1
|
Rolak S, Elhawary A, Diwan T, Watt KD. Futility and poor outcomes are not the same thing: A clinical perspective of refined outcomes definitions in liver transplantation. Liver Transpl 2024; 30:421-430. [PMID: 38240612 DOI: 10.1097/lvt.0000000000000331] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/07/2023] [Accepted: 01/10/2024] [Indexed: 03/16/2024]
Abstract
The term "futility" in liver transplantation is used inappropriately and inaccurately, as it is frequently applied to patient populations with suboptimal outcomes that are often not truly "futile." The term "futile" is used interchangeably with poor outcomes. Not all poor outcomes fulfill a definition of futility when considering all viewpoints. Definitions of "futility" are variable throughout the medical literature. We review futility in the context of liver transplantation, encompassing various viewpoints, with a goal to propose focused outcome definitions, including futility, that encompass broader viewpoints, and improve the utilization of "futility" to truly futile situations, and improve communication between providers and patients/families. Focused, appropriate definitions will help the transplant community develop better models to more accurately predict and avoid futile transplants, and better predict an individual patient's posttransplant outcome.
Collapse
Affiliation(s)
- Stacey Rolak
- Department of Internal Medicine, Mayo Clinic, Rochester, Minnesota, USA
| | - Ahmed Elhawary
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, Mayo Clinic, Rochester, Minnesota, USA
| | - Tayyab Diwan
- Department of Surgery, Mayo Clinic, Rochester, Minnesota, USA
| | - Kymberly D Watt
- Department of Internal Medicine, Mayo Clinic, Rochester, Minnesota, USA
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, Mayo Clinic, Rochester, Minnesota, USA
| |
Collapse
|
2
|
Considering a COVID-19 vaccine mandate for pediatric kidney transplant candidates. Pediatr Nephrol 2022; 37:2559-2569. [PMID: 35333972 PMCID: PMC8949834 DOI: 10.1007/s00467-022-05511-7] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/13/2022] [Revised: 02/10/2022] [Accepted: 02/11/2022] [Indexed: 12/02/2022]
Abstract
The world continues to face the effects of the SARS-CoV-2 pandemic. COVID-19 vaccines are safe and effective in protecting recipients, decreasing the risk of COVID-19 acquisition, transmission, hospitalization, and death. Transplant recipients may be at greater risk for severe SARS-CoV-2 infection. As a result, transplant programs have begun instituting mandates for COVID-19 vaccine for transplant candidacy. While the question of mandating COVID-19 vaccine for adult transplant candidates has garnered attention in the lay and academic press, these discussions have not explicitly addressed children who may be otherwise eligible for kidney transplants. In this paper we seek to examine the potential ethical justifications of a COVID-19 vaccine mandate for pediatric kidney transplant candidacy through an examination of relevant ethical principles, analogous cases of the use of mandates, differences between adult and pediatric kidney transplant candidates, and the role of gatekeeping in transplant vaccine mandates. At present, it does not appear that pediatric kidney transplant centers are justified to institute a COVID-19 vaccine mandate for candidates. Finally, we will offer suggestions to be considered prior to the implementation of a COVID-19 vaccine mandate.
Collapse
|
3
|
Burra P, Samuel D, Sundaram V, Duvoux C, Petrowsky H, Terrault N, Jalan R. Limitations of current liver donor allocation systems and the impact of newer indications for liver transplantation. J Hepatol 2021; 75 Suppl 1:S178-S190. [PMID: 34039488 DOI: 10.1016/j.jhep.2021.01.007] [Citation(s) in RCA: 25] [Impact Index Per Article: 8.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/22/2020] [Revised: 01/04/2021] [Accepted: 01/05/2021] [Indexed: 02/07/2023]
Abstract
Liver transplantation represents a life-saving treatment for patients with decompensated cirrhosis, a severe condition associated with a high risk of waiting list mortality. When decompensation occurs rapidly in the presence of extrahepatic organ failures, the condition is called acute-on-chronic liver failure, which is associated with an even higher risk of death, though liver transplantation can also markedly improve survival in affected patients. However, there are still gaps in our understanding of how to optimise prioritisation and organ allocation, as well as survival among patients with acute-on-chronic liver failure (both before and after transplant). Moreover, it is urgent to address inequalities in access to liver transplantation in patients with severe alcoholic hepatitis and non-alcoholic steatohepatitis. Several controversies still exist regarding gender and regional disparities, as well as the use of suboptimal donor grafts. In this review, we aim to provide a critical perspective on the role of liver transplantation in patients with decompensated cirrhosis and address areas of ongoing uncertainty.
