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THE “DEAD-DONOR RULE” IN THE ETHICS OF ORGAN TRANSPLANTATION
Abstract
Organ transplantation has given rise to numerous questions in the minds of the medical professionals of the world across the globe. There have been an enormous number of unanswered questions regarding the ethical issues about the concept of organ donation and organ transplantation. In this paper, we will discuss the role of dead donors rule and brain death in the context of organ donation. It has been seen since years that different parts of the world and different people of the medical fraternity have different definitions of death. For some the stoppage of the functions of the brain is death, for others, it is the cessation of the circulatory, respiratory and the neurological functions of the body. In this paper, we will define the concept of death, brain death and other related concepts related to this. It has been seen that despite the clarity provided in the definition of the Dead donor rule, there have been lots of questions in the mind of the medical practitioners of the world regarding the ethical issues of organ transplantation. When a person should be considered dead, how to decide if someone is ready for an organ donation, who should give the consent in the case of organ donation is highly important, and many such questions have been hovering over the minds of the doctors and medical professionals since ages. It is, therefore, important to bring clarity to this subject and frame new approaches to a better understanding and applicability of the organ donation and transplantation process.
Role of Brain Death and the Dead-Donor Rule in the Ethics of Organ Transplantation
Millions of children and adults are dying every day due to the lack of potential donors across the globe (Tsai et al., 2000). This dearth in the number of organ donors have made transplantation difficult (Conesa et al., 2003).
(Practical Bioethics, 2016)
History takes us back to the integration of brain death and organ transplantation since the conception of the latter has been evident in the field of medical sciences. By dead donor rule, we understand the bond between the dead donor and the concept of organ transplantation. The rule is meant to reassure the general public that living people will not be sacrificed in the name of organ donation or transplantation (Shelton, 2003). The dead donor rule requires the patient to be declared as dead before any life sustaining organ can be removed from his body. Life-sustaining organs include the heart, entire liver and both the kidneys. Although the concept seems to be quite clear, but there indeed are many associated issues which come along in the way of practicing it in the practical settings. The clarity of the concept and the successful utilisation of the idea can be seen in the hundreds of organ transplantations carried on a daily basis by brain dead individuals. Physicians from all over the world are saving millions of patients by transplanting viable organs from brain dead patients to the ones who need them. Shewmon in his article says that our understanding of death needs to be reconsidered. According to him, we need to have a better vocabulary of the terms related to death (Shewmon, 2004).
(Organ Donors Statistics, 2016)
However, on the other hand, the dead donor rule seems to be failing or creating controversies. These controversies result due to the incoherence of the definition of brain death. The idea of brain death neither fulfils the biological and nor the philosophical definition of death. The dead donor rule depends on a coherent definition of death, but that definition has proved to be elusive. Before the mechanical ventilators and intensive care came into existence the definition of death was quite direct and straightforward. The term death was used only when the respiratory, cardiac and neurological functioning of the body ceased completely. As a matter of fact, cessation of the functioning of any one of these systems leads to the stoppage of the others eventually. Different data suggest that many people view “brain dead” “as good as dead”, if not actually dead (Crowley-Matoka and Arnold, 2004).
With the advancements in the fields of technology and medical sciences, it has been possible to continue the respiratory and cardiac functioning of the body even with the help of mechanical ventilators and cardiac support devices in the absence of any neurological functioning of the body. The patients in this condition are usually comatose but the basic functioning of the body is retained up to a great extent. The debate has been going on in order to ascertain if these patients should be administered anaesthesia at the time of organ transplant procedure.
The ability to sustain life with the help of cardiac support devices and mechanical ventilators has given rise to two important consequences. One is that now the transported organs are more viable as they are procured from an apparently living body, the organ was being perfused by the beating heart till the time of its procurement. Secondly, it has made the definition of death more complicated. The question that “when can a person be labelled as dead?” has given rise to a number of debates than ever before.
In order to bring this issue to an end, the presidential commission in the year 1981 formulated the Uniform Determination of the Death Act. The act stated that a person who has sustained an irreversible circulatory or respiratory failure or an irreversible failure of the brain functioning including the brain stem is term as dead. This standard is now being used by the United States and most parts of the world for the purpose of determining the suitability and feasibility of organ donation (Zubkov and Wijdicks, 2010). Organ donation can be carried out by an individual who has been through cardiac arrest although his neurological functions are intact. This individual may not fulfil the criterion for brain death prior to cardiac arrest (Rady, Verheijde and McGregor, 2006).
Among all these developments, the concept of brain death was defined as a separate entity completely. Although it is considered to be quite obvious that a person is dead when his brain stops functioning, or in other words, when he is brain dead; but this aspect when examined more closely, gave rise to surprisingly different conclusions. To bring about more light into the topic, we can begin by saying that the firm supporters of the concept of whole brain death have acknowledged the fact that there have been patients who have been diagnosed as brain dead do not have the irreversible cessation of the brain functioning. It has been found through multiple studies that the brain dead patients retain the functioning of the posterior pituitary along with some other significant functions of the brain. Calling brain death as an approximation, supporters also insisted that the retained functioning of the brain is insignificant and hence can be ignored. This calls for another major question in this regard, that is, “which functions can be considered as significant?” Our understanding of why pupillary and corneal reflexes are given much importance and electrolyte imbalance is ignored remains doubtful.
(Waiting list deaths, 2016)
A major reason for considering brain death as inevitable death is that these patients die within a short time span of one or two weeks following the establishment of the diagnosis even after being kept on continuous life support. The inevitability of death following a cardiac arrest makes it more of a diagnostic feature of death. The problem arising here is quite obvious; it leads to confusion between prognosis and diagnosis.
