5. 1. Living donation “ First do not harm” Cohercion? Altruism? The risk of black market of organs
6. 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
7. 3. Donation after controlled cardiac death NEJM ; 2008;359(7):709-14. Hastings Center Report 2010(may-june):24-30
11. 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
17. Success of Spanish system is due to its Opt out model? ” Opt-in Opt-out Under discussion Undef./not known
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21. 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
22. 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
23. 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?
24. 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?
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26. 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
27. 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.
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30. Thank you David Rodríguez-Arias Vailhen, PhD [email_address]
Editor's Notes
1. To learn the main statistical data about the Spanish system of organ donation and transplantation 2. To understand the factors that contribute to successful rates of organ donation. 3. To identify and explore some aspects of the system which give rise to ethically debatable issues 4. To learn about the lights and the shadows of the "Spanish Model"
Source: wikipedia April 19th 2010
10. 1. La obtención de órganos de donantes fallecidos para fines terapéuticos podrá realizarse si se cumplen las condiciones y requisitos siguientes: Que la persona fallecida, de la que se pretende extraer órganos, no haya dejado constancia expresa de su oposición a que después de su muerte se realice la extracción de órganos. Dicha oposición, así como su conformidad si la desea expresar, podrá referirse a todo tipo de órganos o solamente a alguno de ellos, y será respetada cualquiera que sea la forma en la que se haya expresado. Artículo 8. Gratuidad de las donaciones. 1. No se podrá percibir gratificación alguna por la donación de órganos humanos por el donante, ni por cualquier otra persona física o jurídica. 10. 2. La extracción de órganos de fallecidos sólo podrá hacerse previa comprobación y certificación de la muerte realizadas en la forma, con los requisitos y por profesionales cualificados, con arreglo a lo establecido en este Real Decreto y teniendo en cuenta los protocolos incluidos en el anexo I del presente Real Decreto , las exigencias éticas, los avances científicos en la materia y la práctica médica generalmente aceptada. Los citados profesionales deberán ser médicos con cualificación o especialización adecuadas para esta finalidad, distintos de aquellos médicos que hayan de intervenir en la extracción o el trasplante y no estarán sujetos a las instrucciones de éstos.
Durante el año 2008 se extrajeron 2.832 riñones para trasplante, de los que no se trasplantaron un total de 738, lo que supone un 26,1% de los generados. (Fig. 3.8). El porcentaje de riñones desechados se ha ido incrementado en los últimos años de forma paralela al incremento del número de donantes. Las causas por las que se desecharon la totalidad de los riñones durante el año 2008 fueron las siguientes: 1) en 225 riñones (30,5%) el motivo fueron las características del donante, 2) en 460 riñones (62,3%) fueron las características del injerto, 3) en otros 43 riñones (5,8%) hubo problemas con el receptor
Leer art’iculo de Shemie, Critical care, 2002, pros and cons
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