Collapse
Affiliation(s)
- Patrizia Burra
- Multivisceral Transplant Unit, Department of Surgery, Oncology and Gastroenterology, Padua University Hospital, Padua, Italy.
| | - Didier Samuel
- Centre Hépato-Biliaire, Paris-Saclay University, Inserm research unit 1193, Hôpital Paul Brousse, Villejuif, France
| | - Vinay Sundaram
- Karsh Division of Gastroenterology and Comprehensive Transplant Center, Cedars-Sinai Medical Center, Los Angeles, CA, USA
| | - Christophe Duvoux
- Department of Hepatology and Medical Liver Transplant Unit Henri Mondor Hospital-APHP, Paris Est University (UPEC), Créteil, France
| | - Henrik Petrowsky
- Swiss HPB and Transplantation Center Department of Surgery and Transplantation University Hospital Zürich, Zürich, Switzerland
| | - Norah Terrault
- Keck School of Medicine of University of Southern California, Los Angeles CA, United States
| | - Rajiv Jalan
- Liver Failure Group, Institute for Liver and Digestive Health, University College London, London and European Foundation for the Study of Chronic Liver Failure, Barcelona, Spain
| |
Collapse
|
4
|
Sakamoto S, Uchida H, Shimizu S, Yanagi Y, Takeda M, Kubota T, Nakazato Y, Fukuda A, Kasahara M. Current status of pediatric deceased donor liver transplantation: Lessons learned from a high-volume center in Japan where living donation remains predominant. JOURNAL OF HEPATO-BILIARY-PANCREATIC SCIENCES 2020; 28:1014-1022. [PMID: 33315309 DOI: 10.1002/jhbp.886] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/30/2020] [Revised: 11/27/2020] [Accepted: 12/02/2020] [Indexed: 12/11/2022]
Abstract
BACKGROUND In Japan, a recent gradual increase in deceased donor donation has expanded opportunities for pediatric patients to obtain deceased grafts. METHODS Forty-three children underwent deceased donor liver transplantation (DDLT) at our institute before February 2020. Twenty-five patients received a split or reduced graft and 18 patients received a whole graft. The clinical outcomes of DDLT were retrospectively analyzed. RESULTS The main organ resource was split/reduced grafts retrieved from adult donors; however, the number of whole grafts retrieved from pediatric donors has increased. The rates of major complications were similar in the two groups. The 5-year graft survival rate of patients who received a split/reduced graft (78.0%) was lower than that of patients who received a whole graft (88.9%; P = .40). The 3-year graft survival rates of patients who recently received a split/reduced graft and a whole graft improved to 92.3% and 91.7%, respectively. CONCLUSIONS The recent amendment of the organ allocation system, especially the introduction of pediatric prioritization, can effectively increase the chance to obtain deceased donor grafts for pediatric DDLT in Japan. The recent refinements in donor and recipient selection and in the surgical technique of split DDLT can improve the outcomes of pediatric DDLT in Japan.
