The scarcity of livers available for transplants forces tough choices upon us. Lives for those not receiving a transplant are likely to be short. One large group of potential recipients needs a new liver because of alcohol consumption, while others suffer for reasons unrelated to their own behaviour. Should the former group receive lower priority when scarce livers are allocated? This discussion connects with one of the most pertinent issues in contemporary political philosophy; the role of personal responsibility in distributive (...) justice. One prominent theory of distributive justice, luck egalitarianism, assesses distributions as just if, and only if, people's relative positions reflect their exercises of responsibility. There is a principled luck egalitarian case for giving lower priority to those who are responsible for their need. Compared to the existing literature favouring such differentiation, luck egalitarianism provides a clearer rationale of fairness, acknowledges the need for individual assessments of responsibility, and requires initiatives both inside and outside of the allocation systems aimed at mitigating the influence from social circumstances. Furthermore, the concrete policies that luck egalitarians can recommend are neither too harsh on those who make imprudent choices nor excessively intrusive towards those whose exercises of responsibility are assessed. (shrink)

Bioethical discourse on organ donation and transplantation medicine covers a wide range of topics, from informed consent procedures and scarcity issues up to transplant tourism and organ trade. Over the past decades, this discourse evolved into a stream of documents of bewildering proportions, encompassing thousands of books, papers, conferences, blogs, consensus meetings, policy reports, media debates and other outlets. Beneath the manifest level of discourse, however, a more latent dimension can be discerned, revolving around issues of embodiment, (...) the moral status of the human body and the concept of bodily integrity. This publication aims to bring these “deeper” questions to the fore. What is envisioned is a “depth” ethics (the moral equivalent of a depth psychology) focussing on the tensions, conflicts and ambiguities at work in bioethical deliberations on organ transplantation, fuelling the viewpoints articulated on the more manifest levels of discourse. Organ donation reopens the question of the status of the body as something which we have, but at the same time are, and as something which constitutes a whole, while at the same time being a set of replaceable elements or parts. (shrink)

This essay, based on data referring to Brazil and Spain, addresses aspects relevant to the scenario of organ donation and transplantation, such as the relationship between supply and demand, current legislation, costs, and possible improvements to increase donation rates and performance in the transplantation process as a whole. The objective is to present current empirical data that increase the relevant empirical knowledge for the bioethical evaluation in an organized way. The two countries stand out when it comes (...) to transplants, Brazil, because it has the largest public system of organ transplants in the world; Spain, for decades the highest rate of effective donor per million inhabitants. Our initial data analyses suggest the need to deal more explicitly with the interests of those affected and with the public opinion, within a systemic articulation between legislation, evidence-based public policies, and research. (shrink)

Bioethical discourse on organ donation covers a wide range of topics, from informed consent procedures and scarcity issues up to ‘transplant tourism’ and ‘organ trade’. This paper presents a ‘depth ethics’ approach, notably focussing on the tensions, conflicts and ambiguities concerning the status of the human body. These will be addressed from a psychoanalytical angle. First, I will outline Lacan’s view on embodiment as such. Subsequently, I will argue that, for organ recipients, the donor organ becomes (...) what Lacan refers to as an object a, the ‘partial object’ of desire, the elusive thing we are deprived of, apparently beyond our grasp. Within the recipient’s body an empty space emerges, a kind of ‘vacuole’, once occupied by a faltering organ. This space can only be filled by a ‘gift’ from the other, by an object a. Once implanted, however, this implant becomes an ‘extimate’ object: something both ‘external’ and ‘intimate’, both ‘embedded’ and ‘foreign’, and which is bound to remain an object of concern for quite some time, if not for life. A Lacanian analysis allows us, first of all, to address the question what organ transplantation has in common with other bodily practices involving bodily parts procured from others, such as cannibalism. But it also reveals the basic difference between the two, as well as the distance between the ‘fragmented body’ of Frankenstein’s ‘monster’—as an aggregate of replaceable parts—and the multiple organ recipients of today. (shrink)

Philosophers have given sustained attention to the controversial possibility of (legal) markets in transplantable human organs. Most of this discussion has focused on whether such markets would enhance or diminish autonomy, understood in either the personal sense or the Kantian moral sense. What this discussion has lacked is any consideration of the relationship between self-ownership and such markets. This paper examines the implications of the most prominent and defensible conception of self-ownership--control self-ownership (CSO)--for both market and nonmarket organ-allocation mechanisms. (...) The paper contends that CSO rules out a large set of nonmarket mechanisms, including escheatage ("presumed consent"), compensated takings of organs, and restricted gifting. It also argues that CSO, if accompanied by an economistic concern for welfare, can underwrite varying types of markets in human organs, ranging from mutual-insurance pools to inter vivos (i.e., live donor) organ sales. (shrink)

A dissociated area of medical research warrants bioethical consideration: a proposed transplantation of a donor’s entire body, except head, to a patient with a fatal degenerative disease. The seeming improbability of such an operation can only underscore the need for thorough bioethical assessment: Not assessing a case of such potential ethical import, by showing neglect instead of facing the issue, can only compound the ethical predicament, perhaps eroding public trust in ethical medicine. This article discusses the historical background of (...) full-body transplantation, documents the seriousness of its current pursuit, and builds an argument for why prima facie this type of transplant is bioethically distinct. Certainly, this examination can only be preliminary, indicating what should be a wide and vigorous discussion among practitioners and ethicists. It concludes with practical suggestions for how the medical and bioethics community may proceed with ethical assessment. (shrink)

