181108 - ETHICAL ISSUES: TRANSPLANTATION / ORGAN HARVESTING; WITHDRAWAL OF CARE

Presentation at a “Residents’ Ethics Training Program” held in Madinah al Munawwarah on November 8, 2018 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:

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 have 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 a 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 the benefit to the recipient of 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 possible but its complications and side effects should be of a lesser degree than the original injury.
• Abuse of transplantation by abducting or assassinating people for their organs could lead to the complete prohibition under the principles of the dominance of the 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.
• The principle of motive will have to be invoked to forbid transplantation altogether if it is abused and 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:

• The 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 a terminal illness. The 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 - 2:

• 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 confusion and misunderstandings, the healthcare workers treating the terminal patient should not be involved in discussions of organ donation or 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 for the organ harvesting team to arrive.

BRAIN DEATH AND ORGAN TRANSPLANTATION:

• Brain death is the 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 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 - 1:

• 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 usually resist. 

WITHHOLDING ARTIFICIAL LIFE SUPPORT - 2:

• 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 sales.
• 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:

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