Collapse
Affiliation(s)
- Seisuke Sakamoto
- Organ Transplantation Center, National Center for Child Health and Development, Setagaya, Japan
| | - Hajime Uchida
- Organ Transplantation Center, National Center for Child Health and Development, Setagaya, Japan
| | - Seiichi Shimizu
- Organ Transplantation Center, National Center for Child Health and Development, Setagaya, Japan
| | - Yusuke Yanagi
- Organ Transplantation Center, National Center for Child Health and Development, Setagaya, Japan
| | - Masahiro Takeda
- Organ Transplantation Center, National Center for Child Health and Development, Setagaya, Japan
| | - Tomomi Kubota
- Organ Transplantation Center, National Center for Child Health and Development, Setagaya, Japan
| | - Yayoi Nakazato
- Organ Transplantation Center, National Center for Child Health and Development, Setagaya, Japan
| | - Akinari Fukuda
- Organ Transplantation Center, National Center for Child Health and Development, Setagaya, Japan
| | - Mureo Kasahara
- Organ Transplantation Center, National Center for Child Health and Development, Setagaya, Japan
| |
Collapse
|
5
|
Linecker M, Krones T, Berg T, Niemann CU, Steadman RH, Dutkowski P, Clavien PA, Busuttil RW, Truog RD, Petrowsky H. Potentially inappropriate liver transplantation in the era of the "sickest first" policy - A search for the upper limits. J Hepatol 2018; 68:798-813. [PMID: 29133246 DOI: 10.1016/j.jhep.2017.11.008] [Citation(s) in RCA: 75] [Impact Index Per Article: 12.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/01/2017] [Revised: 10/11/2017] [Accepted: 11/06/2017] [Indexed: 12/11/2022]
Abstract
Liver transplantation has emerged as a highly efficient treatment for a variety of acute and chronic liver diseases. However, organ shortage is becoming an increasing problem globally, limiting the applicability of liver transplantation. In addition, potential recipients are becoming sicker, thereby increasing the risk of losing the graft during transplantation or in the initial postoperative period after liver transplantation (three months). This trend is challenging the model for end-stage liver disease allocation system, where the sickest candidates are prioritised and no delisting criteria are given. The weighting of the deontological demand for "equity", trying to save every patient, regardless of the overall utility; and "efficiency", rooted in utilitarianism, trying to save as many patients as possible and increase the overall quality of life of patients facing the same problem, has to be reconsidered. In this article we are aiming to overcome the widespread concept of futility in liver transplantation, providing a definition of potentially inappropriate liver transplantation and giving guidance on situations where it is best not to proceed with liver transplantation, to decrease the mortality rate in the first three months after transplantation. We propose "absolute" and "relative" conditions, where early post-transplant mortality is highly probable, which are not usually captured in risk scores predicting post-transplant survival. Withholding liver transplantation for listed patients in cases where liver transplant is not deemed clearly futile, but is potentially inappropriate, is a far-reaching decision. Until now, this decision had to be discussed extensively on an individual basis, applying explicit communication and conflict resolution processes, since the model for end-stage liver disease score and most international allocation systems do not include explicit delisting criteria to support a fair delisting process. More work is needed to better identify cases where transplantation is potentially inappropriate and to integrate and discuss these delisting criteria in allocation systems, following a societal debate on what we owe to all liver transplant candidates.
Collapse
Affiliation(s)
- Michael Linecker
- Swiss HPB and Transplantation Center, University Hospital Zurich, Switzerland; Department of Surgery and Transplantation, University Hospital Zurich, Switzerland
| | - Tanja Krones
- Division of Clinical Ethics, University Hospital Zurich, Switzerland; Institute of Biomedical Ethics and History of Medicine, University of Zurich, Switzerland
| | - Thomas Berg
- Division of Hepatology, University of Leipzig, Germany
| | - Claus U Niemann
- Department of Anesthesiology, University of California, San Francisco, USA; Department of Surgery, University of California San Francisco, USA
| | - Randolph H Steadman
- Department of Anesthesiology and Perioperative Medicine, Ronald Reagan Medical Center, University of California Los Angeles, Los Angeles, USA
| | - Philipp Dutkowski
- Swiss HPB and Transplantation Center, University Hospital Zurich, Switzerland; Department of Surgery and Transplantation, University Hospital Zurich, Switzerland
| | - Pierre-Alain Clavien
- Swiss HPB and Transplantation Center, University Hospital Zurich, Switzerland; Department of Surgery and Transplantation, University Hospital Zurich, Switzerland
| | - Ronald W Busuttil
- Dumont-UCLA Transplant Center, Ronald Reagan Medical Center, University of California Los Angeles, USA
| | - Robert D Truog
- Center for Bioethics, Harvard Medical School, Boston, USA; Department of Anesthesia, Perioperative and Pain Medicine, Boston Children's Hospital, USA
| | - Henrik Petrowsky
- Swiss HPB and Transplantation Center, University Hospital Zurich, Switzerland; Department of Surgery and Transplantation, University Hospital Zurich, Switzerland.