The assumption that procuring more organs will save more lives has inspired increasingly forceful calls to increase organ procurement. This project, in contrast, directly questions the premise that more organ transplantation means more lives saved. Its argument begins with the fact that resources are limited and medical procedures have opportunity costs. Because many other lifesaving interventions are more cost‐effective than transplantation and compete with transplantation for a limited budget, spending on organ transplantation consumes (...) resources that could have been used to save a greater number of other lives. This argument has not yet been advanced in debates over expanded procurement and could buttress existing concerns about expanded procurement. To support this argument, I review existing empirical data on the cost‐effectiveness of transplantation and compare them to data on interventions for other illnesses. These data should motivate utilitarians and others whose primary goal is maximizing population‐wide health benefits to doubt the merits of expanding organ procurement. I then consider two major objections: one makes the case that transplant candidates have a special claim to medical resources, and the other challenges the use of cost‐effectiveness to set priorities. I argue that there is no reason to conclude that transplant candidates’ medical interests should receive special priority, and that giving some consideration to cost‐effectiveness in priority setting requires neither sweeping changes to overall health priorities nor the adoption of any specific, controversial metric for assessing cost‐effectiveness. Before searching for more organs, we should first ensure the provision of cost‐effective care. (shrink)

An analysis of the identity issues involved in facial allograft transplantation is provided in this paper. The identity issues involved in organ transplantation in general, under both theoretical accounts of personal identity and subjective accounts provided by organ recipients, are examined. It is argued that the identity issues involved in facial allograft transplantation are similar to those involved in organ transplantation in general, but much stronger because the face is so closely linked with (...) personal identity. Recipients of facial allograft transplantation have the potential to feel that their identity is a mix between their own and the donor’s, and the donor’s family is potentially likely to feel that their loved one ‘‘lives on’’. It is also argued that facial allograft transplantation allows the recipients to regain an identity, because they can now be seen in the social world. Moreover, they may regain expressivity, allowing for them to be seen even more by others, and to regain an identity to an even greater extent. Informing both recipients and donors about the role that identity plays in facial allograft transplantation could enhance the consent process for facial allograft transplantation and donation. (shrink)

Organ transplantation centers set criteria for candidate qualification, which has led to disparate healthcare resource allocation practices affecting those with a substance use history. These individuals are denied organ transplants by committees and healthcare providers who assign them lower priority status. The lower priority argument claims that healthcare resources should not be provided equally to individuals who fail to share responsibility for not doing enough to address the diseases associated with substance use. The purpose of this paper (...) is to explore the interrelatedness between the ethics of a merit-based system of moral responsibility and the lower priority setting involved in healthcare resource allocation pertaining to those with substance use histories. An interdisciplinary approach to the argument against the lower prioritists is taken with a focus on the relationship between different organ allocation practices affecting substance users and the justification for resource allocation practices of healthcare and transplant committees. Lower priority setting is challenged, and an argument is offered in which substance users are assigned higher priority when relying on "doing enough" in a merit-based system of moral responsibility. It is determined that one cannot substantiate assigning a lower priority status since a lack of success in rehab does not imply a lack of effort. Additionally, neither to confirmatory behavior nor to non-conforming behavior may freedom be justifiably ascribed in a merit-based system of responsibility because freedom to choose can neither be established a priori nor a posteriori concerning meritorious behavior. (shrink)

We explore the ethics of using motivational interviewing, an evidence-based, client-centred and directional counselling method, in conversations with next of kin about deceased solid organ donation. After briefly introducing MI and providing some context around organ transplantation and next of kin consent, we describe how MI might be implemented in this setting, with the hypothesis that MI has the potential to bring about a modest yet significant increase in next of kin consent rates. We subsequently consider the (...) objection that using MI in this context would be manipulative. Although we cannot guarantee that MI would never be used in a problematically manipulative fashion, we conclude that its use would, nevertheless, be permissible as a potential means to increase next of kin consent to deceased solid organ donation. We propose that MI be trialled in consent situations with next of kin in nations where there is widespread public support for organ donation. (shrink)

In Canada, there are currently no guidelines at either the federal or provincial level regarding the provision of kidney transplantation services to foreign nationals (FN). Renal transplant centres have, in the past, agreed to put refugee claimants and other FNs on the renal transplant waiting list, in part, because these patients (refugee claimants) had health insurance through the Interim Federal Health Programme to cover the costs of medication and hospital care. However, severe cuts recently made to this programme have (...) forced clinicians to question whether they should continue with transplants for FNs, for financial and ethical reasons. This paper first examines different national policies (eg, in Canada, USA, France and the UK) to map the diversity of approaches regarding transplantation for FNs, and then works through different considerations commonly used to support or oppose the provision of organs to these patients: (1) the organ shortage; (2) the free-rider problem; (3) the risk of becoming a transplant destination; (4) the impact on organ donation rates; (5) physicians’ duties; (6) economic concerns; (7) vulnerability. Using a Canadian case as a focus, and generalising through a review of various national policies, we analyse the arguments for and against transplantation for FNs with a view to bringing clarity to what is a sensitive political and clinical management issue. Our aim is to help transplant centres, clinicians and ethicists reflect on the merits of possible options, and the rationales behind them. (shrink)

