MSTP Students Recognized for Bioethics Essays
Two Medical Scientist Training Program students were recognized on April 28, 2016 at the University of Wisconsin School of Medicine and Public Health's 8th Annual Bioethics Symposium for their exceptional written essays on the symposium theme: “Transplant Ethics: Past, Present, and Future.”
Third-year medical student Jeff Jensen received an honorable mention for his entry, "Ethical Calculus: Organ Donation at the End of Life."
Imminent Death Donation Fits the Bill
By Ryan Denu
Over 120,000 adults and children are waiting for an organ in the US, and an average of 20 Americans die every day from the lack of available organs. Currently, organ transplant policy and laws in the US allow for organ procurement from three sources: neurologic deaths, controlled circulatory deaths, and living organ donors. Imminent death donation (a form of living organ donation) represents a potential solution to our organ shortage crisis, and proper balancing of patient autonomy with non-maleficence and respect for persons makes this an ethically permissible strategy.
Transplant surgeons have long been held to the “dead-donor rule,” which posits that organ procurement should not cause a donor’s death and that a patient with no brain function could be “brain-dead” and therefore able to donate organs. 1,2 There are a number of issues with this rule. 3 First, the dead-donor rule is based on the false assumption that people must be dead to donate organs; obviously this is not true, as living people routinely donate kidneys.
Second, it is more consistent with current practices to procure organs if doing so does not violate the interests of the donor rather than whether or not the donor is “dead.”4 For example, society does not require that a patient be “dead” before ending life-sustaining therapy, but rather it requires that removing life-sustaining therapy does not violate the patient’s interests. It is not clear why we should have more stringent rules for procuring organs than ending life-sustaining therapy.
Third, many people that are “brain-dead” still retain hypothalamic function, and therefore are not truly “brain-dead” 3,5,6 Perhaps what we mean by “brain-dead” is actually lack of brain cortical activity. In summary, a patient does not have to be dead to donate organs.
Critics of imminent death donation state that donation at imminent death is not in the interest of the donor and therefore violates the ethical principle of non-maleficence. While it may not be in the medical interest of the donor, it can still be in the general interest of the donor, as the donor benefits in other ways. Allowing donation at imminent death can give these donors dignity, pride, honor, and legacy before they die, which is certainly in their best interest.
As health care professionals, we can certainly comment on what is in the patient’s medical interest, but it is up to the patient to incorporate this information and determine what is in his/her overall best interest. Therefore, imminent death donation is consistent with the ethical principles of autonomy and beneficence.
With regard to a limit on the number of organs to be donated, it is most ethically defensible to allow the donation of one kidney at this time. This procedure is unlikely to hasten the death of the donor; therefore, the ethical principles of non-maleficence and respect for persons are upheld. Harvesting additional organs before the patient is dead may violate respect for persons. However, this must be balanced with patient autonomy; if the patient is fully consented, competent, and understands that donating additional organs would hasten death, then we must respect patient autonomy and allow the patient to do so.
In order to make imminent death donation a reality, the United Network for Organ Sharing (UNOS) needs to change from assessing all-cause donor mortality to donation-specific mortality. Under the current assessment, an individual could donate a kidney without complication but die in a car accident on the way home, and this would appear as a donor-related death and put the institution’s organ donation program at risk of suspension. Changing to donation-specific mortality would allow patients with chronic disease (e.g., cystic fibrosis, amyotrophic lateral sclerosis) to donate organs at the time of imminent death.
An additional benefit to this proposal is that it provides these patients with a meaningful, rewarding experience and legacy at the end of their lives, which many patients strongly desire. 7 In a pilot study conducted by Fost, a group of adult cystic fibrosis patients were asked if they would donate their kidneys prior to death if they were admitted to the hospital for terminal care. About one-third said yes, and another one-third said they would like to learn more about it. 3
At the end of the day, there remain over 120,000 people waiting for an organ. Our previous efforts to increase organ donation have been ineffective. Now is the time for implementing innovative and ethical solutions to save lives. Imminent death donation fits the bill.
