.² The second issue is the absence of consensus about when HCV treatments can or should be either withheld or delayed.³

Patients evaluated by Geppert et al.¹ felt devastated by HCV infection and feared death, mostly from liver cirrhosis and hepatocellular carcinoma, and both diseases have significantly increased in incidence in the last decade.⁴ Yet, despite two decades of research on the usefulness of interferon-based therapies in achieving viral clearance of HCV, the U.S. Preventive Services Task Force recently found no data to support the efficacy of HCV treatments in reducing morbidity and mortality from HCV infection.⁵

Nonetheless, clinicians rely on consensus guidelines to navigate through a multitude of cumulative and prognostic factors (HCV genotype, HCV RNA viral load, race, gender, age, body mass index, etc.) and incorporate results from liver pathology and the course of HCV-induced liver disease to formulate individualized treatment recommendations for their patients.^6,7 Expecting that patients will fully grasp and comprehend the complexities of HCV infection and understand that the intuitive value of its treatment, as just and moral as it may seem ethically, may be impractical and unattainable, especially in the case of patients with HCV and comorbid psychiatric illness. In fact, the patient educational material available from the Department of Veterans Affairs Hepatitis C Resource Centers website (www.hepatitis.va.gov) provides patients with general information about HCV infection and treatment issues; however, it calls for a discussion between patients and their providers about available treatment options, as well as the value of non-treatment and watchful waiting.

The efforts to obtain full and informed consent for HCV treatment is a laudable cause, but it is complicated when there is comorbid psychiatric illness.⁸ The cognitive effects of HCV infection, coupled with comorbid psychiatric illness and interferon-induced neuropsychiatric adverse effects necessitates the participation of psychiatrists to act as advocates for their patients’ best interests.⁹ The participation of a psychiatrist provides safeguards to protect patients from the medical and psychiatric adverse effects associated with HCV treatments, treatments that so far have no proven efficacy in reducing morbidity or mortality from HCV infection. A dynamic dialogue between hepatologists, psychiatrists, other medical and psychosocial support personnel, as well as the patient and his or her proxy, will result in a true multidisciplinary formulation and a realistic risk–benefit assessment that is guided by the patient’s treatment inclinations.¹⁰

Such an evaluation process would incorporate predictors of viral clearance, the likelihood of interferon-induced neuropsychiatric adverse effects, availability of psychosocial resources, and the patient’s treatment preferences, and this process would be superior to the evaluation process described by Geppert et al.,¹ in which mental health professionals merely gave a "clearance for HCV treatment."^1,3

The absence of a consensus about when to recommend delaying HCV treatment because of the low likelihood of viral clearance, the high likelihood of neuropsychiatric adverse effects, or absent psychosocial support resources adds to the monumental undertaking of clinicians caring for patients with HCV infection as these clinicians struggle on a daily basis with providing treatment recommendations for their patients. For example, should HCV treatments be delayed or withheld if the likelihood of viral clearance is 30%? How about 15%? Should treatment be delayed or withheld if there is a high likelihood of neuropsychiatric adverse effects with HCV treatment (e.g., mania or psychosis that was associated with a previous course of interferon treatment)? What about the patient who has advancing cirrhosis and may progress to end-stage liver disease and requires a liver transplant if he or she is not treated?

The introduction of newer HCV treatment modalities (e.g., HCV protease inhibitors), which are likely to yield an increased likelihood of viral clearance (i.e., >55%), may, we would hope, allay some of these ethical concerns. The improved viral clearance rates would also strengthen the case for providing HCV treatment to patients with psychiatric illness and may encourage clinicians to engage these patients in HCV treatment.

REFERENCES

1. Geppert CMA, Dettmer E, Jakiche A: Ethical challenges in the care of persons with Hepatitis C infection: a pilot study to enhance informed consent with veterans. Psychosomatics 2005; 46:392–401[Abstract/Free Full Text]
2. Rifai MA: Interferon treatment of hepatitis C patients with psychiatric illness: evidence-based risk-benefit assessment. Prim Care Companion J Clin Psychiatry 2005; 7:74–75[Medline]
3. Rifai MA, Loftis JM, Hauser P: Interferon treatment of patients with hepatitis C: the role of a comprehensive risk-benefit assessment. CNS Drugs 2005; 19:719–721; author reply: 721-712[CrossRef][Medline]
4. el-Serag HB, Davila JA, Petersen NJ, et al: The continuing increase in the incidence of hepatocellular carcinoma in the United States: an update. Ann Intern Med 2003; 139:817–823[Abstract/Free Full Text]
5. Chou R, Clark EC, Helfand M: Screening for hepatitis C virus infection: a review of the evidence of the U.S. Preventive Services Task Force. Ann Intern Med 2004; 140:465–479[Abstract/Free Full Text]
6. Strader D, Wright T, Thomas DL, et al: Diagnosis, management, and treatment of hepatitis C. Hepatology 2004; 39:1147–1171[CrossRef][Medline]
7. National Institutes of Health Consensus Development Conference Statement: Management of Hepatitis C:2002. Hepatology2002; 36:S3-S20
8. Yovtcheva SP, Rifai MA, Moles JK, et al: Psychiatric comorbidity among hepatitis C-positive patients. Psychosomatics 2001; 42:411–415[Abstract/Free Full Text]
9. Rifai MA, Bozorg B, Rosenstein DL: Interferon for hepatitis C patients with psychiatric disorders. Am J Psychiatry 2004; 161:2331–2332[Free Full Text]
10. Rifai MA, Rosenstein DL: Interferon treatment of hepatitis C patients with psychiatric disorders: evidence-based, risk-benefit assessment. Psychosomatics 2005; 46:165–166

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