Organ transplantation centers set criteria for candidate qualification, which has led to disparate healthcare resource allocation practices affecting those with a substance use history. These individuals are denied organ transplants by committees and healthcare providers who assign them lower priority status. The lower priority argument claims that healthcare resources should not be provided equally to individuals who fail to share responsibility for not doing enough to address the diseases associated with substance use. The purpose of this paper (...) is to explore the interrelatedness between the ethics of a merit-based system of moral responsibility and the lower priority setting involved in healthcare resource allocation pertaining to those with substance use histories. An interdisciplinaryapproach to the argument against the lower prioritists is taken with a focus on the relationship between different organ allocation practices affecting substance users and the justification for resource allocation practices of healthcare and transplant committees. Lower priority setting is challenged, and an argument is offered in which substance users are assigned higher priority when relying on "doing enough" in a merit-based system of moral responsibility. It is determined that one cannot substantiate assigning a lower priority status since a lack of success in rehab does not imply a lack of effort. Additionally, neither to confirmatory behavior nor to non-conforming behavior may freedom be justifiably ascribed in a merit-based system of responsibility because freedom to choose can neither be established a priori nor a posteriori concerning meritorious behavior. (shrink)

The Australian Federal Government has announced a two-year trial scheme to compensate living organ donors. The compensation will be the equivalent of six weeks paid leave at the rate of the national minimum wage. In this article I analyse the ethics of compensating living organ donors taking the Australian scheme as a reference point. Considering the long waiting lists for organ transplantations and the related costs on the healthcare system of treating patients waiting for an organ, (...) the 1.3 million AUD the Australian Government has committed might represent a very worthwhile investment. I argue that a scheme like the Australian one is sufficiently well designed to avoid all the ethical problems traditionally associated with attaching a monetary value to the human body or to parts of it, namely commodification, inducement, exploitation, and equality issues. Therefore, I suggest that the Australian scheme, if cost-effective, should represent a model for other countries to follow. Nonetheless, although I endorse this scheme, I will also argue that this kind of scheme raises issues of justice in regard to the distribution of organs. Thus, I propose that other policies would be needed to supplement the scheme in order to guarantee not only a higher number of organs available, but also a fair distribution. (shrink)

The wishes of registered organ donors are regularly set aside when family members object to donation. This genuine overruling of the wishes of the deceased raises difficult ethical questions. A successful argument for providing the family with a veto must (a) provide reason to disregard the wishes of the dead, and (b) establish why the family should be allowed to decide. One branch of justification seeks to reconcile the family veto with important ideas about respecting property rights, preserving autonomy, (...) and preventing harm. These arguments are ultimately unsuccessful. Another branch of arguments is consequentialist, pointing out the negative consequences of removing the veto. Whether construed as concerning family distress or as a potential drop in the organs available, these arguments are unsuccessful; the first fails to recognize the tremendous distress associated with waiting for an organ, while the second has little supporting evidence. A final section considers and rejects whether combining some of the arguments just examined could justify the family veto. We should thus remove the family veto in organ donation. (shrink)

The arrival of synthetic organs may mean we need to reconsider principles of ownership of such items. One possible ownership criterion is the boundary between the organ’s being outside or inside the body. What is outside of my body, even if it is a natural organ made of my cells, may belong to a company or research institution. Yet when it is placed in me, it belongs to me. In the future, we should also keep an eye on (...) how the availability of synthetic organs may change our attitudes toward our own bodies. (shrink)

This chapter aims to raise the profile of organ trafficking among the academic community researching human trafficking in general. It explains how the various elements of organ trafficking are defined and how they relate to and differ from transplant tourism and organ markets. Some of the most important international declarations on organ trafficking are outlined, as well as some selective national legislation. Shifting global patterns of organ trafficking will be illustrated with an emphasis on India, (...) Pakistan, Nepal and China. Some of the difficulties in curbing such trafficking are considered before outlining recommendations for increasing effective prevention, improving prosecution of perpetrators, and offering protection and support for victims. (shrink)

Background: Several countries have recently changed their model of consent for organ donation from opt-in to opt-out. We undertook a systematic review to determine public knowledge and attitudes towards these models in Europe. Methods: Six databases were explored between 1 January 2008 and 15 December 2017. We selected empirical studies addressing either knowledge or attitudes towards the systems of consent for deceased organ donation by lay people in Europe, including students. Study selection, data extraction, and quality assessment were (...) conducted by two or more reviewers independently. Findings: Awareness of the consent model was lower in opt-out countries than in opt-in countries. A majority of the public agrees with opt-in, regardless of the law in their own country. There are ambivalent attitudes regarding the opt-out system. The public tend to prefer opt-in and mandatory choice over opt-out when several options are offered. Interpretation: The assumption that people in opt-out countries are aware of the legal requirements to be excluded from the pool of potential donors is not supported by the results of this review. This is a concern, since ignorance hinders people's autonomy regarding organ donation decision-making. Higher awareness of consent model in opt-in countries may reflect greater efforts to inform the public through campaigns to motivate donation. Legal moves towards opt-out are at odds with people's expressed preferences. Main limitations of this review are the lack of data from some countries, study population heterogeneity, and methodological shortcomings. (shrink)

After a long search, Jonathan has finally found someone willing to donate a kidney to him and thereby free him from dialysis. Meredith is Jonathan's second cousin, and she considers herself a generous person, so although she barely knows Jonathan, she is willing to help. However, as Meredith learns more about the donation process, she begins to ask questions about Jonathan: “Is he HIV positive? I heard he got it using drugs. Has he been in jail? He's already had one (...) live donor, so what happened to the first kidney? Did he forget to take his drugs or something?” The transplant center must, then, decide if Meredith is, in fact, entitled to answers to these kinds of questions. According to the Consensus Statement on the Live Organ Donor, “It is incumbent on the transplant center to provide full and accurate disclosure to potential donors of all pertinent information regarding risk and benefit to the donor and recipient.” But whether answers to the Meredith's questions count as “pertinent information regarding the risk and benefit” is the issue at hand. (shrink)