| |
Collapse
|
6
|
Dreyzin A, Lunz J, Venkat V, Martin L, Bond GJ, Soltys KA, Sindhi R, Mazariegos GV. Long-term outcomes and predictors in pediatric liver retransplantation. Pediatr Transplant 2015; 19:866-74. [PMID: 26362966 DOI: 10.1111/petr.12588] [Citation(s) in RCA: 30] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 07/29/2015] [Indexed: 12/12/2022]
Abstract
Historically, 9-29% of pediatric liver transplant recipients have required retransplantation. Although outcomes have improved over the last decade, currently published patient and graft survival remain lower after retransplant than after primary transplant. Data from liver retransplantation recipients at our institution between 1991 and 2013 were retrospectively reviewed. Kaplan-Meier estimates were used to depict patient and graft survival. Predictors of survival were analyzed using a series of Cox proportional hazards models. Predictors were analyzed separately for patients who had "early" (≤ 30 days after primary transplant) and "late" retransplants. Eighty-four patients underwent retransplant at a median time of 241 days. Sixty percent had late retransplants. At one, five, and 10 yr, actuarial patient and graft survival were 73%/71%, 66%/63%, and 58%/53%, respectively. Since 2002, patient and graft survival improved to 86%/86% at one yr and 93%/87% at five yr. While operative complications were a common cause of death after earlier retransplants, since 2002, infection has been the only cause of death. Significant morbidities at five-yr follow-up include renal dysfunction (15%), diabetes (13%), hypertension (26%), chronic rejection (7%), and PTLD (2%). Current survival after pediatric liver retransplantation has improved significantly, but long-term immunosuppressant morbidity remains an opportunity for improvement.
Collapse
Affiliation(s)
| | - John Lunz
- Department of Pathology, Thomas E. Starzl Transplantation Institute, University of Pittsburgh Medical Center, Pittsburgh, PA, USA
| | - Veena Venkat
- Division of Pediatric Gastroenterology, Children's Hospital of Pittsburgh of UPMC, University of Pittsburgh Medical Center, Pittsburgh, PA, USA
| | - Lillian Martin
- Hillman Center for Pediatric Transplantation, Children's Hospital of Pittsburgh of UPMC, Thomas E. Starzl Transplantation Institute, University of Pittsburgh Medical Center, Pittsburgh, PA, USA
| | - Geoffrey J Bond
- Hillman Center for Pediatric Transplantation, Children's Hospital of Pittsburgh of UPMC, Thomas E. Starzl Transplantation Institute, University of Pittsburgh Medical Center, Pittsburgh, PA, USA
| | - Kyle A Soltys
- Hillman Center for Pediatric Transplantation, Children's Hospital of Pittsburgh of UPMC, Thomas E. Starzl Transplantation Institute, University of Pittsburgh Medical Center, Pittsburgh, PA, USA
| | - Rakesh Sindhi
- Hillman Center for Pediatric Transplantation, Children's Hospital of Pittsburgh of UPMC, Thomas E. Starzl Transplantation Institute, University of Pittsburgh Medical Center, Pittsburgh, PA, USA
| | - George V Mazariegos
- Hillman Center for Pediatric Transplantation, Children's Hospital of Pittsburgh of UPMC, Thomas E. Starzl Transplantation Institute, University of Pittsburgh Medical Center, Pittsburgh, PA, USA
| |
Collapse
|
7
|
Rana A, Pallister ZS, Guiteau JJ, Cotton RT, Halazun K, Nalty CC, Khaderi SA, O'Mahony CA, Goss JA. Survival Outcomes Following Pediatric Liver Transplantation (Pedi-SOFT) Score: A Novel Predictive Index. Am J Transplant 2015; 15:1855-63. [PMID: 25689873 DOI: 10.1111/ajt.13190] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/16/2014] [Revised: 12/22/2014] [Accepted: 12/24/2014] [Indexed: 01/25/2023]
Abstract
