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Presentation at a “Residents’ Ethics Training Program” held in Madinah al Munawwarah on October 13, 2016 by Professor Dr. Omar Hasan Kasule Sr. MB ChB (MUK). MPH (Harvard), DrPH (Harvard) Chairman of the Ethics Committee King Fahad Medical City
Learning objectives:
At the end of the learning unit, the trainee should be able to:
- Apply
key ethical and religious principles governing organ transplantation and
withdrawal of care.
- Be
familiar with the legal and regulatory guidelines regarding organ
transplantation and withdrawal of care.
- Counsel
patients and families in the light of applicable ethical and religious
principles.
- Guide
patients and families to make informed decisions.
Introduction:
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The first
organs involved in transplantations were the skin, the bone, the teeth, and the
cornea.
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Later kidney,
heart, lung, and liver transplants were achieved.
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Glandular and
neurohumoral organs will be transplantable in the future.
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Transplantation
decisions are a balance between risk and benefit.
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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
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Uses of
textual, nass, evidence has limited success because the issues involved in
transplantation are new and were not dealt with before.
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General
Purposes of the Law, maqasid al sharia, and the General Principles of Fiqh,
al qawaid al fiqhiyyat are the more appropriate tools.
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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
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Under the
principle of hardship, necessity and hardship legalize what would otherwise be
objectionable or risky.
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Lowering donor
risk has precedence over benefit to the recipient the complications.
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Side-effects to
the recipient must be a lesser harm than the original disease.
Legal rulings about transplantation: Qa’idat al dharar
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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.
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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
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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 transplant-ation: Abuses
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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.
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Protecting
innocent people from criminal exploitation is a public interest that has
priority over the health interests of the organ recipient.
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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
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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.
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The following
are allowed: use of animal organs, use of artificial organs,
auto-transplantation, transplantation from a living donor.
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Organs from
prisoners condemned to death can be used provided there is dharuurat.
Indications, side effects, and complications
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Main indication
for transplantation is organ failure and sub-optimal organ function.
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Transplantation
on the basis of preventive maintenance of organs in good condition is not
allowed.
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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
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The decision to
donate organs can be made by a competent patient before or during terminal
illness. Sale of organs is forbidden.
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Hospitals train
their staff to have the necessary sensitivity to broach this difficult subject
with the patients.
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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 - 2
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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.
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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.
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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
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Brain death is
cessation of all functions including blood circulation in the brain.
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Brain death is
diagnosed based on clinical criteria and laboratory as well as radiological
confirmatory tests.
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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.
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There is
consensus that brain stem death is clinical death and is also a legal
definition of death.
Withholding artificial life support - 1
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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.
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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.
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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.
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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.
Withholding artificial life support - 2
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Life support
theoretically should be stopped as soon as the patient is brain dead or when it
is clearly futile.
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Clinical signs
of brain death are reliable in this matter and confirmation can be by brain
encephalography and imaging as well as laboratory tests.
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To make sure,
the testing for brain stem death should be repeated after 6-12 hours for
confirmation.
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Withdrawal of
life support is followed by death in many cases immediately and the doctor is
seen as pulling the plug.
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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.
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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
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The demand for
organs is more than the supply.
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Human organs
could be obtained either as voluntary gifts or voluntary sale.
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The donor may
be living or may be dead.
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Living donors
could be free persons or prisoners condemned to death (ethically
controversial).
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Harvesting
organs from an individual without his or her free consent is not allowed by the
law.
Case scenario:
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