Joshua Mezrich is a practicing transplant surgeon who draws on his experiences, and those of his patients, to provide a "here's where we're at" moment in the story of transplant medicine. In so doing, he explains what it is like to practice while telling the stories of his patients, donors, and the pioneering surgeons who persisted in the face of failure to make what Mezrich does a work of healing. Written for a popular audience, When Death Becomes Life is perhaps (...) the most accessible work yet on the modern history of organ transplantation and what the current "standard of care" actually looks like. Indeed, it rounds out a "trinity" of quality books about the transplant experience, this one from the surgeon's... (shrink)

Altruism and solidarity are concepts that are closely related to organ donation for transplantation. On the one hand, they are typically used for encouraging people to donate. On the other hand, they also underpin the regulations in force in each country to different extents. They are often used indistinctly and equivocally, despite the different ethical implications of each concept. This paper aims to clarify to what extent we can speak of altruism and solidarity in the predominant models of (...) organ donation. It also raises the ethical question of whether these categories are adequate as a basis for such models, bearing in mind that organs are a scarce resource and that a shortage of them may mean that fewer lives are saved or improved. (shrink)

Several European countries are approving legislative reforms moving to a presumed consent system in order to increase organ donation rates. Nevertheless, irrespective of the consent system in force, family's decisional capacity probably causes a greater impact on such rates. In this contribution we have developed a systematic methodology in order to analyse and compare European organ procurement laws, and we clarify the weight given by each European law to relatives' decisional capacity over individual's preferences (expressed or not while (...) alive) regarding the destination of his or her organs after death. In this sense, the results constitute the first comprehensive and comparative legislative mapping on European transplantation laws. (shrink)

A number of bioethicists have been critical of the power of the family to “veto” a patient’s decision to posthumously donate her organs within opt-in systems of organ procurement. One major objection directed at the family veto is that when families veto the decision of their deceased family member, they do something wrong by violating or failing to respect the autonomy of that deceased family member. The goal of this paper is to make progress on answering this objection. I (...) do this in two stages. First, I argue that the most plausible interpretation of what happens when a person registers as an organ donor in an opt-in system is that she gives her consent to the state to posthumously remove her organs for transplantation purposes. Call this the Authorization Account. Second, given the Authorization Account, I argue by analogy that when families veto an individual’s decision to donate and the individual’s organs are not in the end removed, neither the doctors nor the family violate the individual’s autonomy in any morally objectionable sense. Call this the Nonremoval Thesis. I argue that since the Nonremoval Thesis is true, we do not violate or fail to respect the autonomy of registered donors when we fail to remove their organs because their family has objected. (shrink)

Families play an essential role in deceased organ procurement. As the person cannot directly communicate his or her wishes regarding donation, the family is often the only source of information regarding consent or refusal. We provide a systematic description and analysis of the different roles the family can play, and actions the family can take, in the organ procurement process across different jurisdictions and consent systems. First, families can inform or update healthcare professionals about a person’s donation wishes. (...) Second, families can authorize organ procurement in the absence of deceased’s preferences and the default is not to remove organs, and oppose donation where there is no evidence of preference but the default is to presume consent; in both cases, the decision could be based on their own wishes or what they think the deceased would have wanted. Finally, families can overrule the known wishes of the deceased, which can mean preventing donation, or permitting donation when the deceased refused it. We propose a schema of 4 levels on which to map these possible family roles: no role, witness, surrogate, and full decisional authority. We conclude by mapping different jurisdictions onto this schema to provide a more comprehensive understanding of the consent system for organ donation and some important nuances about the role of families. This classificatory model aims to account for the majority of the world’s consent systems. It provides conceptual and methodological guidance that can be useful to researchers, professionals, and policymakers involved in organ procurement. (shrink)

Goal: To assess public knowledge and attitudes towards the family’s role in deceased organ donation in Europe. -/- Methods: A systematic search was conducted in CINHAL, MEDLINE, PAIS Index, Scopus, PsycINFO, and Web of Science on December 15th, 2017. Eligibility criteria were socio-empirical studies conducted in Europe from 2008 to 2017 addressing either knowledge or attitudes by the public towards the consent system, including the involvement of the family in the decision-making process, for post-mortem organ retrieval. Screening and (...) data collection were performed by two or more independent reviewers for each record. -/- Results: Of the 1482 results, 467 studies were assessed in full-text form, and 33 were included in this synthesis. When the deceased has not expressed any preference, a majority of the public support the family's role as a surrogate decision-maker. When the deceased expressly consented, the respondents' answers depend on whether they see themselves as potential donors or as a deceased's next-of-kin. Answers also depend on the relationship between the deceased and the decision-maker(s) within the family, and on their ethnic or cultural background. -/- Conclusions: Public views on the authority of the family in organ donation decision-making require further research. A common conceptual framework and validated well-designed questionnaires are needed for future studies. The findings should be considered in the development of Government policy and guidance regarding the role of families in deceased organ donation. (shrink)

