CURRENT TECHNOLOGY ISSUES AND DILEMMASORGAN AND TISSUE PROCUREMENT; ORGAN TRANSPLANTATIONDEATH AND THE DEAD DONOR RULE

Jellou Ray M. Macayan, RN

ORGAN TRANSPLANTATION the moving of an organ from one body to another or from a donor site to another location on the person's own body, to replace the recipient's damaged or absent organ.The emerging field of regenerative medicine is allowing scientists and engineers to create organs to be re-grown from the person's own cells (stem cells, or cells extracted from the failing organs)

ORGAN TRANSPLANTATION Organs and/or tissues that are transplanted within the same person's body are called autografts. Transplants that are recently performed between two subjects of the same species are called allografts. Allografts can either be from a living or cadaveric source.Organs that can be transplanted are the heart, kidneys, liver, lungs, pancreas, intestine, and thymus. Tissues include bones, tendons (both referred to as musculoskeletal grafts), cornea, skin, heart valves, nerves and veins. Worldwide, the kidneys are the most commonly transplanted organs, followed by the liver and then the heart. Cornea and musculoskeletal grafts are the most commonly transplanted tissues.

VALUABLE ORGANS

ORGAN AND TISSUE PROCUREMENT The ethical and legal issues related to organ and tissue procurement and transplantation are often discussed in light of such principles as autonomy, benevolence, non-maleficence, free and informed consent, respecting the dignity, integrity and equality of human beings, fairness, and the common good. The Judeo-Christian perspective affirms the great dignity of each human person created in the image of God.

The various aspects, parts and functions of a human person participate in this dignity. We are also social beings who have a responsibility as co-creators and stewards of God's creation. "In the donation and transplantation of human organs, respect is to be given to the rights of the donor, the recipient and the common good of society."

In a recent case described by Dr. Joseph Darby at the University of Pittsburgh Medical Center, the family of a man with devastating brain injury requested withdrawal of life support. The man had been a strong advocate of organ donation, but he was not a candidate for any of the traditional approaches. His family therefore sought permission for him to donate organs before death. To comply with the DDR, plans were made to remove only nonvital organs (a kidney and a lobe of the liver)

while he was under anesthesia and then take him back to the intensive care unit, where life support would be withdrawn. Although the plan was endorsed by the clinical team, the ethics committee, and the hospital administration, it was not honored because multiple surgeons who were contacted refused to recover the organs: the rules of the United Network for Organ Sharing (UNOS) state that the patient must give direct consent for living donation, which this patient's neurologic injury rendered impossible. Consequently, he died without the opportunity to donate. If there were no requirement to comply with the DDR, the family would have been permitted to donate all the patient's vital organs.

Ethical Issues Regarding the Donor

a) From the Deceased1956 Pope Pius XII A person may will to dispose of his [or her] body and to destine it to ends that are useful, morally irreproachable and even noble, among them the desire to aid the sick and suffering. One may make a decision of this nature with respect to his own body with full realization of the reverence which is due it....this decision should not be condemned but positively justifiedPontifical Academy of Sciences - Taking into consideration the important advances made in surgical techniques and in the means to increase tolerance to transplants, this group holds that transplants deserve the support of the medical profession, of the law, and of people in general. The donation of organs should, in all circumstances, respect the last will of the donor, or the consent of the family present

To donate, however, is not considered obligatory. Transplantation is against some people's consciences for religious or other reasons. Consideration for the sensibilities of the survivors may also make some people hesitate to sign over their bodies.

The Catholic Health Association of Canada (CHAC) considers transplantations of brain cells (presuming irreversible cessation of all brain functions of the donor) in order to restore functions lost through disease as permissible "as long as the unique personal identity and abilities of the recipient are not compromised in any way."

