David Rodríguez-Arias - The Ethics of Organ Donation. an international perspectivePresentation Transcript
The Ethics of Organ Donation: An international Perspective David Rodríguez-Arias
Organ Donation in a global context of organ shortage. Some strategies
Theoretical framework to understand the ethics of organ donation
Canada and Spain: a comparative view
Spanish Choices for organ donation
Debate Organ donation Policies: “how should we choose the hill where we want to die on”?
UNOS reported 6,229 deaths on the waiting list in 2008
More than half of the people on the waiting list will die before they get a transplant, and the organ shortage keeps getting worse every year.
In the US, the transplant waiting list hit 100,000 for the first time in 2008. About 50,000 more people joint the list in 2009
Some strategies to face organ shortage
1. Living donation “ First do not harm” Cohercion? Altruism? The risk of black market of organs
2. Regulated Market of OD Larijani B, Zahedi F, Taheri E. Ethical and legal aspects of organ transplantation in Iran. Transplant Proc 2004;36(5):1241-4. 83% of kidneys from living donors Donors: 30/40 year old 84% poor 16% middle class Related morbidity risk: 20% Risk of death: 0.03%. Recipients: 50% poor 36% middle class
3. Donation after controlled cardiac death NEJM ; 2008;359(7):709-14. Hastings Center Report 2010(may-june):24-30
4. Organ conscription Spital A. Am J Transplant 2005;5(5):1170-1.
4. Donation after euthanasia
2. Ethical judgement I. Kant (1724 - 1804) J.S. Mill (1806 - 1873) Consequentialism Some acts are necessarily wrong, regardless of their consequences Acts have to be morally judged according to their results Deontologism Moral dilemas
1/3 of people in Toronto identify themselves as Canadian and 1/5 are foreign born
13,8 % over 65 years old
Median Age: 39.5
Density: 3.41/km2 ; 8.3/sq mi
Organ Donors in Spain and other countries 2009: 34.4 pmp
Outcomes: Spain vs Canada (2008) www.ont.es , 2009; CIHI, 2009 http://secure.cihi.ca/cihiweb/products/corr_annual_report_2010_e.pdf SPAIN CANADA Deaths on waiting list: number of deaths/total of patients on the WL (%) Times on waiting list 68/453 (15%) 29/1099 (2.6%)
763/1243 (39%) 235/2328 (10%)
Reliance on living donation: living donors/total transplants (type of organ) (%) 44/282 (15.6%) 19/413 (4.6%)
14/131 (10.6%) 29/453(6.2%)
92/587 (15.6%) 158/2144 (7.4%)
-- 135; <96h urg
-- 170; 2.4 urgency
43 for DD / 11-18 for LD 30 (OCATT)
Some crucial questions:
What have been the necessary means to reach these results?
Is Spain paying an ethical price for its impressive success?
Should Canada also pay it to increase its OD rates?
(“Soft”) Presumed consent (Opt-out) (Ley 30/1979, de 27 de octubre, sobre extracción y trasplante de órganos, Art. 5.3; (Real Decreto 2070/1999, art. 10.1)
The “softness” of the presumed consent: two rare but significant settings
- when the proxies are not available
- when they refuse the explicit consent of the donor
Altruism (Real Decreto 2070/1999, art. 8)
Separation between diagnostic and transplant teams (Real Decreto 2070/1999, a rt. 10.2)
2. Official legal and moral framework
Success of Spanish system is due to its Opt out model? ” Opt-in Opt-out Under discussion Undef./not known
Presumed consent: Under which conditions can it be considered a type of consent?
Do the Spansh people know the current legal framework on presumed consent?
- Do they agree?
25% 75% Conesa Bernal C, et al. [Population attitude toward presumed consent legislation to cadaveric organ donation]. Med Clin (Barc). 2004 Jan 24;122(2):67-9. Is this utilitarian policy ethically acceptable?
Transplant coordinator (family interview, 17% of family refusal)
Low judicial refusal
Training: donor detection, brain death diagnosis, family approach…,
Expanded criteria. Spain vs Canada (2008)
The mean age of deceased donors is 44.3
62% were older than 40
44% were older than 50
20% were older than 60
The mean age of deceased donors is 54.2
73% were older than 45
44% were older than 60
23% were older than 70
Spanish Model is not the most efficient one EFFICIENCY Roels L, Cohen B, Gachet C. Am J Transplant . 2007 Cuende et al. Am J Transplant . 2007 PROCURED KIDNEYS from Deceased donors THAT COULD NOT BE TRANSPLANTED (% of total Kidneys procured) NON-USEFUL DONORS
End-of-life policies and the “induction” of Brain Death The Dutch protocol : “Starting or continuing mechanical ventilation in patients who are not brain dead, but who are beyond hope of meaningful survival, with the sole intent of awaiting brain death and the possibility of organ donation bears some risk that the patient will not die but remain alive in a persistent vegetative state. ( Erwin J.O. Kompanje, 2006 ) Is this utilitarian policy ethically acceptable? The Spanish Protocol : “In the name of the principle of justice, it is considered that these patients must be hospitalized in the ICU. It is considered ethically acceptable that, even though some of them become in PVS because of an aggressive treatment in the ICU, and even though it violates the non-maleficience principle, the social benefice that organ donation entails is a priority. A clear information to the proxies on these procedures and its probabilities must be given. The State should assume the social costs that follow the perpetuation of those PVS patients (Mercedes Lara ) http://www.uninet.edu/cin2000/conferences/MLara/mlara1/index.htm
Donation after uncontrolled cardiac death Manipulation of the place and timing for the determination of death Preserving techniques without patient or family explicit consent Hardening of the initially “soft” presumed consent Lack of information to the families Unclear if donor brain dead Is this utilitarian policy ethically acceptable?
Economic aspects 1. Professionals are paid by the hospital according to the number of organs procured AND transplanted Compromising patients’ interests? 2. Families receive a compensation if they accept the donation. That includes - Funeral expenses - Repatriation of the corpse “ Unwelcomed irresistible offers”? (R. Veatch) Are these practices compatible with altruism? And again, is this ethically acceptable?
(“Soft”) Presumed consent (Opt-out)?
Separation between teams?
Actual framework Why do we care –or should care- about consistency between law and practice? “ Any too transgressed law is a bad one. The legislator should abrogate it or modify it so that the contempt in which this senseless law has fallen do not permeate fairer laws”. (M. Yourcenar, Memoirs of Hadrian )
Diagnostic and procurement teams are really separated? New Conflicts of Interest When the coordinator is an intensivist who - treats the patient - participates in the identification and maintenance of potential donors - is likely to receive more income if the procurement is performed
What is a conflict of interests and why should we worry about them? Definition : A professional judgement concerning a primary interest (such a patient's welfare) tends to be unduly influenced by a secondary interest (such as organ transplantation, financial gain, reputation, etc) The secondary interest is usually not illegitimate in itself. Only its relative weight in professional decision is problematic Conflict-of-interest rules seek : 1. to maintain the integrity of professional judgement. 2. to maintain confidence in professional judgment.
Unrelated living donation
Unrelated Liver LD?
Donation after Controlled DCD?
Current and future challenges Something to learn from Canada
Are Spanish policies in organ donation ethically acceptable, considering its good results and the pervasive threaten of organ shortage?
Should other countries, as Canada, partially or totally incorporate them?
Thank you David Rodríguez-Arias Vailhen, PhD [email_address]