A prognostic index to predict survival after liver transplantation could address several clinical needs. Here, we devised a scoring system that predicts recipient survival after pediatric liver transplantation. We used univariate and multivariate analysis on 4565 pediatric liver transplant recipients data and identified independent recipient and donor risk factors for posttransplant mortality at 3 months. Multiple imputation was used to account for missing variables. We identified five factors as significant predictors of recipient mortality after pediatric liver transplantation: two previous transplants (OR 5.88, CI 2.88-12.01), one previous transplant (OR 2.54, CI 1.75-3.68), life support (OR 3.68, CI 2.39-5.67), renal insufficiency (OR 2.66, CI 1.84-3.84), recipient weight under 6 kilograms (OR 1.67, CI 1.12-2.36) and cadaveric technical variant allograft (OR 1.38, CI 1.03-1.83). The Survival Outcomes Following Pediatric Liver Transplant score assigns weighted risk points to each of these factors in a scoring system to predict 3-month recipient survival after liver transplantation with a C-statistic of 0.74. Although quite accurate when compared with other posttransplant survival models, we would not advocate individual clinical application of the index.
Collapse
Affiliation(s)
- A Rana
- Division of Abdominal Transplantation and Division of Hepatobiliary Surgery, Michael E. DeBakey Department of Surgery, Baylor College of Medicine, Houston, TX.,Department of Surgery, Texas Children's Hospital, Houston, TX
| | - Z S Pallister
- Division of Abdominal Transplantation and Division of Hepatobiliary Surgery, Michael E. DeBakey Department of Surgery, Baylor College of Medicine, Houston, TX
| | - J J Guiteau
- Division of Abdominal Transplantation and Division of Hepatobiliary Surgery, Michael E. DeBakey Department of Surgery, Baylor College of Medicine, Houston, TX
| | - R T Cotton
- Division of Abdominal Transplantation and Division of Hepatobiliary Surgery, Michael E. DeBakey Department of Surgery, Baylor College of Medicine, Houston, TX
| | - K Halazun
- Division of Transplantation, Department of Surgery, Emory University School of Medicine, Atlanta, GA
| | - C C Nalty
- Division of Abdominal Transplantation and Division of Hepatobiliary Surgery, Michael E. DeBakey Department of Surgery, Baylor College of Medicine, Houston, TX
| | - S A Khaderi
- Division of Abdominal Transplantation and Division of Hepatobiliary Surgery, Michael E. DeBakey Department of Surgery, Baylor College of Medicine, Houston, TX
| | - C A O'Mahony
- Division of Abdominal Transplantation and Division of Hepatobiliary Surgery, Michael E. DeBakey Department of Surgery, Baylor College of Medicine, Houston, TX.,Department of Surgery, Texas Children's Hospital, Houston, TX
| | - J A Goss
- Division of Abdominal Transplantation and Division of Hepatobiliary Surgery, Michael E. DeBakey Department of Surgery, Baylor College of Medicine, Houston, TX.,Department of Surgery, Texas Children's Hospital, Houston, TX
| |
Collapse
|
8
|
A comparison of two validated scores for estimating risk of mortality of children with intestinal failure associated liver disease and those with liver disease awaiting transplantation. Clin Res Hepatol Gastroenterol 2014; 38:32-9. [PMID: 23856636 DOI: 10.1016/j.clinre.2013.06.001] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/15/2013] [Revised: 06/05/2013] [Accepted: 06/19/2013] [Indexed: 02/04/2023]
Abstract
BACKGROUND AND AIMS To evaluate risk of mortality in children with intestinal failure associated liver disease (IFALD) compared with other liver disease using two validated scores. METHODS Sixty-seven children listed for transplant were studied: cholestatic liver disease (CLDn23); liver disease secondary to other processes (LDsec n11); (IFALDn22), acute liver failure (ALFn11). Paediatric Hepatology Score (PHD) score and Pediatric end-stage liver disease score (PELD) were evaluated by Receiver Operating Curves (ROC), proportional hazards regression. RESULTS The highest PHD and PELD scores were found in ALF; the lowest in LDsec. Both scores correlated well in identifying waiting list (WL) mortality in patients with CLD and ALF, but not in those with IFALD where PELD scores were lower. Cox