Another important justification given in this regard is that these patients become permanently unconscious. This is indeed true as no patients who have once been declared as brain dead ever revived again. Patients who are permanently in a vegetative state are also believed to be permanently unconscious. But these patients are different from the brain dead ones as they breathe regularly and are fed by gastric tubes for years; it helps them in surviving for a longer period of time. It, therefore, can be argued upon that if brain dead patients are dead, then the patients in their vegetative state are also dead.
Different places of the world have tried to formulate their own rules and regulations regarding the practice of organ donation. In Japan, the term brain dead is further subjected to classifications like brain stem dead and the whole brain dead. They are defined clearly for their utilisation in the concept of organ donation. The term brain dead is only used for cases which are considered to be eligible for organ donation (Kumaido, Sugiyama and Tsutsumi, 2015). Although the dead donor rule has been implemented to its fullest, but the general people are still lacking in knowledge about the same (Siminoff, Burant and Youngner, 2004).
The most convincing justification for considering brain dead as dead depends on the idea that death is the loss of functioning of the whole organism. The explanation here is that the brain is the central organ that coordinates the functioning of the whole body; when the central organ fails to work the body is bound to progress towards deterioration and eventually death becomes inevitable. This explanation emerges from the belief that every diagnosed patient of brain death develops cardiac arrest within some time. The issue with this justification is that it once was true, but not anymore. Nowadays, brain dead patients develop cardiac arrest because either they are made to donate organs or their life support is withdrawn. Studies have shown that if the brain dead patients are provided with life support during the acute phase of neurological deterioration, then cardiac arrest no longer remains imminent or certain. At the extreme, it has been seen that a brain dead patient can survive for more than fourteen years. The notion that complex organisations require a central control in the form of a brain can be criticised. The point which has been stated in proving this statement false is that even plants have a complex structure but they lack a brain or any form of neurological control like human beings.
Overall it can be said that there are different definitions of death and each of them have their own limitations, strong points and beliefs. It can be said that we cannot decide upon a particular definition of death depending solely on the scientific knowledge and principles. The nature of the uncertainty in the definition of death when seen in the light of scientific knowledge, gives the idea that death cannot be defined based on the knowledge of science alone. The knowledge of societal prospects is required to construct the definition of death (Truog and Robinson, 2003). The procurement of organs has created many ethical issues at different levels (Bos, 2005).
The controversies related to the definition of death have jeopardized the program of organ transplantation to a great extent. In other words, this debate, instead of generating a general consensus, has put up questions on the integrity and success of the organ transplantation program. The issues have cropped up mainly due to the influence of dead donor rule in relation to the organ donation practice.
(Candidates on Waiting List, 2016)
Talking about the ethical solution to the question of organ donation, many experts are of the view that the organ donation rule should be based more on “nonmaleficence”. It should take into consideration the condition of the patient and respect the integrity of the patient. The rule should focus more on the human ethics rather than the diagnosis of brain death or the dead- donor rule. It calls for a completely different approach towards organ donation. The approach should be based on the fact that sometimes dying does a relatively lesser harm to the patients and he should be allowed to take a voluntary decision regarding the same if the person is capable of being an organ donor. If this particular approach is accepted and followed then it will make the whole process of organ transplantation more ethical and humane. However, it is equally important to ascertain the conditions when dying can be considered as a smaller harm and the patient in question can be allowed to proceed for organ donation keeping his own life at stake. The class of people in whom death is imminent can be taken as a valuable example. The terminally ill patient must be ready to reduce few more minutes of his life for the purpose of making another person’s life a healthier one.
The society needs to decide through public deliberation and proper legislation if the terminally ill patients should have the right to take the decision about terminating their lives if they are qualified as suitable donors. With this approach, the category will get limited to the patients who are on life support and will die within few minutes of withdrawing the support and those for whom no other treatment options are available or desired. Different philosophers have different opinion about the dead- donor rule. Some suggest formulating better definitions, whereas some others call for a deeper look into the history of the patient before taking the much valuable decision (Koppelman, 2003). Some call for a proper consent from the terminally ill patient regarding the withdrawal of the life support system and simultaneously taking consent for donating organs (Miller, Truog and Brock, 2010).
These have led the doctors or physicians to another set of problems. They are now confused if they are murderers or lifesavers. They come across questions if the patients are really dead before the transplantation procedure can be initiated. They are in a dilemma if they have the right to bring the terminally ill patients out of the mechanical ventilators before the patient dies naturally. It thus becomes an obligation to declare these patients as dead before proceeding for the organ transplantation procedure. It helps in reducing the feeling of guilt among the doctors.
The whole process of diagnosis of brain death and organ transplantation require a multidisciplinary approach. Nurses have a crucial role to play in this regard. They have tremendous knowledge about the criterion for brain death and can work in close coordination with the doctors, patients, the relatives of the patients and other medical staff (Lovasik, 2000).
Conclusion
Thus, it can be concluded that the hard question, “What is death?” is replaced by another difficult question, “When are patients sufficiently close to death that they can choose to be organ donors?”. That way, the suggested approaches have done no good to the difficult question. However, it cannot be completely denied that the ethical, method discussed in the paper will lead to two major advantages. The first one is that the new approach no longer considers the controversial dead- donor rule or the brain death concept. Secondly, it considers the ethical principles. It is based on nonmaleficence and it respects the person involved in the process. It considers the wish of the patient and demands his consent before the removal of the organs can be considered. According to all the discussions made above, the new question that arises is “Might this approach lead to a decrease in organ donations, if adopted as the unique method?” This question still remains unanswered and needs a more logical and better approach to be dealt with.
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