Cet article propose une évaluation éthique des institutions qui organisent la transplantation avec donneurs décédés, au travers du rôle qu’elles accordent à la famille survivante. Son objectif est double. Il s’agit, premièrement, de montrer que la famille possède un pouvoir de décision considérable en matière de prélèvement posthume bien que les législations soient habituellement décrites comme fondées sur le consentement ou l’opposition des personnes concernées. Deuxièmement, il s’agit de montrer que les politiques qui octroient un tel pouvoir aux familles (...) manquent à un devoir d’équité, en négligeant les intérêts à la fois des personnes concernées et des malades en attente de greffe. (shrink)

This descriptive study explores the views of resident physicians working in intensive care units (ICUs) concerning deceased organ donation and examines the various ethical issues surrounding organ donation encountered by residents. This was a qualitative, descriptive study utilizing solo interviews with participants together with focus group discussions. The participants' experiences and views were elicited via interviews and focus group discussions covering the following topics: ethical thoughts about deceased organ donation, barriers that impede or prevent organ donation, (...) its effect on the next of kin, and its relationship with futile treatment. The discussions were reviewed using qualitative content analysis. The residents commented that deceased organ donation is a complex and stressful process for the family of the potential donor as well as the transplant team, and still lacks wide acceptance in Turkish society. The opt-in system requires informed consent, thus creating a major barrier for both the patient’s family and the ICU team to overcome. The participants stated that new legal, ethical, and medical arrangements are needed to increase organ donation rates in Turkey. In order to increase rates of deceased organ donation and reduce cases of futile treatment, improved communication between the ICU, transplant team, and patient relatives is critical to ensure that ethical issues are properly managed. On a societal level, the subject of deceased organ donation needs to receive greater attention from public health authorities to increase public awareness. Residents can make valuable contributions to the deceased organ donation process as physicians and as psychosocial support for patients and their families. (shrink)

This descriptive study explores the views of resident physicians working in intensive care units (ICUs) concerning deceased organ donation and examines the various ethical issues surrounding organ donation encountered by residents. This was a qualitative, descriptive study utilizing solo interviews with participants together with focus group discussions. The participants' experiences and views were elicited via interviews and focus group discussions covering the following topics: ethical thoughts about deceased organ donation, barriers that impede or prevent organ donation, (...) its effect on the next of kin, and its relationship with futile treatment. The discussions were reviewed using qualitative content analysis. The residents commented that deceased organ donation is a complex and stressful process for the family of the potential donor as well as the transplant team, and still lacks wide acceptance in Turkish society. The opt-in system requires informed consent, thus creating a major barrier for both the patient’s family and the ICU team to overcome. The participants stated that new legal, ethical, and medical arrangements are needed to increase organ donation rates in Turkey. In order to increase rates of deceased organ donation and reduce cases of futile treatment, improved communication between the ICU, transplant team, and patient relatives is critical to ensure that ethical issues are properly managed. On a societal level, the subject of deceased organ donation needs to receive greater attention from public health authorities to increase public awareness. Residents can make valuable contributions to the deceased organ donation process as physicians and as psychosocial support for patients and their families. (shrink)

This paper develops a philosophical account of moral disruption. According to Robert Baker, moral disruption is a process in which technological innovations undermine established moral norms without clearly leading to a new set of norms. Here I analyze this process in terms of moral uncertainty, formulating a philosophical account with two variants. On the harm account, such uncertainty is always harmful because it blocks our knowledge of our own and others’ moral obligations. On the qualified harm account, there is no (...) harm in cases where moral uncertainty is related to innovation that is “for the best” in historical perspective or where uncertainty is the expression of a deliberative virtue. The two accounts are compared by applying them to Baker’s historical case of the introduction of mechanical ventilation and organ transplantation technologies, as well as the present-day case of mass data practices in the health domain. (shrink)

There is a global shortage of organs for transplantation and despite many governments making significant changes to their organ donation systems, there are not enough kidneys available to meet the demand. This has led scientists and clinicians to explore alternative means of meeting this organ shortfall. One of the alternatives to human organ transplantation is xenotransplantation, which is the transplantation of organs, tissues, or cells between different species. The resurgence of interest in xenotransplantation and (...) recent scientific breakthroughs suggest that genetically-engineered pigs may soon present a realistic alternative as sources of kidneys for clinical transplantation. It is therefore important for nurses and allied health professionals to understand what is involved in xenotransplantation and its future implications for their clinical practices. First, we explore the insufficiency of different organ donation systems to meet the kidney shortage. Second, we provide a background and a summary of the progress made so far in xenotransplantation research. Third, we discuss some of the scientific, technological, ethical, and economic issues associated with xenotransplantation. Finally, we summarise the literature on the attitudes of healthcare professionals toward xenotransplantation. (shrink)

Formal clinical trials of pig-to-human organ transplant—known as xenotransplantation—may begin this decade, with the first trials likely to consist of either adult renal transplants or pediatric cardiac transplant patients. Xenotransplantation as a systematic scientific study only reaches back to the latter half of the 20th century, with episodic xenotransplantation events occurring prior to that. As the science of xenotransplantation has progressed in the 20th and 21st centuries, the public's knowledge of the potential therapy has also increased. With this, there (...) have been shifting ethical stances toward xenotransplantation in key areas, such as religious and public viewpoints towards xenotransplantation, animal rights, and public health concerns. This review provides a historical–ethical account of xenotransplantation and details if or how viewpoints have shifted over time. (shrink)

This paper discusses (in German) an idea enshrined in the recent (2012) revision of the German transplantation law. The law allows family members to make claims about what the deceased would have wanted to happen to his/her organs/tissue even though he/she never has voiced any relevant opinions. I argue that this is illegitimate.

