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Presentation
at a training program ‘Applying the Principles of Ethics to Clinical
Practice:’ held at Aramco Dhahran April 6, 2015 by Professor Omar Hasan
Kasule Sr. MB ChB (MUK). MPH (Harvard), DrPH (Harvard) Chairman of the Ethics
Committee King Fahad Medical City.
Introduction
·
The first organs involved in transplantations were the skin, the bone,
the teeth, and the cornea.
·
Later kidney, heart, lung, and liver transplants were achieved.
·
Glandular and neurohumoral organs will be transplantable in the future.
·
Transplantation decisions are a balance between risk and benefit.
·
Ethical and legal problems of transplantation are temporary; they will
disappear with the use of xenografts, artificial organs, and cloned organs.
Legal rulings about transplantation: sources
·
Uses of textual, nass, evidence has limited success because the issues
involved in transplantation are new and were not dealt with before.
·
General Purposes of the Law, maqasid al sharia, and the General
Principles of Fiqh, al qawaid al fiqhiyyat are the more appropriate
tools.
·
The main guide about transplantation is the purpose of maintaining life
of the donor and the recipient.
Legal rulings about transplantation; qa’idat al mashaqqat
·
Under the principle of hardship, necessity and hardship legalize what
would otherwise be objectionable or risky
·
Lowering donor risk has precedence over benefit to the recipient the
complications
·
Side-effects to the recipient must be a lesser harm than the original
disease.
Legal rulings about transplantation: qa’idat
al dharar
·
Under the principle of injury, transplantation relieves an injury to
the body in as far as is possible but its complications and side-effects should
be of lesser degree than the original injury.
·
Abuse of transplantation by abducting or assassinating people for their
organs could lead to complete prohibition under the principles of dominance of
public over individual interest prevention of harm has priority over getting a
benefit and pre-empting evil.
Legal rulings about transplantation: qa’idat
al qasd
·
Under the principle of custom brain death fulfills the criteria of
being a widespread, uniform, and predominant customary definition of death that
is considered a valid custom.
Legal rulings about transplantation: abuses
·
Selling organs could open the door to criminal commercial exploitation
and may be forbidden under the purpose of maintaining life, the principle of
preventing injury, the principle of closing the door to evil and the principle
of motive.
·
Protecting innocent people from criminal exploitation is a public
interest that has priority over the health interests of the organ recipient.
·
Principle of motive will have to be invoked to forbid transplantation
altogether if it is abused and is commercialized for individual benefit because
the purpose will no longer be noble but selfish. Matters are to be judged by
the underlying motive and not the outward appearances.
Legal rulings about transplantation: other considerations
·
Other considerations in transplantation are free informed consent,
respect for the dignity of the human ownership and sale of organs, taharat
of the organs, sadaqat, and iithaar.
·
The following are allowed: use of animal organs, use of artificial
organs, auto-transplantation, and transplantation from a living donor.
·
Organs from prisoners condemned to death can be used provided there is
dharuurat.
Indications, side effects, and complications
·
Main indication for transplantation is organ failure and sub-optimal
organ function.
·
Transplantation on the basis of preventive maintenance of organs in
good condition is not allowed.
·
The associated side effects and complications of immune suppression,
infection, neoplasia, graft rejection, and drug toxicity are treated under 2
principles of the Law: hardship, mashaqqa, and injury, dharar.
Procuring and harvesting organs
·
The demand for organs is more than the supply.
·
Human organs could be obtained either as voluntary gifts or voluntary
sale.
·
The donor may be living or may be dead.
·
Living donors could be free persons or prisoners condemned to death
(?ethically controversial)
·
Harvesting organs from an individual without his or her free consent is
not allowed by the law.
Case
scenario 1:
An ICU doctor kept a
brain stem dead patient on artificial life support to maintain the vitality of
his organs until the arrival of the transplant team to harvest the heart and
lungs donated by the patient while still conscious in favor of his cousin who
was born with severe congenital abnormalities and would die without the
transplantation