- Pernick M: Brain Death in a Cultural Context: the Reconstruction of Death 1967-1981., in Younger SJ, Arnold RM, Schapiro R (eds): The Definition of Death. Baltimore, MD, Johns Hopkins University Press, 1999, pp 9-11
- Beecher HK: Harvard Ad Hoc Committee. A definition of irreversible coma: Report of the ad hoc committee of the Harvard Medical School to examine the definition of brain death. JAMA 205:337-40, 1968
- Fost N: Reconsidering the dead donor rule: is it important that organ donors be dead? Kennedy Inst Ethics J 14:249-60, 2004
- Arnold RM, Youngner SJ: The dead donor rule: should we stretch it, bend it, or abandon it? Kennedy Inst Ethics J 3:263-78, 1993
- Sade RM: Brain death, cardiac death, and the dead donor rule. J S C Med Assoc 107:146-9, 2011
- Iltis AS, Cherry MJ: Death revisited: rethinking death and the dead donor rule. J Med Philos 35:223-41, 2010
- Mezrich J, Scalea J: As They Lay Dying, The Atlantic, 2015
Ethical Calculus: Organ Donation at the End of Life
By Jeff Jensen
My family would never be the same after my youngest brother, Reilly, was born without functional kidneys. Reilly’s odds were grim and physicians repeatedly advised my mother to withdraw care. Her stubborn refusal to give up on Reilly led him to be placed on dialysis as a neonate, and to an eventual kidney transplant from our father. Reilly is now finishing his first year of college at UC San Diego where he is majoring in electrical engineering. By risking his own survival, my father was able to give the gift of life to Reilly. My father was able to make Reilly whole.
Every 22 minutes an individual in the United States dies while waiting for a life-saving organ transplant.1 Despite the immense morbidity and mortality extolled by the organ shortage, questionable restrictions preclude many donors from willingly donating their organs. Such precluded donors include the financially incentivized, the pediatric population, and the terminally ill.2
In considering the case of terminally ill organ donors, there is a conflict between the age-old ethical principle of “do no harm,” and the recently championed principles of beneficence and autonomy, which empower physicians to care for organ donors and recipients in a way that respects patients’ desires and serves the greater good.
The case against terminally ill organ donation rests on “do no harm,” which demands that doctors deny any intervention that will actively hurt somebody without a chance of benefit for that person. While this may seem self-evident, it is overly simplistic and if strictly observed would preclude all living donor transplants as the donor is exposed to risk, which is ethically synonymous with harm, without any personal physical gain.
Transplantation regulations have thus ambiguously relaxed “do no harm,” and a patient is regarded as qualified to donate if they have a meaningful chance of returning to full health after donation.3 Almost as if swimming across the English Channel and drowning during the final pitch, this dictum allows for living organ donor transplantation at-large but disqualifies the terminally ill from being living donors.
In the opinion of the author, this standard disqualifies those from donating organs that would benefit from it the most. Organ donation can give a sense of meaning and purpose to a patient whose life is ending. Physicians are expected by society to give of themselves for their patients, to be “worthy to serve the suffering.” As physicians we should strive to enable that same virtue of altruism for the terminally ill.
Moreover, prohibiting the terminally ill from donating on the basis of “do no harm” rests on a narrow interpretation of that ethos, blind to the immense benefit received by the organ recipient and the functional harm imparted on the recipient by delaying transplantation.
Better outcomes for the organ recipient are associated with donations from living donors. Also, many patients awaiting transplant are in a precarious state of health and are needlessly endangered by delaying transplant. The end of life for terminally ill patients can involve large amounts of medication with the potential to damage subsequently donated cadaveric organs, further harming the eventual transplant recipient.
These practical aspects suggest that denying a terminally ill patient their request to donate before death causes functional harm to the potential recipient, which if nothing else violates the spirit of “do no harm.” In the ethical calculus of organ transplantation, the donor and recipient are not independent variables but a system of equations, and the solution to this problem is for the reasonable desire of a terminally ill patient to serve the greater good to be respected by laws and physicians alike.
“Do no harm” has served physicians well since its inception thousands of years ago, but the authors of the Hippocratic Oath did not foresee the ethical challenges posed by organ transplantation. Organ transplantation saves lives, like Reilly’s. Our ethical codes of conduct as physicians must be modernized to appreciate all of the risks and benefits for both the donor and recipient, and to facilitate the charitable act of organ donation for the sake of the donors who need it most.
Reilly after receiving a kidney transplant from his father (also pictured).
18 years later, Reilly and the author after hiking out of Havasupai Canyon.
About the author: Jeffrey Lee Jensen is a seventh-year student in the Medical Scientist Training Program at the University of Wisconsin-Madison. He holds a doctorate degree in Cellular and Molecular-Biology from the University of Wisconsin-Madison and a PhD minor in Clinical Investigation.
- www.organdonor.gov/about/data.html, “Organdonor.gov | The Need is Real: The Data”
- Diethelm AG. Ethical Decisions in the History of Organ Transplantation. Annual Meeting of the Southern Surgical Association, 1989.
- Mezrich J, Scalea J. As They Lay Dying. The Atlantic, 2015.