The Japanese Transplantation Law is unique among others in that it allows us to choose between "brain death" and "traditional death" as our death. In every country 20 to 40 % of the popularion doubts the idea of brain death. This paper reconsiders the concept, and reports the ongoing rivision process of the current law. Published in Hastings Center Report, 2001.

I argue that physicians can save women from life-threatening pregnancies by performing a craniotomy, placentectomy, or salpingotomy without intending death or harm. To support this conclusion, I defend the relevance thesis about intentions (a person intends X only if X explains the action). I then criticize the identity thesis (if a person intends X and knows X is Y then the person intends Y) and three mistakenly strict moral principles: (1) one may not intend something that is a serious harm (...) for an innocent person, (2) one may not intend to terminate pregnancy before viability, which would prohibit, and (3) one may not act on a person’s body in a harmful way in order to benefit another person. (1) would prohibit procuring organs from living donors, (2) would prohibit treating hepatic pregnancies and other ectopic pregnancies, and (3) would prohibit procuring organs from living donors and performing many prenatal surgeries. (shrink)

The dead donor rule justifies current practice in organ procurement for transplantation and states that organ donors must be dead prior to donation. The majority of organ donors are diagnosed as having suffered brain death and hence are declared dead by neurological criteria. However, a significant amount of unrest in both the philosophical and the medical literature has surfaced since this practice began forty years ago. I argue that, first, declaring death by neurological criteria is both (...) unreliable and unjustified but further, the ethical principles which themselves justify the dead donor rule are better served by abandoning that rule and instead allowing individuals who have suffered severe and irreversible brain damage to become organ donors, even though they are not yet dead and even though the removal of their organs would be the proximal cause of death. (shrink)

Although much has been written on the dead-donor rule in the last twenty-five years, scant attention has been paid to how it should be formulated, what its rationale is, and why it was accepted. The DDR can be formulated in terms of either a Don’t Kill rule or a Death Requirement, the former being historically rooted in absolutist ethics and the latter in a prudential policy aimed at securing trust in the transplant enterprise. I contend that the moral core of (...) the rule is the Don’t Kill rule, not the Death Requirement. This, I show, is how the DDR was understood by the transplanters of the 1960s, who sought to conform their practices to their ethics—unlike today’s critics of the DDR, who rethink their ethics in a question-begging fashion to accommodate their practices. A better discussion of the ethics of killing is needed to move the debate forward. (shrink)

Berry, Daniels, and Ladin make a strong argument for discontinuing the use of, “lack of social support,” as an organ transplantation listing criterion. This argument, however, actually leads to conclusions much stronger than those that the authors’ propose: The argument works equally well against using, (1) any “psychosocial” factors at all as a listing criterion, and, (2) any criteria other than factors that directly relate to empirically established medical need, and/or empirically established survival rate. Moreover, while the authors (...) rightly point to a lack of empirical evidence connecting social support to survivability, they neglect mentioning that the empirical literature on social support provides grounds to favor listing persons who seem to, sadly, lack a social support system. (shrink)

This academic paper on Ethical issues of using umbilical cord blood stem cell therapy of John Stuart Mill perspective aim to investigate the new approaches in the treatment of diseases by using umbilical cord blood stem cells. And also to study ethical issues from the use of umbilical cord blood stem cells in the treatment of diseases considered by Mill’s utilitarianism. 21st century, the medical industry was interested in organ transplantation from stem cells especially stem cells from the (...) umbilical cord to treat chronic and degenerative organ diseases, blood cancer and organ transplantation which successful and widespread throughout the world. Thailand has about 900 new children with Leukemia every year. About 50 percent are leukemia which needs to be treated correctly and urgently. In general Standardized chemotherapy but if the cancer patient has a bad prognosis Or have recurrent cancer Patients need to be treated with bone marrow transplants or stem cells to have a chance to heal. According to Mill’s Utilitarianism, the ethical concepts that determine what is the basic criterion used to determine whether it should or should not concern with the popular benefit that the criterion used is the amount of happiness that results from actions. Treating the disease using stem cells will make the patient recover from the disease, healthier and happier in life. As Mill said "The correctness of an action depends on the tendency that the action will lead to happiness. (shrink)

This paper develops a philosophical account of moral disruption. According to Robert Baker (2013), moral disruption is a process in which technological innovations undermine established moral norms without clearly leading to a new set of norms. Here I analyze this process in terms of moral uncertainty, formulating a philosophical account with two variants. On the Harm Account, such uncertainty is always harmful because it blocks our knowledge of our own and others’ moral obligations. On the Qualified Harm Account, there is (...) no harm in cases where moral uncertainty is related to innovation that is “for the best” in historical perspective, or where uncertainty is the expression of a deliberative virtue. The two accounts are compared by applying them to Baker’s historical case of the introduction of mechanical ventilation and organ transplantation technologies, as well as the present-day case of mass data practices in the health domain. (shrink)

