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Clare Gilbride

on 2 November 2014

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Welcome to the 21st century! It is a world for medical professionals like yourself that is full of vastly changing, impressive and exciting new therapeutic options for our patients. With technology advancing at a great velocity, medical interventions are reaching extraordinary heights. And with that growth comes even greater responsibility for us as doctors. Organ transplantation is one area in which doctors may possess many qualms. By engaging in this learning package you will explore the many ethical dilemmas that doctors face.
To make the most of this learning package it is recommended you watch the videos, read the articles and answer the questions as you go. You might even consider conversing with your colleagues over the issues that are presented here.

Once you have completed the questions, proceed on to the answers. Try not to peak!
How to use this resource
Review the bioethical principles underlying organ transplantation
Understand the key ethical theories surrounding organ transplants
Understand the key legal issues surrounding organ donation
Understand organ allocation, including the ethical issues and the criteria used for liver transplantation
Learning objectives
Let's begin!
Organ donor confidentiality,
including their families right to privacy
The implications of knowing your donor's identity.
In this story, Derryn's donor was a criminal who Derryn very vocally spent his entire life shaming. How might the recipient of a transplantation feel if the donor was a murderer? Does it matter?
Consent to organ donation
, both by the family and the living donor before their passing.
Risks involved in organ transplant.

Chosing a transplant recipient.
What considerations do ethical boards go through when considering an organ transplant recipient, particularly given the fierce competition for organs.
Donation of tainted organs.
The donor in this situation was very high risk for Hepatitis C and HIV. It would be at least 3 months before the Derryn would know if he had been infected.
Ethical scenarios raised:
The state of doing or producing good. Also the moral principle that actions are right in so far as they produce good.

This principles imposes a responsibility on health professionals to be an advocate for their patients.
(Veatch et al.)
The state of not doing harm or evil. Also the moral principle that actions are right insofar as they avoid or prevent producing harm or evil. One of the most memorable quotes in the history of codes in medical ethics is primum non nocere, which, translated into English means, "Above all, do no harm".

In practice, this applies to practitioners when having to consider the burdens associated with treatment, weighed up against the benefits of treatment.

Non-maleficence also encompasses patient confidentiality, as in order to minimise harm caused to the patient, personal information should not be disclosed.
(Veatch et al.)
A Self-Directed Learning Package for Medical Professionals
Created by Clare Gilbride
Follow the link below to watch the 60 minutes report on the controversial radio host Derryn Hinch's own experience with organ transplantation. As you are watching, consider the ethical dilemas that are raised.
In order to approach an ethical dilemma in any clinical setting, the four key principles of bioethics can be applied. We will now revise this core framework, which includes:

Respect for autonomy

Before continuing, revise and understand the meaning of these core frameworks. How might these be applied to the video you just watched?
In the documentary, the patient had a small chance of being infected with HIV or Hepatitis C. Even if the patient DID get infected, his years of quality life would still be greatly increased.
The governing of oneself according to one's own system of morals and beliefs or life plan.

This principle is fundamental in the process of informed consent, whereby a patient is fully aware of the processes involved in their health care. This aim to put the patient in the most knowledgeable position to make thir own decision regarding their health. Autonomy respects a patients right to self-determination and also respects patient privacy.

For medical professionals, it ensures the obligation to tell the truth to patients and to provide informed consent. Ultimately, it is promoting a patient-centered approach to health and rejects the old fashioned notion of paternalism. (Veatch et al.)
Derryn Hinch was fully informed of the risks of his organ transplantation, including the risks of a tainted organ and infection. He was given the right to self-determination. Ultimately, it was his own decision.

In terms of patient confidentiality, Hinch's celebrity status in the community led him to reveal the details of his surgery to the community. This was at the patient's discretion. In terms of the donor family, it was also at their discretion to contact Hinch.
The act of fair and equitable distribution of resources or access to benefits.

The standard of what is deemed fair distribution among society is determined by justified norms of what seem to be either owed or fairly due to a group or individual in the same situation. (Veatch et al.)

Distributive justice is the most commonly discussed aspect within justice in the health care setting. It generally refers to inequity among societal groups in terms of monetary wealth, or it refers to the distribution of limited social goods or economic goods to a given population.
As medical professionals, we are a member of and represented by the Australian Medical Council (AMC). As a member, we must respect the Good Medical Practice code which is designed to establish the aims and expectations of all Australian medical practitioners.

Additionally, we must be aware of Australian legislation on organ transplantation.

Read the case study and use the text to answer the questions provided.
The following is a list of professional values and qualities expected in Australian medical practice, as according to the AMC:

I. Doctors have a duty of care to be ethical and trustworthy
II. Doctors willdisplay qualities of integrity, truthfulness, dependability and compassion.
III. Doctors will protect a patient's confidentiality.
IV. Doctors must play a role in health promotion and health protection for the patient and the wider community.
V. Cultural awareness is expected, with an understanding of diversity in patient culture, beliefs and values.
VI. A patient-centred approach is strongly encouraged.
VII. Good communication.
VIII. Professionalism underpinning all medical practice, including self-awareness and self-reflection.

