Are organ donors really dead?

BioEdge

Xavier Symons

What does it mean for a human being to “die”? This question is more complex than one might think. In the domain of vital organ procurement, there is significant disagreement about the criteria that we should employ to assess when someone has died.

The standard criterion for several decades has been the “brain death” criterion, according to which a patient can be pronounced dead once “whole brain death” has occurred. Whole brain death refers to the comprehensive and irreversible cessation of brain function, typically caused by trauma, anoxia or tumor.

Yet transplant surgeons have in recent years employed a different, more ethically contentious definition of death, the so-called “circulatory criterion for death”. “Circulatory death” refers to the permanent cessation of cardiopulmonary function, after which point brain tissue quickly begins to deteriorate (if it hasn’t already).

According to proponents of the circulatory criterion, a patient’s heart will never spontaneously restart after 2 or so minutes of pulselessness. As such, it is seen as ethically permissible to begin organ procurement once this short time period has elapsed. There are in practice different time periods specified by healthcare regulators for when organ procurement can begin (typically between 75 seconds and 5 minutes).

Yet several scholars have criticised the cardiopulmonary definition of death, arguing that the impossibility of autoresuscitation does not necessarily indicate that death has occurred. Critics point out that CPR could still restart a person’s heart even when autoresuscitation has become an impossibility.

The most recent criticism came from Kennedy Institute for Ethics bioethicist Robert Veatch, who wrote an extended blog post on the topic this week. Veatch states:

If one opts for requiring physiological irreversibility, death should be pronounced whenever it is physiologically impossible to restore brain function. Autoresuscitation is completely irrelevant. If autoresuscitation can be ruled out before physiological irreversibility, one must still wait until that point is reached. On the other hand, if it becomes physiologically impossible to restore function before autoresuscitation can be ruled out, death can be pronounced at the earlier point. Either way autoresuscitation is irrelevant.


This article is published by Xavier Symons and BioEdge under a Creative Commons licence. You may republish it or translate it free of charge with attribution for non-commercial purposes following these guidelines. If you teach at a university we ask that your department make a donation to BioEdge. Commercial media must contact BioEdge for permission and fees.

You’re a surgeon. A patient wants to look like a lizard. What do you do?

As medical treatments advance, the need to accommodate conscientious objection in healthcare is more pressing

The Guardian
Reproduced with permission

David S. Oderberg*

Imagine that you are a cosmetic surgeon and a patient asks you to make them look like a lizard. Would you have ethical qualms? Or perhaps you are a neurosurgeon approached by someone wanting a brain implant – not to cure a disability but to make them smarter via cognitive enhancement. Would this go against your code of professional ethics? With the rapid advance of medical technology, problems of conscience threaten to become commonplace. Perhaps explicit legal protection for conscientious objection in healthcare is the solution.

There is limited statutory protection for those performing abortion, and there is some shelter for IVF practitioners. Passive euthanasia (withdrawal of life support with intent to hasten death) is also part of the debate over doctors’ conscience rights. That’s about it as far as UK law is concerned – though freedom of conscience is enshrined in numerous conventions and treaties to which we are party. Abortion, artificial reproductive technologies (involving embryo research and storage) and passive euthanasia are the flashpoints of current and historic controversy in medical ethics. The debate over freedom of conscience in healthcare goes to the heart of what it means to be a medical practitioner.

Curing, healing, not harming: these are the guiding principles of the medical and nursing professions. But what if there is reasonable and persistent disagreement over whether a treatment is in the patient’s best interests? What if a practitioner believes that treating their patient in a particular way is not good for them? What if carrying out the treatment would be a violation of the healthcare worker’s ethical and/or religious beliefs? Should they be coerced into acting contrary to their conscience?

Such coercion, whether it involve threats of dismissal, denial of job opportunities or of promotion, or shaming for not being a team player, is a real issue. Yet in what is supposed to be a liberal, pluralistic and tolerant society, compelling people to violate their deeply held ethical beliefs – making them do what they think is wrong – should strike one as objectionable.