PT. A noção de “pessoa”, pensada a partir do legado antropológico e filosófico do ocidente, afirma-se como uma unidade corporal e espiritual que determina a sua singularidade no seio da comunidade. A “pessoa” assim perspectivada assume uma importância destacada na reflexão ética das aplicações científicas de artificialização da vida humana. Muito concretamente, a noção de “pessoa” deve contribuir para a fundamentação ética das terapêuticas de transplantação. A transplantação representa um dos mais notáveis avanços da medicina do século XX e com (...) um impacto incontornável na prestação de cuidados de saúde. Os transplantes são considerados o tratamento mais eficaz para patologias crónicas que afectam a funcionalidade de determinados órgãos vitais, restituindo ao doente uma melhoria na sua saúde e/ou qualidade de vida. O sucesso desta terapêutica é, no entanto, condicionado pela disponibilização de pessoas que queiram fazer dádiva de si, do seu próprio corpo, para o bem-estar de outrem. Deste modo, a doação, realizada após a morte da pessoa ou ainda em vida, enfrenta vários desafios técnicos, mas também, e principalmente, desafios éticos. A nossa dissertação centra-se na reflexão ética da doação de órgãos e tecidos para transplante e no impacto que a dádiva de uma parte específica do corpo pode comportar na noção de “pessoa”. Deste modo, ao mesmo tempo em que se procura promover a doação de órgãos para aumentar o número de transplantes, também se vão delineando estratégias para salvaguardar a integridade corporal do dador e a eminente dignidade que o constitui como pessoa. As estratégias consistem fundamentalmente num diálogo entre o princípio de autonomia, que determina a singularidade da pessoa, e o princípio de solidariedade, que é desencadeado pela relação com o outro. Estes princípios éticos, articulados e uma vez cumpridos, são os alicerces da doação voluntária e altruísta, e impedem a instrumentalização e exploração da pessoa dadora. -/- EN. The western anthropological and philosophical notion of ‘person’ emerges as a corporal and spiritual entity, which determines his singularity at the level of community. From this perspective, the notion of ‘person’ holds an important place in ethical considerations concerning the scientific applications of artificial manipulation of human life. More precisely, the notion of ‘person’ must contribute towards the ethical basis of transplant therapeutics. The transplantation of human organs and tissues is one of the most notable advances in twentieth century medicine, and, as such, has had an unquestionable impact on health care practice. Transplants are now seen as the best treatment for chronic diseases that impair the function of some vital organs, improving the patient health and/or quality of life. The success of organs transplantation depends entirely upon the altruism of people giving their bodies for the well-being of others. Organ donation, performed during life or after death, raises not only technical, but also mainly ethical challenges. This work focuses on the ethical considerations associated with human organs and tissue donation for transplantation and on the impact that a donation of an organ has on the notion of ‘person’. At the same time that one recognizes the need to increase the number of organs for transplanting, there is also the need to preserve the donor’s corporal integrity and his eminent dignity. Strategies to preserve the donor’s corporal integrity and dignity must take into consideration the dialogue between the principle of autonomy, which is characterized by the singular entity, and the principle of solidarity, born out of one’s relationship with those around you. These ethical principles, once engaged and fulfilled, are the bases of a voluntary and altruistic donation, and prevent the donor from becoming a mere instrument and being exploited as such. (shrink)

There are increasing calls for rejecting the ‘dead donor’ rule and permitting ‘organ donation euthanasia’ in organ transplantation. I argue that the fundamental problem with this proposal is that it would bestow more worth on the organs than the donor who has them. What is at stake is the basis of human equality, which, I argue, should be based on an ineliminable dignity that each of us has in virtue of having a rational nature. To allow mortal (...) harvesting would be to make our worth contingent upon variable quality of life of judgments that can only be based on properties that come in degrees. Thus, rejecting the ‘dead donor’ rule comes at the expense of our egalitarian principles with respect to the value each individual human life has in relation to the protections against killing. (shrink)

RD, a 32-year-old male, was admitted to the hospital with hypoxic COVID pneumonia–a potentially life-threatening condition characterized by dangerously low levels of oxygen in the body- during one of the pandemic’s surges. While RD’s age gave the clinical team hope for his prognosis, his ability to recover was complicated by his being unvaccinated and having multiple comorbidities, including diabetes and obesity. His condition worsened to the point that he required extracorporeal membrane oxygenation (ECMO), a machine that maintains the functioning of (...) a person’s heart and lungs. -/- Given its scarcity–only 264 of the over 6,000 hospitals in the United States offer ECMO, according to the Extracorporeal Life Support Organization–as well as its high cost and the inadequate supply of staff required to maintain it, ECMO primarily serves as a bridge to support critically ill patients until they can receive an organ transplant or implanted medical device. For RD, ECMO was started to support him until he could be evaluated for, and possibly receive, a bilateral lung transplant. Despite its intended use as a treatment of last resort, some patients can remain on ECMO for weeks or months. And some are awake, alert, and capable of medical decision-making. -/- RD was one such patient. However, the transplant evaluation committee ruled out RD’s candidacy for bilateral lung transplantation, based on his poor potential for recovery and a lack of family and friends to provide post-transplant support. This determination raised the prospect of continued ECMO treatment being a bridge to nowhere. But RD was comfortable on ECMO and wanted to remain in the ICU. The ICU intensivist contacted the ethics consult service with questions about whether continued ECMO support was medically and ethically inappropriate. (shrink)

There are about 100 different contradictory definitions of life. The definition of life based on symbiosis that is presented here differs fundamentally from them; it gives life a value. So this definition offers a basis for ethical and legal action e.g. in organ transplants. It is based on principles and is not an ad hoc model: Significant processes for life are basis for a theoretical concept. Quality criteria for definitions are employed to control the concept. There is a graduation, (...) not a clear division, between inanimate and animate. The graduation is based on the amount of symbiosis to be found. Life is based on symbiosis. The ideas of “ethics” and “reality” are considered in the context of this definition. (shrink)

