Role of brain death and the dead-donor rule in the ethics of organ transplantation

The "dead-donor rule" requires patients to be declared dead before the removal of life-sustaining organs for transplantation. The concept of brain death was developed, in part, to allow patients with devastating neurologic injury to be declared dead before the occurrence of cardiopulmonary arrest. Brain death is essential to current practices of organ retrieval because it legitimates organ removal from bodies that continue to have circulation and respiration, thereby avoiding ischemic injury to the organs. The concept of brain death has long been recognized, however, to be plagued with serious inconsistencies and contradictions. Indeed, the concept fails to correspond to any coherent biological or philosophical understanding of death. We review the evidence and arguments that expose these problems and present an alternative ethical framework to guide the procurement of transplantable organs. This alternative is based not on brain death and the dead-donor rule, but on the ethical principles of nonmaleficence (the duty not to harm, or primum non nocere) and respect for persons. We propose that individuals who desire to donate their organs and who are either neurologically devastated or imminently dying should be allowed to donate their organs, without first being declared dead. Advantages of this approach are that (unlike the dead-donor rule) it focuses on the most salient ethical issues at stake, and (unlike the concept of brain death) it avoids conceptual confusion and inconsistencies. Finally, we point out parallel developments, both domestically and abroad, that reflect both implicit and explicit support for our proposal.

Is this live-organ donor your patient?

The transplant community is in the midst of an ethical reflection regarding the manner in which live-organ transplantation should be practiced. There is a fundamental aspect to be addressed and reaffirmed. It is the doctor-patient relationship between the transplant surgeon and the live-organ donor. This relationship brings a mutual responsibility to the physician and the donor patient to each other, which should not be abrogated by the claim of donor autonomy nor the obligation fostered by the recipient's needs. If equipoise is not affirmatively achieved in the risk-benefit calculation for the donor and the recipient, then sound medical judgment should override all other concerns.

Before pigs' germs fly: xenotransplantation and a call for federal action

When surgeons transplant animal organs into humans, people who did not receive the organs incur risks. These third parties may stand near or far in time or space. No one knows the likelihood, breadth, or nature of the risks in question. The common wisdom among infectious-disease specialists is that in the best of xenotransplant conditions, such third-party risk may be minimized but not eliminated.

Is the unified list system for organ transplants fair? Analysis of opinions from different groups in Brazil

In the 1960s, when Dr. Belding Scribner discovered how to accomplish the process of dialysis in a repeated way, he could not imagine that in solving such a problem others as or more difficult would appear. Given the technological progress and the impossibility of assisting all patients through the most modern methods, the medical doctor often finds himself faced with the moral dilemma of choosing which patient in the waiting list will receive the treatment. This same dilemma is amplified in the case of organ transplants. Professionals, students, professors of the juridical and health fields, and the population in general, were interviewed as a means of documenting the moral concepts and opinions surrounding this problem. In the reality in which we find ourselves, it seems to us that deciding who lives, and the responsibility for all the events that culminate in such decisions, is still a subject left open to discussion.

Organ transplantation: an ethical road map

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The ethics of organ transplantation for prisoners

Organ transplantation for prisoners raises numerous ethical issues. Questions immediately emerge about how to justify the use of scarce organs for prisoners when law-abiding citizens are waiting. The answer to whether and why we ought to perform organ transplants for prisoners lies in how we understand society's commitments to prisoners' health and health care, and whether being incarcerated changes the priority of a patient waiting for a transplant. While prisoners forfeit many freedoms, access to and the provision of adequate health care are guaranteed to them, and ought to include access to organ transplants.

Organ allocation: a case for not transplanting the violent criminal

As organ transplantation outcomes become ever more successful, vigilance as to appropriate recipient selection must be ensured, for without careful monitoring the already great disparity between organ supply and demand will continue to grow. There is a public perception that justice requires equal access to treatment for all, but this is not always the case. We suggest that, while violent felons do not account for a large number of transplant recipients, transplanting even one such individual should be deemed inadvisable-and could well be fraught with irreparable public repercussions.