Freedom of conscience is not only about performing an act but about assisting with it. There are some people who ask doctors to amputate healthy limbs. If you were a surgeon, my guess is that you would refuse. But what about being asked to help out? Would you hand over the instruments to a willing surgeon? Or supervise a trainee surgeon to make sure they did the amputation correctly? If conscientious objection is to have any substance in law, it must also cover these acts of assistance.

This country has a long and honourable tradition of accommodating conscientious objectors in wartime – those who decline to fight or to assist or facilitate the fighting by, say, making munitions. They can be assigned to other duties that may support the war effort yet are so remote a form of cooperation as not to trouble their consciences. In any war, the objectors are a tiny fraction of the combat-eligible population. Yet when it comes to one’s rights, do numbers matter? Has their existence ever prevented a war from being carried out to the utmost? I fail to see, then, why we are tolerant enough to make adjustments for conscientious objectors in the midst of a national emergency, yet in peacetime would be reluctant to afford similar adjustments to members of one of the most esteemed professions.

Do we think medical practitioners should be no more than state functionaries, dispensing whatever is legal no matter how much it is in conflict with personal conscience and professional integrity – lest they be hounded out of the profession? Some academics think expulsion is not good enough. Or should healthcare workers be valets, providing whatever service their patients demand? Perhaps when practitioners find themselves faced with demands for the sorts of treatment I’ve mentioned – or perhaps gene editing treatments or compulsory sterilisation, society will act. Or maybe by then it will be too little, too late.

David S Oderberg is professor of philosophy at the University of Reading, and author of Declaration in support of conscientious protection in medicine

 

 

Is Costa Rica at the Epicenter of a Global Black Market in Human Organs?

If the events are in fact true, there were many people turning a blind eye and/or being paid off to not say anything about what was happening in these medical centers for years.

The Costa Rica Star

Wendy Anders

With criminal proceedings underway on a human organ trafficking case involving the trial of four Costa Rican doctors and their alleged accomplices, many interesting details are coming to light.

Intersecting forces of greed, corruption and international black markets are being identified and dissected as evidence is presented in this first of a kind trial in Costa Rica. More details will be forthcoming as prosecutors weigh testimony by numerous individuals over the next two months. . .[Full text]

 

Canadian surgeons harvesting organs from euthanised patients

BioEdge

Michael Cook

March 29, 2017 (BioEdge) — Taking advantage of the country’s new law, Canadian transplant surgeons have harvested organs from dozens of euthanasia patients. According to the National Post, 26 people in Ontario who died by lethal injection have donated tissue or organs. This involved mostly corneas, skin, heart valves, bones and tendons.

The National Post’s report only covered Ontario. Bioethicists, Transplant Quebec and an ethics committee of the Quebec government in Quebec argued last year that euthanasia could be a good source of organs, so it is quite possible that similar procedures have been carried out in that province as well.

“If we accept people can make decisions to end life, and we accept the idea of cardiac death being sufficient for organ donation, this should be acceptable,” Dr James Downar, of Dying with Dignity Canada, told the Post, to allay fears that patients could be pressured into donating organs.

Oddly enough, this is a topic which did not emerge in discussions about euthanasia before the Supreme Court legalised it in 2015. An influential report by a Royal Society of Canada Expert Panel did not even mention it, for instance, nor the Supreme Court’s decision in Carter vs Canada.

Coordinating organ transplants with euthanised donors has been going on for several years in Belgium and the Netherlands. About 40 cases in the two countries have been reported. Last year Dutch physicians at the Maastricht University Medical Center and the Erasmus University Medical Center Rotterdam published a multidisciplinary manual for the complex procedure.

A recent article in the Impact Ethics blog by Professor Jennifer A. Chandler, of the University of Ottawa, pointed out that combining organ donation with euthanasia could lead to some tricky issues in ethics, law and conscientious objection:

• What if a patient seeks euthanasia to direct his donation to a family member? The potential for abuse is obvious.

• What if a next-of-kin is asked to approve organ donation after a person has been euthanised but has left no instructions?

• What if the transplant surgeon has a conscientious objection to the procedure? Should he be forced to do it?

• What if a recipient objects to receiving an organ from a euthanised patient?