The German Bishops' Conference and the Council of the German Evangelical Church consider the transplant of "reproductive glands" as unethical, "since it intervenes in the genetic individuality of the human being." This does not seem to exclude transplanting all sexual body parts, but the gonads. Any child that resulted following an ovary or testicle transplant would have the dead donor and not the living recipient as its biological mother or father. This would violate the rights of the child.

b) From Living Persons (Adults, Mentally Disabled, Minors) Transplants between living persons raise the question whether it can ever be ethical to mutilate one living person to benefit another. Concerning this many distinguish between parts of the body that can regenerate (e.g. blood and bone marrow) and parts that do not regenerate. Regarding the latter some are paired (e.g. kidneys, corneas and lungs), whereas others are not (e.g. heart). Before transplants of organs such as kidneys were performed, many Catholic theologians considered this unethical between living persons. They thought it violated the Principle of Totality which allowed the sacrifice of one part or function of the body to preserve the person'sownhealth or life.

Gerald Kelly (1956) argued that such donations which have as their purpose helping others could be justified by the Principle of Fraternal Love or Charity provided there was only limited harm to the donor. Some ethicists argued this did not violate the Principle of Totality provided that functional integrity of the body was not destroyed, even though there is some loss to anatomical (physical) integrity. Donating one of one's kidneys could be justified for proportionate reasons, since one can function with one healthy kidney. Donating one of one's functioning eyes, however, cannot be justified, since one's ability to see (functional integrity) would be seriously impaired.

Basic to medical ethics is the Principle of Free and Informed Consent. To be properly informed the potential living donor should be given the best available knowledge regarding risks to him/her, the likelihood of success/failure of the transplant and of any alternatives.

The above principles would allow in some cases such procedures as "transplanting part of the liver from a living adult donor into a child recipient, whereafter the adult donor's liver regenerates within a month and the child's new partial liver develops as the child grows"(LRCC, 15), or donating one's heart if one were to simultaneously receive a heart and lung transplant (Garrett et al., 2000).When a living person donates an organ as a result of a personal decision, then the organ's transplant is to be carried out with due attention, and post-operative medical care of the donors as well as the recipients must be provided. Further, consideration must be given so that no problems develop in the relationship between the donor and the recipients (dependence, excessive gratitude and guilt feeling)

c) From Anencephalic InfantsAnencephalic infants are born with a major portion of the brain absent. If born alive they die within a few days, although in rare cases some survive for weeks or months. They can suck and cry and some argue that their degrees of consciousness or unconsciousness may vary. According to the widely accepted criteria of death as irreversible cessation of all brain functions, they are living human beings/persons. To increase the likelihood of procuring viable organs from them, some would like to redefine death in terms of partial brain death so that they could be considered dead.Many others, however, argue that partial brain death criteria are invalid in light of our present knowledge and/or such an arbitrary move would endanger other classes of living human beings and lead many more people to refuse to sign organ donor cards. Although extraordinary means of prolonging the life of anencephalic infants do not need to be used, they should be given the normal care of dying persons.

d) From Human FetusesIf the fetus has died of natural causes, the ethical issues would be similar to other transplants from the deceased. When the fetus has died or will die as a result of procured abortion, however, other ethical issues arise. The Catholic Church considers direct abortion (the intentional killing of an innocent human being) to be gravely immoral. Some argue that to use tissues from a fetus killed by abortion could be done without approving direct abortion (cf. using tissues or organs from a murder victim). Such use, however, could "justify" abortion for many women who otherwise are unsure about having an abortion.A good end though does not justify an evil means. The timing of the abortion may be influenced as well. The widespread usage of electively aborted fetuses would establish an "institutional and economic bond between abortion centers and biomedical science.

Another issue involves consent. Anyone involved in procured abortion would not qualify as the fetus' guardian since they hardly have his/her best interests at heart. The Catholic Health Association of Canada (CHAC) concludes that, "Transplantations using organs and tissues from deliberately aborted fetuses are ethically objectionable."

Ethical Issues Regarding the Recipient

Nobody has a claim on organs or tissue of any person, living or dead. The sick should thus accept the tissue and organs freely offered by others as a gift.This position is widely accepted. Another moral issue involving the recipient is free and informed consent. A competent person who could possibly benefit from receiving a transplant should be adequately informed regarding the expected benefits, risks, burdens and costs of the transplant and aftercare, and of other possible alternatives. So should the guardian(s) of an incompetent person. A legally incompetent person who can understand some things that are relevant to their condition, a proposed transplant, and decisions that they are capable of making, should be informed of these in an appropriate way. Guardians should respect the wishes, if known and reasonable, of incompetent persons in their care.