Brain death: resolving inconsistencies in the ethical declaration of death

PURPOSE

The first criteria for the determination of brain death were developed in 1968 in part to address concerns that had arisen with the retrieval of organs for transplantation. Despite over 30 years of application, some professional and public doubt persists over the validity of the theoretical construct underlying this method of determining death. Our review will address historical perspectives on the development of brain death criteria, and inconsistencies in current clinical criteria.

METHOD

Narrative review from selected MEDLINE references and other published sources.

PRINCIPLE FINDINGS

The primary construct of the determination of death is that either cardiopulmonary or neurological function irreversibly ceases. However, there is inconsistency in the neurological criteria for death between jurisdictions, between patient populations, and in the use of confirmatory tests. These inconsistencies may cause concern in the public or profession about the validity of the determination of death by neurological criteria.

CONCLUSIONS

Organ transplantation is premised on professional and public acceptance that the donor is dead. Given that the criteria for brain death or their application remain variable, we suggest that it is reasonable to consider a national consensus to address these inconsistencies. Alternatively, the standard use of confirmatory radiographic testing prior to the retrieval of organs from donors who meet clinical brain death criteria should be considered to provide conclusive evidence of permanent and irreversible loss of brain function.

Laryngeal and tracheal transplantation: ethical limitations

Over the last decade, there have been extraordinary developments in the field of transplantation science. As a result, organ transplantation enjoys a success that is unparalleled since its introduction nearly 50 years ago. Progress in the laboratory has translated into less toxic, more effective immunosuppressive therapies that have improved both allograft survival and patient quality of life. Consequently, physicians and their patients look toward a new frontier, the transplantation of non-vital organs. While the transplantation of non-vital organs is technically feasible, as demonstrated by the recent success of a human laryngeal transplant, a variety of ethical concerns must be confronted before tracheal and laryngeal transplantation can be offered to patients as a reconstructive option. When considering the risks and benefits of non-vital organ transplantation, one must consider the immeasurable impact of a procedure on the patient s quality of life. The focus of this article is on quality of life and the role of laryngotracheal transplantation in contemporary medicine.

Uterus transplantation

Until recently, only life and death situations warranted organ transplantation. Nonvital transplantation, to further a patient s wishes and goals, was not considered justified. It can be argued, however, that this distinction is not morally significant. Patients with kidney failure, for example, can be kept alive by dialysis. But their quality of life would be greatly enhanced by kidney transplant, which is thus considered a justified procedure. So a spectrum of rationales may justify transplantation. Transplantation of the uterus would relieve the anguish of women who greatly desire to conceive a child. Some women do not have a uterus. In some cases this is due to a congenital absence (Rokitansky s syndrome). In other cases, surgical removal of the uterus was required to repair an obstetrical rupture. With a transplanted uterus, many of these women could have the opportunity to become pregnant as a result of nonvital organ transplant. While other organ transplant donations most often come from cadavers and less often from living donors (kidney or partial liver), the donor source for a uterus may be an otherwise healthy living patient who requires uterus removal as a standard care procedure. Furthermore, it should be possible to remove the transplanted uterus from the recipient after successful pregnancies, so the patient would not be subjected to lifelong antirejection medications. Since animal uterus transplantation has been done successfully, human uterus transplantation might be considered for select cases. One such case has been reported.

Legal and ethical issues related to nonheart beating organ donation

Major breakthroughs in immunosuppressant medication and advances in surgical techniques have increased the number of successful transplantations, but the demand for organs far outweighs the supply. People continue to die while waiting for donor organs to become available. Nonheart beating organ donation is a means of increasing the supply of organs to be transplanted. It is based on cardiac cessation criteria. This article explores the ethical and legal considerations, as well as implications for perioperative nurses.

Extension of organ transplantation: some ethical considerations

The concept of vital organ transplantation is critically analyzed by considering how traditional transplantation modifies the commitment to saving lives. Problems such as those associated with immunosuppression might seem to provide a compelling reason to oppose extension of transplantation to non-lifesaving situations. A closer examination, however, shows that immunosuppression does not present an intractable objection. For some organ transplants, such as the uterus, use of immunosuppression could be limited to the childbearing years. Complexities associated with assessment of quality of life are discussed using the example of hand transplantation. Assessment of success and functionality in a hand transplant is more complicated than it might appear at first. These complications suggest that monitoring and assessment should be a part of any extension of organ transplantation. Informed consent provides a limited, but important, component in justifying extended transplantation. Such justification, however, does not rest on patient autonomy, but on the reasonable prospect of benefit. Transplant programs considering an extension of traditional transplantation should develop formal protocols that include assessment of costs, benefits, quality of life, and the adequacy of informed consent.