This article is published by Michael Cook and BioEdge under a Creative Commons licence. You may republish it or translate it free of charge with attribution for non-commercial purposes following these guidelines. If you teach at a university we ask that your department make a donation to BioEdge. Commercial media must contact BioEdge for permission and fees.

 

Doctors harvesting organs from Canadian patients who underwent medically assisted death

What if people agree to donate, but then change their mind about euthanasia? Would they feel compelled to follow through, knowing someone is waiting for their organs?

National Post

Sharon Kirkey

Doctors have already harvested organs from dozens of Canadians who underwent medically assisted death, a practice supporters say expands the pool of desperately needed organs, but ethicists worry could make it harder for euthanasia patients to voice a last-minute change of heart.

In Ontario, 26 people who died by lethal injection have donated tissue or organs since the federal law decriminalizing medical assistance in dying, or MAID, came into effect last June, according to information obtained by the Post. A total of 338 have died by medical assistance in the province. . . [Full text]

 

 

Medical journal to retract paper after concerns organs came from executed prisoners

Study published in Liver International examined the outcomes of 564 transplantations at Zhejiang University’s First Affiliated hospital in China

The Guardian

A prestigious medical journal will retract a scientific paper from Chinese surgeons about liver transplantation after serious concerns were raised that the organs used in the study had come from executed prisoners of conscience.

The study was published last year in Liver International. It examined the outcomes of 564 liver transplantations performed consecutively at Zhejiang University’s First Affiliated hospital between April 2010 and October 2014.

According to the study authors, “all organs were procured from donors after cardiac death and no allografts [organs and tissue] obtained from executed prisoners were used”. . . .[Full text]

 

Everybody’s a winner when euthanasia combines with organ donation, say doctors

BioEdge

Michael Cook

Several Dutch and Belgian doctors have proposed legal reforms to increase the popularity of combining euthanasia and organ donation in the Netherlands and Belgium.

Writing in the Journal of Medical Ethics, they report valuable unpublished information about the prevalence of the procedure. So far, it has been performed only about 40 times in the two countries. However, there is “a persisting discrepancy between the number of organ donors and the number of patients on the waiting lists for transplantation” – which euthanasia patients could help to balance.

The authors stress that euthanasia is not a cure-all for the organ shortage. Most euthanasia patients suffer from cancer, which is a contraindication for organ transplantation. However, 25 to 30% of them do not, so there is obviously a real possibility of expanding the supply.

Furthermore, the authors say, public perception of this formerly abhorrent practice is increasingly positive:

. . . transplant coordinators in Belgium and the Netherlands notice a contemporary trend towards an increasing willingness and motivation to undergo euthanasia and to subsequently donate organs as well, supported by the increasing number of publications in popular media on this topic.

Ethically, the procedure is basically uncontroversial as long as the patient is not pressured to donate, they contend.

In the context of organ donation after euthanasia, the right of self-determination is a paramount ethical and legal aspect. It is the patient’s wish and right to die in a dignified way, and likewise his wish to donate his organs is expressed. Organ donation after euthanasia enables those who do not wish to remain alive to prolong the lives of those who do, and also—compared with ‘classical’ donation after circulatory death—allows many more people to fulfil their wish to donate organs after death.

However, there are some legal hitches in both countries. In the Netherlands, unlike Belgium, euthanasia is regarded as an “unnatural death” which has to be reported to the public prosecutor. This could delay donations. If the law were changed to allow the cause of death to be reported as the underlying condition, the procedure would be more expeditious. And “In Belgium, the current policy of determination of death by three independent physicians could be abandoned, facilitating a more lean procedure with only one physician.”

Public perceptions need to be managed as well. At the moment, it is necessary to maintain a strict separation between the request for euthanasia and the need for the organ. Partly this is needed to ensure that the donor is not being pressured. But the public also needs to have confidence that physicians will give objective advice.