Significant associations have been found between specific human leukocyte antigen (HLA) alleles and organ transplant rejection, autoimmune disease development, and the response to infection. Traditional searches for disease associations have conventionally measured risk associated with the presence of individual HLA alleles. However, given the high level of HLA polymorphism, the pattern of amino acid variability, and the fact that most of the HLA variation occurs at functionally important sites, it may be that a combination of variable amino acid sites (...) shared by several alleles (shared epitopes) are better descriptors of the actual causative genetic variants. Here we describe a novel approach to genetic association analysis in which genes/proteins are broken down into smaller sequence features and then variant types defined for each feature, allowing for independent analysis of disease association with each sequence feature variant type. We have used this approach to analyze a cohort of systemic sclerosis patients and show that a sequence feature composed of specific amino acid residues in peptide binding pockets 4 and 7 of HLA-DRB1 explains much of the molecular determinant of risk for systemic sclerosis. (shrink)

A compilation of 16 papers selected from two UNESCO Bangkok Bioethics Roundtables, with research and policy dialogues from different countries in the region. It includes papers on informed consent, ethics committees, communication, organ transplants, traditional medicines and sex selection.

Here I develop an account of our persistence that accommodates each of the following compelling intuitions: (i) that we are animals, (ii) that we existed prior to the onset of whatever psychological capacities are necessary for personhood, and we can continue to exist with the loss of those and other psychological capacities, (iii) that with suitable psychological continuity, the person goes with the brain/cerebrum in remnant person and brain/cerebrum transplant cases, and (iv) that it is possible for us to survive (...) gradual large-scale replacement of organic with inorganic parts. With the help of a couple of recent “hybrid” animalist accounts I develop an analysis of our persistence that entails (ii)–(iv) while being consistent with (i). (shrink)

It is envisioned that one day xenotransplantation will bring about a future where transplantable organs can be safely and efficiently grown in transgenic pigs to help meet the global organ shortage. While recent advances have brought this future closer, worries remain about whether it will be beneficial overall. The unique challenges and risks posed to humans that arise from transplanting across the species barrier, in addition to the costs borne by non-human animals, has led some to question the value (...) of xenotransplantation altogether. In response, we defend the value of xenotransplantation research, because it can satisfy stringent welfare conditions on the permissibility of animal research and use. Along the way, we respond to the alleged concerns, and conclude that they do not currently warrant a cessation or a curtailing of xenotransplantation research. (shrink)

Janet Radcliffe Richards’ The Ethics of Transplants outlines a novel framework for moral inquiry in practical contexts and applies it to the topic of paid living kidney donation. In doing so, Radcliffe Richards makes two key claims: that opponents of organ markets bear the burden of proof, and that this burden has not yet been satisfied. This paper raises four related objections to Radcliffe Richards’ methodological framework, focusing largely on how Radcliffe Richards uses this framework in her discussion of (...) kidney sales. We conclude that Radcliffe Richards’ method of inquiry hinders our ability to answer the very question that it ought to help us resolve: What is there best reason to do, all things considered? (shrink)

Since 1968, the irreversible loss of functioning of the whole brain, called brain death, is assimilated to individual’s death. The almost universal acceptance of this neurological criterion of death had decisive consequences for the contemporary medicine, such as the withdrawal of mechanical ventilation in these patients and organ retrieval for transplantation. The new criterion was successfully accepted in part because the assimilation of brain death state to death was presented by medicine --and acritically assumed by most of societies-- (...) as a scientific and objective fact. Nevertheless, many people do not think that the patients suffering brain death are actually dead. We show here that those people are not necessarily wrong. It can be argued that, in fact, the justification of the neurological criterion is not scientific but moral. We outline the thesis that the problem surrounding the vital status of brain dead patients is due to a confusion between factual and normative questions. Furthermore, we claim that the donation of organs and the withdrawal of life-support could be ethically acceptable even if the patients suffering brain death are considered as alive. As an alternative to the dead donor rule, we propose a justification for organ donation of brain-dead patients based on the (moral) concepts of harm and consent : what truly justifies the procurement of organs on those patients is not that they are dead, but that they wish to donate their organs and that, since they have irreversibly lost their brain, they cannot be harmed. (shrink)

In this paper, I claim that live uterus donors ought to be considered for the possibility of compensation. I support my claim on the basis of comparable arguments which have already been applied to gamete donation, surrogacy, and other kinds of organ donation. However, I acknowledge that there are specificities associated with uterus donation, which make the issue of incentive and reward a harder ethical case relative to gamete donation, surrogacy, and other kinds of organ donation. Ultimately, I (...) contend that while reimbursement for the costs incurred by live uterus donors should be treated as a necessary ethical minimum, how much further we ought to remunerate uterus donations remains an open question. (shrink)

In this chapter, we provide an overview of the ethical considerations relevant to the use of nudges in organ donation policy. We do not defend a position on the permissibility of nudging in this context, but instead aim to clearly outline the strongest arguments on the different sides of this issue that have been presented in the English-language scholarly bioethics literature. We also highlight the questions that are in need of further investigation. In part 1, we briefly discuss nudging (...) before considering proposals to use nudges to increase the number of registered organ donors, including opt-out donor registration systems and the use of “nudge statements.” In part 2, we discuss the use of nudges to influence the decision-making of family members in circumstances where they have a veto over the donation of their loved one’s organs. (shrink)