DEATH AND THE DEAD DONOR RULE

The ethics of organ transplantation have been premised on the dead-donor rule (DDR), which states that vital organs should be taken only from persons who are dead. Yet it is not obvious why certain living patients, such as those who are near death but on life support, should not be allowed to donate their organs, if doing so would benefit others and be consistent with their own interests

Our society generally supports the view that people should be granted the broadest range of freedoms compatible with assurance of the same for others. Some people may have personal moral views that preclude the approach we describe here, and these views should be respected. Nevertheless, the views of people who may freely avoid these options provide no basis for denying such liberties to those who wish to pursue them. Death must be declaredbeforeany cutting and harvesting begins. Otherwise, the transplant surgeons might be accused of causing death by removing vital organs.Also the concepts of death must be accepted by people who donate organs. If there is too-subtle a difference betweenbeing aliveandbeing dead, then those who must approve donations will have qualms and

1. BRAIN DEATHThe definition of brain-death usually meansthatallof the functions of the human brain have come to apermanent stop. the complete and irreversible loss of brain function (including involuntary activity necessary to sustain life).Drowning and freezing must be ruled out,since these ways ofalmost dying show most of the same signs as brain-death. However, in the Western world,brain-death has been accepted in all modern medical practice.Laypersons do not always understand (since they can see the body still breathing and the heart still beating),but with enough explanation most people can acceptthat their loved one has now passed over into death.

COMA OR PERMANENT UNCONSCIOUSNESSIn medicine, a coma is a state of unconsciousness in which a person: cannot be awakened; fails to respond normally to painful stimuli, light, or sound; lacks a normal wake-sleep cycle; and does not initiate voluntary actions. It is more controversial to consider transplanting organs from donors who are 'merely' in a coma or who are permanently unconscious. Such conditions are harder to define and more difficult to certify. In the early days of considering this new definition of death, it will probably only be used in those rare caseswhere the patients have givenapproval in advancefor using this definition of deathfor themselves.If a specific patient and his or her proxies are all in agreement that permanent unconsciousness can be certified as death, then the doctor who is called upon to declare death will merely have to determine scientifically that there isno chance that consciousness will ever return to this body.

PERSISTENT VEGETATIVE STATEA disorder of consciousness in which patients with severe brain damage are in a state of partial arousal rather than true awareness. It is a diagnosis of some uncertainty in that it deals with a syndrome. After four weeks in a vegetative state (VS), the patient is classified as in a persistent (or 'continuing') vegetative state.It has emerged as a end-of-life condition because of advances in medical science and technology. Our advances in understanding how the body operates have empowered us to keep thebiological functions of the bodygoing even when thelife of the personis completely over. But because being in PVS is such a hopeless state, and because future advances in neurological science will make it even easier to certify this condition, eventually well-proven PVS will be acceptedas an adequate definition ofthe death of a human person

ALZHEIMER'S DISEASE It is a chronic neurodegenerative disease that usually starts slowly and gets worse over time. Gradually, bodily functions are lost, ultimately leading to death. People with Alzheimer's disease eventually loseall of the capacities that make a human being a person.But the millions of people in the USA with various degrees of dementia shouldnever be defined as dead no matter how debilitated they become.However, when we foresee Alzheimer's as the last phase of our own lives, we can leave detailed instructions about what should be done, including avoluntary death or a merciful death followed by organ donation.

ConclusionA number of the many ethical issues concerning organ and tissue transplants have been treated in this paper. These issues concern the donor, the recipient. Organ donation, carried out under proper conditions, is a beautiful and modern expression of Christian charity: it gives dignity to the person who in death becomes a life-support for another; it shows noble concern for the respect of the life of others; and it implies a sense of communion with humanity. The Gospel proclaims that there is no greater love than to give one's life for another. Jesus welcomes the good done to another as though it were done to himself.

The dead-donor rule should continue to be observed in transplant practice. But the definition of death can advance over the centuries, as science develops more precise tests of brain-function. Progressively, we will accept organs from thebrain-dead,from former persons who arepermanently unconscious, from former persons who are inpersistent vegetative state, and from patients who have lost their personhood toAlzheimer's disease. Giving our organs to people who can make good use of them will allow these other persons to havemany more years of meaningful life.

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