Trust and trustworthiness in organ transplantation: good samaritan and emotionally related living donors

Organ transplantation, and living donor organ transplantation in particular, could not occur without society s trust in medicine and in transplant programs. This paper explains the importance of that trust and shows how the concept can be used to define the moral requirements for structuring organ transplant programs. The discussion goes on to outline what a trustworthy program must be, and to provide a conceptual perspective for drawing lines and setting boundaries for ethically acceptable living donor transplantation. It also explains the morally relevant considerations for accepting emotionally related or unrelated living donors.

Sharing our body and blood: organ donation and feminist critiques of sacrifice

Feminist analysis of cultural mythology surrounding organ donation offers a critical perspective on current U.S. transplant policy. My argument is three-pronged. First, I argue that organ donation is appropriately understood as a sacrifice. Structurally, donation accords both to general and to specifically Christian archetypes of sacrifice. The characterization of donation as sacrifice resonates in the cultural psyche even though it is absent in public rhetoric. Second, I characterize widespread feminist concerns about the over-glorification of sacrifice. These concerns provide a helpful framework for considering whether the sacrifice of organ donation is over-glorified in our culture. Third, I consider several specific aspects of organ recruitment and organ allocation. Each demonstrates an over-glorification of sacrifice that leads to a dangerous "routinization" of sacrifice. None of these excesses are addressable without due attention to the symbolic import of organ donation and transplantation. I close by suggesting lessons my analysis offers to Christian churches who support donation, to the discourse of bioethics, and to the general public.

Solid organ transplantation and HIV infection

HIV infection has been traditionally considered to be an absolute contraindication for solid organ transplantation. Recent advances in HIV treatment, as highly active antiretroviral therapy (HAART), significantly reduced HIV-related mortality and morbidity. At the same time the number of HIV-infected patients with end-stage organ diseases constantly increased. Current data describing solid organ transplantation in HIV-infected patients demonstrated comparable outcome to that in the HIV-negative population. In light of this, solid organ transplantation should be considered as a treatment option for selected HIV-positive patients with end-stage organ disease.

Ethical issues in organ transplantation

Clinical organ transplantation has been recognized as one of the most gripping medical advances of the century as it provides a way of giving the gift of life to patients with terminal failure of vital organs, which requires the participation of other fellow human beings and of society by donating organs from deceased or living individuals. The increasing incidence of vital organ failure and the inadequate supply of organs, especially from cadavers, has created a wide gap between organ supply and organ demand, which has resulted in very long waiting times to receive an organ as well as an increasing number of deaths while waiting. These events have raised many ethical, moral and societal issues regarding supply, the methods of organ allocation, the use of living donors as volunteers including minors. It has also led to the practice of organ sale by entrepreneurs for financial gains in some parts the world through exploitation of the poor, for the benefit of the wealthy. The current advances in immunology and tissue engineering and the use of animal organs, xenotransplantation, while offering very promising solutions to many of these problems, also raise additional ethical and medical issues which must be considered by the medical profession as well as society. This review deals with the ethical and moral issues generated by the current advances in organ transplantation, the problem of organ supply versus organ demand and the appropriate allocation of available organs. It deals with the risks and benefits of organ donation from living donors, the appropriate and acceptable methods to increase organ donation from the deceased through the adoption of the principle of 'presumed consent', the right methods of providing acceptable appreciation and compensation for the family of the deceased as well as volunteer and altruistic donors, and the duties and responsibilities of the medical profession and society to help fellow humans. The review also deals with the appropriate and ethically acceptable ways of utilizing the recent advances of stem cell transplantation from adult versus fetal donors, tissue engineering and the use of organs from animals or xenotransplantation. Data provided in support of the concept that clinical organ and tissue transplantation can be more beneficial and life saving if everyone involved in the process, including physicians and medical institutions, respect and consider the best interests of the patients, as well as honor the ethical, moral and religious values of society and are not tempted to seek personal fame or financial rewards.