Organ Transplantation

In praise of organ-ised sport

By Dominic Wilkinson (@NeonatalEthics)

The BBC reports today on a recent organ donation initiative in Brazil. This initiative has led to a 400% increase in the numbers of heart transplants in a local hospital. The waiting list for organs in the city of Recife reportedly dropped to zero in the first year after introduction of this innovation.

What sort of initiative could lead to such a dramatic increase in organ donation numbers? Continue reading

The Texan flautist and the fetus

Imagine that when you woke up this morning, you found yourself lying next to an unconscious stranger. The stranger has a rare life-threatening illness, and unbeknownst to you he was plugged in to your organs during the night. You are now stuck to the stranger. If you disconnect the life support he will die. If, though, you remain connected to him for most of the next year his illness will have recovered, and he can safely ben unplugged. What should you do? Are you obliged to stay attached to the stranger? It might be generous of you to give up your body, and good if you choose to do so, but should we require you to remain connected?

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Keeping pace?

If you receive an implanted pacemaker for your heart, does it become your property? When it is no longer any use to you (because you have died), do you have to give it back?

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The Tragedy of Moral Mistakes

A tragic case was recently reported of a man who died following botched care via the NHS’ telephone helpline. Suffering from blood poisoning, a series of errors, mis-recording and failure to listen meant that he was told simply to take the remedy ‘Gaviscon’. He died shortly afterwards.  This was rightly widely reported in the press as a major failing of the health system. Many such catastrophic errors in medicine are reported in the press, and wherever possible safeguards put in place to prevent their re-occurrence.

However, we seem to accept deaths that occur not through medical mistakes but through what I will call moral mistakes. For example, each day 3 people die on the waiting list to receive organ transplants. Many of those could be saved if all those eligible and consenting to give organs did so. But instead, organs are withheld even when those who have opted in to organ donation die, because their families decide against it. Others are withheld because we have failed to introduce an opt out system of consent, meaning that those who simply never got around to signing up are excluded from bringing life to another person.

This is just one example of how mistakes in medical ethics can kill people. There are many more.

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Pushethics: How to get a lung for your child

By Julian Savulescu & Brian D. Earp

[updated version]

Sarah Murnaghan is a 10-year-old from Pennsylvania. Suffering from cystic fibrosis, she was likely to die without a lung transplant. Her situation was deteriorating. But because of a rule that says that children under the age of 12 have the lowest priority for adult donor lungs, Sarah would have to wait for another child’s lungs to become available, a much rarer occurrence.

Sarah’s parents sprang into action. They got the attention of members of congress and the media. They shared Sarah’s story on social networking sites, showing pictures of their daughter in the hospital bed. They said that the “Under 12” rule was discriminatory against children, and got a federal judge to agree. So, with the help of a court order temporarily preventing the enforcement of the Under 12 rule, Sarah got a second chance at life. An adult lung match became available, and Sarah is now recovering from transplant surgery.

It’s a story with a happy ending—depending upon how you tell it. Certainly the news is good for Sarah. Yet as Sarah’s mother acknowledged in a post on Facebook, “We … know our good news is another family’s tragedy.”

But who are those families? What are their stories? What are the names of those who will die—or who have already died—without a lung transplant of their own?

What this case illustrates is something we might call “pushethics” – a way of pushing one’s own story, or that of one’s family member, into the moral spotlight. Since ordinary human beings—from news anchors to congressmen to federal judges—are more likely to feel empathy for known individuals with compelling narratives of suffering, they can become motivated to bend the rules in favor of those specific individuals whose stories best capture their attention.

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Artificial organs: “good guys” finish last to technology

It is hardly a keen insight to note that there are a lot of problems in the world today, and that there are also lots of suggested solutions. Often these can be classified under three different labels:

  • “Good guy” solutions which rely on changing individual people’s attitudes and behaviours.
  • Institutional solutions which rely on designing good institutions to address the problem.
  • Technological solutions which count on technology to resolve the problem.