Finally, there is the tradition of the dead donor rule “that donation should not cause or hasten death”. The authors imply that this could be scrapped for euthanasia volunteers:

Since a patient undergoing euthanasia has chosen to die, it is worth arguing that the no-touch time (depending on the protocol) could be skipped, limiting the warm ischaemia time and contributing to the quality of the transplanted organs. It is even possible to extend this argument to a ‘heart-beating organ donation euthanasia’ where a patient is sedated, after which his organs are being removed, causing death.

The article’s proposals were not received with great enthusiasm in the UK where there is a simmering debate on assisted dying. Tory MP Fiona Bruce told the Daily Mail: “The paper confirms the worst fears expressed by Parliament when the House of Commons conclusively voted to stop the legalisation of assisted suicide in this country. The possibility of euthanasia achieved through live organ donation, such as by removing a patient’s beating heart, as posited in this paper is shocking and chilling.”

And Lord Carlile of Berriew, a Liberal Democrat peer who is a leading lawyer, said: “I have extreme concerns about the ghoulish nature of the combined euthanasia and organ donation systems in the Netherlands and Belgium. Both can result in unbearable and irresistible pressure on an individual to die, and on a doctor to encourage death.”


cclicense-some-rightsThis article is published by Michael Cook and BioEdge under a Creative Commons licence. You may republish it or translate it free of charge with attribution for non-commercial purposes following these guidelines. If you teach at a university we ask that your department make a donation to BioEdge. Commercial media must contact us for permission and fees. Some articles on this site are published under different terms.

 

Legal and ethical aspects of organ donation after euthanasia in Belgium and the Netherlands

Med Ethics doi:10.1136/medethics-2015-102898

Jan Bollen

Abstract

Organ donation after euthanasia has been performed more than 40 times in Belgium and the Netherlands together. Preliminary results of procedures that have been performed until now demonstrate that this leads to good medical results in the recipient of the organs. Several legal aspects could be changed to further facilitate the combination of organ donation and euthanasia. On the ethical side, several controversies remain, giving rise to an ongoing, but necessary and useful debate. Further experiences will clarify whether both procedures should be strictly separated and whether the dead donor rule should be strictly applied. Opinions still differ on whether the patient’s physician should address the possibility of organ donation after euthanasia, which laws should be adapted and which preparatory acts should be performed. These and other procedural issues potentially conflict with the patient’s request for organ donation or the circumstances in which euthanasia (without subsequent organ donation) traditionally occurs. [Full text]

Doctors grapple with organ donation question

National Post

Sharon Kirkey

As the nation awaits legalized doctor-assisted death, the transplant community is grappling with a potential new source of life-saving organs  –  offered by patients who have chosen to die.

Some surgeons say every effort should be made to respect the dying wishes of people seeking assisted death, once the Supreme Court of Canada ruling comes into effect next year, including the desire to donate their organs.

But the prospect of combining two separate requests  –  doctor-assisted suicide and organ donation  –  is creating profound unease for others. Some worry those contemplating assisted suicide might feel a societal pressure to carry through with the act so that others might live, or that it could undermine struggling efforts to increase Canada’s mediocre donor rate. . . [Full text]

Dignity and the Ownership and Use of Body Parts

Cambridge Quarterly of Healthcare Ethics / Volume 23 / Issue 04 / October 2014, pp 417-430

Charles Foster

Abstract: Property-based models of the ownership of body parts are common. They are inadequate. They fail to deal satisfactorily with many important problems, and even when they do work, they rely on ideas that have to be derived from deeper, usually unacknowledged principles. This article proposes that the parent principle is always human dignity, and that one will get more satisfactory answers if one interrogates the older, wiser parent instead of the younger, callow offspring. But human dignity has a credibility problem. It is often seen as hopelessly amorphous or incurably theological. These accusations are often just. But a more thorough exegesis exculpates dignity and gives it its proper place at the fountainhead of bioethics. Dignity is objective human thriving. Thriving considerations can and should be applied to dead people as well as live ones. To use dignity properly, the unit of bioethical analysis needs to be the whole transaction rather than (for instance) the doctor-patient relationship. The dignity interests of all the stakeholders are assessed in a sort of utilitarianism. Its use in relation to body part ownership is demonstrated. Article 8(1) of the European Convention of Human Rights endorses and mandates this approach. [Full Text]