(Australian Medical Council, 2014)

AMC Code of Conduct
Definition of death
Under Australia's federal legal system, legal regulation of organ donation is the responsibility of the states and territories. Not only is there no Commonwealth legislation governing organ donation, but there is no national coordinating body or agency with legislated powers.

Although there is no federal legislation, the Commonwealth still has the ability to regulate current practices. For example, the Australian Law Reform Commission (ALRC) in 1977 conducted a review of organ transplantation that included creating clear definitions on "opting out", "brain death" and "live donations". The idea behind this reform was to attempt to unify all states in their current protocol for organ transplantation.

The Human Tissue and Transplant Act of 1982 is Western Australian's governing document. We will now review the following in order to gain a comprehensive view of the legislation surrounding organ transplantation:
The definition of death
"Opting in" versus "opting out"

A person has died when either:
Irreversible cessation of all function of the brain, or
Irreversible cessation of circulation of blood in the body of the person has occurred. (Minson, 2000, pg 19)
This definition of death was omited from Western Australian Law as the Minister for Health at the time felt that much more public debate was needed on this difficult subject before the definition is embodied in the Statute.

Although there is no statutory definition, for the purpose of human tissue removal, the Act provides that tissue shall not be removed until tow medical practitioners have certified that all brain function has irreversibly ceased.
A case study
The Human Tissue and Transplant Act 1982 (Western Australia) requires that a designated officer for the hospital may authorise the removal of tissue from a dead person in circumstances where the desginated officer has made inquiries that -
the deceased person during his lifetime expressed the wish for, or consented to, the removal after death of tissue from his body and had no revoked the consent; or
the deceased person had not expressed an objection to the removal after death of tissue from his body and the senior available next of kin consents to the removal of tissue. (Section 22 of the Human Tissue and Transplant Act 1982, Western Australia)

This encompasses written and oral consent of the donor and the next of kin where the donor had not explicitly expressed a wish to be a donor. In practice however, regardless of the individual's registration as a donor, consent for donation is always sought from the next of kin.

(Minson, 2000, pg 24)
'Opting in' vs 'opting out'
In all states and territories in Australia the current system for organ donation is by "opting in". This means that individuals need to actively volunteer themselves forward as an organ donor and further inform their families of this decision for it to go ahead. An indication on an individual's driver's license to be an organ donor is no longer considered informed consent.

If here has been neither rejection nor active opting in by a patient who may qualify as a donor, then the decision is left to the family.

"Opting in", also known as "presumed consent" refers to a system where all organs of a deceased person are available for transplantation purposes, unless the person expressed a contrary wish before their death. Such as system makes organ donation routine and eliminates the additional emotional burden which may be placed on the deceased family in having to make a decision during a time of emotional turbulence.

It is no difficult to see how the countries with the highest donor rate have a "presumed consent" model.

(Minson, 2000)

Mike is a 36-year-old banker with a passion for motorbikes. One winter evening when he is traveling back from a conference down the M1 his bike skids on a patch of black ice. He was driving at 145km/h. He hits the windscreen of an oncoming car and his helmet splits in half. An ambulance arrives at the scene within minutes and Mike is intubated and rushed to hospital. He has sustained severe injuries - he has fractured his pelvis and several vertebrae. At hospital he is assessed in the intensive care unit. Attempts to resuscitate him are unsuccessful and when he is weaned off the ventilator he does no make any respiratory effort. Tests performed by two different consultants confirm that he has had massive brainstem injuries, and he is declared brainstem dead despite the ventilator continuing to keep his heart and lungs working and consequently the rest of his organs perfused. A nurse discovers that Mike is registered on the national organ donation database and so it is decided to keep him ventilated until his next of kin are traced and contacted, so that they can be asked for their permission to use Mike's organs.
How can someone donate his or her organs after death?
Can the next of kin prevent organ donation?
(Johnston & Bradbury, 2008)
Consider the case study again, what are the ethical implications of preserving the body of a patient that is clinically dead whilst consent is being established?
Despite consent and respect for the individual being at the heart of the Human Tissue Act, it has a slightly utilitarian flavour. Remember that a utilitarian theory is that which provides that the right course of action is that which promotes the greatest happiness for the greatest number. By allowing the recently deceased to be preserved while consent to donation can be established or refused by the family, utilitarian theory is met. This theory makes it permissible to ventilate a patient after death has been confirmed.

In every other aspect of medicine consent to 'treatment' cannot be made by another adult, unless they have a lasting power of attorney. But, a deceased person lacks capacity - so can treatment even be given in the patients best interest? Does a dead person have any interests? Can any harm be caused to a dead patient?