In this view, it is tremendously good news that scientists are getting closer to producing artificial organs. If this goal is achieved, it will be a technological solution to the problem of transplant organ shortages – and technological solutions tend to be better than institutional solutions, which are generally much better than “good guy” solutions. The “good guy” solution to organ donation was to count on people to volunteer to donate when they died. Better institutions (such as an opt-out system where you have to make a special effort not to be a donor, rather than a special effort to be a donor) have resulted in much improved donation rates. But cheap artificial organs would really be the ultimate solution.

Of course I don’t denigrate the use of getting people on your side, nor the motivations of those who sincerely want to change things. But changes to people’s attitudes only tend to stick around as long term solutions if this is translated into actual institutional or technological changes.

Take slavery, for instance. Continue reading

Obligatory Ventilation: why Elective Ventilation should not be elective

On the BBC’s Moral Maze this evening, the question of elective ventilation was discussed at some length. (For those who missed it, the program is still available here). There were several striking features of that discussion, but one argument that stood out was the argument against elective ventilation based on the importance of respecting the autonomy of patients, and the absence of consent, This has been the basis of previous ethical concerns about Elective Ventilation.

But actually, it seems to me that the consent/autonomy argument is completely upside down.* Patient autonomy provides one of the strongest arguments in favour of elective ventilation. So strong, in fact, that the proposed form of Elective Ventilation should arguably not be ‘elective’. It is morally obligatory that we embrace Elective Ventilation. Continue reading

Back from the grave: Should we allow Elective Ventilation?

Mary is 62 years old. She is brought to hospital after she collapsed suddenly at home. Her neighbour found her unconscious, and called the ambulance. When they arrived she was deeply unconscious and at risk of choking on her own secretions. They put a breathing tube in her airway, and transported her urgently to hospital.

When Mary arrives she is found to have suffered a massive stroke. A brain scan shows very severe bleeding inside her brain. In fact the picture on the scan and her clinical state is described by the x-ray specialist as ‘devastating’. She is not clinically brain dead, but there is no hope. The emergency department doctors have contacted the neurosurgical team, but they have decided not to proceed with surgery as her chance of recovery is so poor.

In Mary’s situation, the usual course of events is to contact family members urgently, to explain to them that there is nothing more that can be done, and to remove her breathing tube in the emergency department. She would be likely to die within minutes or hours. She would not be admitted to the intensive care unit – if called, the ICU team would be likely to say that she is not a “candidate” for intensive care. However, new guidance from the National Institute of Clinical Effectiveness, released late last year, and endorsed in a new British Medical Association working paper, has proposed a radical change to this usual course of events. Continue reading

Nothing to lose? Killing is disabling

In a provocative article forthcoming in the Journal of Medical Ethics (one of a new series of feature articles in the journal) philosophers Walter Sinnott Armstrong and Franklin Miller ask ‘what makes killing wrong?’ Their simple and intuitively appealing answer is that killing is wrong because it strips an individual of all of their abilities – acting, moving, communicating, thinking and feeling.

So what, you might ask? If this is right, say Sinnott-Armstrong and Miller, it means that it would be just as bad to commit an act that caused someone to be in a permanent vegetative state, as it would to kill them. Continue reading

Settling the Final Reckoning for Organ Donors

In the news this week, the Nuffield Council on Bioethics suggests that the NHS should test the idea of paying for the funerals of organ donors who have previously signed the organ donor register, in order to try to encourage more of the public to sign up. When I was asked to write about this proposal for the BBC’s web site, I found with surprise that I could think of no plausible ethical objections to it. This despite the fact that I’ve previously written here and elsewhere about the dangers of introducing a cash market for donor organs, and even about the dangers of other kinds of non-cash incentives. If the council’s proposal were found in trials to be both practically effective in increasing donations, and also affordable, then my clear view is  that it should be implemented in the UK.

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