proportional hazard regression of time spent on the waiting list prior to death or transplant/delisting showed significant associations with PHD (P=0.006) and PELD (P=0.008). WL mortality was strongly predicted by disease group (6/8 deaths in IFALD). ROC analysis of all data showed that a PHD score greater than 15.5 had sensitivity of 87.5% and specificity of 81% for waiting list mortality (P<0.001); PELD greater than 8 had a sensitivity of 87.5% and specificity of 40%. Neither PHD nor PELD scores correlated with post-transplant mortality. CONCLUSION PHD and PELD scores had the same sensitivity for identifying risk of WL mortality in all patients, but PELD failed to identify the sickest children with IFALD, lowering its specificity. The PHD score has the added advantage for European centres of being in SI units, not requiring a computer application to calculate and was simpler to use at bedside.
Collapse
|
9
|
Yazigi NA. Long term outcomes after pediatric liver transplantation. Pediatr Gastroenterol Hepatol Nutr 2013; 16:207-18. [PMID: 24511516 PMCID: PMC3915734 DOI: 10.5223/pghn.2013.16.4.207] [Citation(s) in RCA: 61] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/01/2013] [Accepted: 12/03/2013] [Indexed: 12/29/2022] Open
Abstract
Long term outcomes after liver transplantation are major determinants of quality of life and of the value of this heroic treatment. As short term outcomes are excellent, our community is turning to take a harder look at long term outcomes. The purpose of this paper is to review these outcomes, and highlight proposed treatments, as well as pressing topics needing to be studied. A systemic review of the English literature was carried in PubMed, covering all papers addressing long term outcomes in pediatric liver transplant from 2000-2013. Late outcomes after pediatric liver transplant affect the liver graft in the form of chronic liver dysfunction. The causes include rejection particularly humoral rejection, but also de novo autoimmune hepatitis, and recurrent disease. The metabolic syndrome is a major factor in long term cardiovascular complication risk. Secondary infections, kidney dysfunction and malignancy remain a reality of those patients. There is growing evidence of late cognitive and executive function delays affecting daily life productivity as well as likely adherence. Finally, despite a good health status, quality of life measures are comparable to those of children with chronic diseases. Long term outcomes are the new frontier in pediatric liver transplantation. Much is needed to improve graft survival, but also to avoid systemic morbidities from long term immunosuppression. Quality of life is a new inclusive measure that will require interventions and innovative approaches respectful not only on the patients but also of their social circle.
Collapse
Affiliation(s)
- Nada A Yazigi
- MedStar Georgetown Transplant Institute, Georgetown University Hospital, Washington DC, USA
| |
Collapse
|
10
|
Abstract
Is there a rational and ethical basis for efforts to rescue individuals in dire straits? When does rescue have ethical support, and when does it reflect an irrational impulse? This paper defines a Rule of Rescue and shows its intuitive appeal. It then proceeds to argue that this rule lacks support from standard principles of justice and from ethical principles more broadly, and should be rejected in many situations. I distinguish between agent-relative and agent-neutral reasons, and argue that the Rule of Rescue qualifies only in a narrow range of cases where agent-relative considerations apply. I conclude that it would be wise to set aside the Rule of Rescue in many cases, especially those involving public policies, where it has only weak normative justification. The broader implications of this analysis are noted.
Collapse
Affiliation(s)
- Nancy S Jecker
- University of Washington, A 204 Health Sciences Bldg, Seattle, WA 98195 USA.
| |
Collapse
|
11
|
|