If the answer to these question is no, it could be justified that consent in this scenario does not matter, and all healthy organs should removed and donated to a living person to maximise utility.

Deontological theory, a moral theory based on rights and obligations, would consider this act morally unacceptable as no person should be used solely as a means to an end.

(Johnston & Bradbury, 2008)
A major issue for medical practitioners is the allocation of organs. We will now consider the ethical considerations of organ allocation, including distributing organs fairly and the ethics of distributing organs to patients who have a disease due to their own voluntary life decisions, such as smoking.

We wil then consider eligibility criteria for Australian organ donations, with a specific focus on liver transplantation.

Ethical Principles of Organ Allocation
The ethical principles that govern organ allocation, are:

the view that an action is deemed morally acceptable because it produces the greatest balance of good over evil, taking into account all individual affected. It particularly includes beneficience, the state of doing or producing good, and nonmaleficence, not doing harm or evil.
: the moral obligation to act on the basis of fair adjudication between two competing claims.
Respect for autonomy
: the governing of oneself according to one's own system of morals and beliefs or life plan.

Additionally, when quantifying benefit in transplantation, benefit is usually measured in terms of years of life added per transplant. In medical term however, quality of life is used to adjust this number. This calculation produces a unit called a QALY or "quality-adjusted life year".
When voluntary risks cause a need for organs
Distributing Organs Fairly
This deals with the issue of providing organs to a larger geographical area. For Western Australian's this is a very pertinent issue, as it explores the issue of receiving transplants from the east coast of Australia. The following ethical issues arise:
The moral principle of justice require that resources be allocated to create patterns of distribution benefit that treats similarly situated people equally. For instance, there may be more organ donors on the east coast, but there are the same number of equally sick recipients on the west coast. In this way, east coast people are more likely to receive a transplant and be benefited more.
A utilitarian view point would argue that the cold ischemia time is a problem when transporting organs, and it is possible that more good would be done in the long run giving the organs to somewhat healthier patients in a smaller geographical area.
Hence, those commited to just allocation rather than utility-maximizing allocation have tended to support the government effort to get organs allocated over a wider area.
(TSANZ, 2014)
A very controversial issue in organ allocation is when a person's lifestyle choices has led to their need for an organ transplant. Respect for autonomy is one of the relevant moral priniciples in this scenario.
If we respect freedom of individuals, we tolerate, choices to smoke, eat junk food, live a sedentary life and consume alcohol, even though these are not healthy decisions.
Some argue that, if someone has voluntarily chosen a lifestyle with a known risk of damaging an organ, then that person desrves a lower priority for an organ.
However, for this decision to be defensible a few assumptions must be made:
lifestyle choices are complex. They result from habits formed early in life, before one is a substantially autonomous adult.
Some may have a genetic component beyond voluntary control of the individual.
A utilitarian view is not concerned with this, rather the how much good can be done for those on waiting lists. For instance, alcoholics have been found to do just as well with liver transplants (so long as they are no longer alcholics) as other people on the waiting list and therefore deserved the same considerations as anyone else on the list.
Those with opposing views to his, give more weight to the principle of justice. This argues that individuals should be treated equally but considered a hisoty of a voluntary choice that damaged their otherwise good liver to be relevant and thus deserved some degree of lower priority.

The Transplantation Society of Australia and New Zealand released a document on the eligibilty criteria and allcoation protocols.

Decisions regarding eligibility and allocation take into account the following ethical factors:

relative urgency of the need
medical factors which affect likelihood of success (eg. tissue matching)
relative severity of illness and disability
relative length of time on the waiting list
likelihood that the recipient will (be able to) comply with the necessary ongoing treatment after transplantation
(TSANZ, 2014)

Allocation protocols
Allocation protocols 2
Decisions regarding eligibility and allocation do not take into account the following ethically irrelevant factors:
marital status
sexual orientation
social status
capacity to pay
the need for transplant arising out of past behaviour
location of residence
age (except where age may affect the outcome)
(TSANZ, 2014)
Liver Allocation
Liver transplantation is highly successful treatment for selected patients with end-stage liver disease, such as hepatocellular carcinoma and other disorders in which liver transplant is curative. Patient-survival rates are above 80%at 5-years. Unfortunately, due to lack of suitable donors, waiting list mortality is in the range of 10 to 15%. Live donation is offered in some centers across Australia however this does not seem to have an affect on waiting list mortality rates.
(TSANZ, 2014)
Inclusion Criteria
Exclusion Criteria
Special Circumstances
Congratulations on reaching the end of this self-directed learning package on organ transplantation for patients in need. From this guide, you should now go forth in confidence as doctors and return to this model if you find yourself with an ethical dilemma surrounding organ transplants. It is vital to remember that the gift of organ transplant is incredibly valuable. It is a decision that we, as medical practitioners, need to consider with great attention and thought.
(TSANZ, 2014)
(TSANZ, 2014)
(TSANZ, 2014)
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