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Presentation at a residents’ ethics training program Madina Munawarah October 13, 2016 by Professor Omar Hasan Kasule Sr. MB ChB (MUK). MPH (Harvard), DrPH (Harvard) Chairman of the Ethics Committee King Fahad Medical City. Professor at the Faculty of Medicine and Chairman of the Ethics Committee at Fahad Medical City Riyadh Saudi Arabia.
Learning
objectives
at
the end of the learning unit, the trainee should be able to
a. Apply key ethical and religious principles governing organ
transplantation and withdrawal of care
b. Be familiar with the legal and regulatory guidelines regarding
organ transplantation and withdrawal of care
c. Counsel patients and families in the light of applicable ethical
and religious principles
d. Guide patients and families to make informed decisions
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, 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.
Discussion
with the patients regarding organ donation, harvesting and transplantation 1
The
decision to donate organs can be made by a competent patient before or during
terminal illness. Sale of organs is forbidden.
Hospitals
train their staff to have the necessary sensitivity to broach this difficult
subject with the patients.
Most
patients are realistic and can face the reality of their impending death and
its consequences. They are ready to discuss these consequences including
decisions about donating their organs and tissues for research or for
transplantation.
Discussion
with the patients regarding organ donation, harvesting and transplantation 1
A
few patients may find the discussion of impending death very frightening
especially if they suspect that the healthcare workers are interested in taking
their organs and not their treatment.
To
avoid confusions and misunderstandings, the healthcare workers treating the
terminal patient should not be involved in discussions of organ donation or the
actual harvesting. Special teams from specialized organ donation organizations
should be contacted to come to the hospital and take over the whole process.
Even
the surgeons who harvest the organs should not be from the hospital. It is
acceptable to continue ventilation for some time after brain death to give time
to the organ harvesting team to arrive
Brain
death and organ transplantation
- Brain death is cessation of all
functions including blood circulation in the brain.
- Brain death is diagnosed based on
clinical criteria and laboratory as well as radiological confirmatory
tests.
- Brain death can be total brain
death if it involves the whole brain or can be brain stem death if it
affects the vital centers of the brain stem.
- There is consensus that brain
stem death is clinical death and is also a legal definition of death.
Withholding
artificial life support:
- The decision to
withhold life support is made when the patient is found already brain dead
or when there is clear evidence that such support will be a medical
futility.
- This is however
easier said than done because practical realities condition the behavior
of attending doctors. Faced with a critically ill patient with anxious
family members looking to the doctor to save the patient, the doctor will
find it emotionally difficult to withhold life support that in his better
judgment is futile.
- In addition the
doctor cannot take such a serious and irreversible decision because of
uncertainty in clinical assessment and lack of enough time to absorb the
facts.
- Many doctors
therefore play safe by starting life support and this creates a new
problem of stopping it another emotion-laden decision that families
normally resist.
Withdrawing
artificial life support:
- Life support
theoretically should be stopped as soon as the patient is brain dead or
when it is clearly futile.
- Clinical signs
of brain death are reliable in this matter and confirmation can be by
brain encephalography and imaging as well as laboratory tests.
- To make sure, the testing for brain stem death should be
repeated after 6-12 hours for confirmation.
- Withdrawal of
life support is followed by death in many cases immediately and the doctor
is seen as pulling the plug.
- Families many
times oppose pulling the plug and doctors sometimes acquiesce and wait for
some time to give the family time to come to terms with the reality and
finality of death.
- Withdrawal
decisions can be affected by bed availability in the intensive care unit.
In cases of bed shortage, there are more aggressive and frequent efforts
to test for brain stem death.
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