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Bioethics project- group 6

case 2
by

lau man

on 8 April 2013

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Transcript of Bioethics project- group 6

Step 12 Step 6 Step 3 Step 2 Step 4 Step 7 Step 8 Step 9 Step 10 Step 11 Case scenario Step 5 Step 1 Step 1: Identification of ethical dilemmas 1. Patient’s beneficence VS Judy’s non-maleficence Step 2:
Medical context from caregiver's perspective Patient’s status: urgent
may deteriorate to life-threatening condition Step 3: Patient's values, perspective and
preferences Wish/Preference:
pay a living donor for > receive the liver from Judy
liver in mainland china Step 4: Family's values, perspective and preferences Treatment expectations:
Husband--same as patient (pay a living donor)
Judy--Donate her liver
Disturbed by the idea of paying a living donor in mainland Step 5: Societal & cultural factors Influenced by Chinese culture Step 6: Legal Guides Step 8: Assumptions made Step 9: Human values
freedom of choice
right of self-determination Family’s values:
Judy’s non-maleficence > patient’s beneficence

(Patient prefers waiting for cadaver liver or paying for a living donor in mainland rather than receiving donation from Judy) Step 4: Family's values, perspective and preferences
To keep the deceased intact
To preserve a complete body and no mutilation Step 5: Societal & cultural factors Is Judy allowed to donate her organs to save her mother? Emancipated minors Is paying a living donor for liver transplant legal? Step 6: Legal Guides

No organization or individual may sale human organs in any form, and shall not engage in activities related to the sale of human organs. "Human Organ Transplant Ordinance" illegal! Step 7: Missing information (Applicable) Judy can obtain approval from court for the donation and when her mother is in life threatening situation

(1) A person is guilty of an offence if, in Hong Kong, he-

(a) makes or receives any payment for the supply of, or for an offer to supply;

(b) seeks to find a person willing to supply for payment, or offers to supply for payment......

an organ which has been or is to be removed from a dead or living person, whether in Hong Kong or elsewhere Step 6: Legal Guides Is paying a living donor for liver transplant legal? Cap 465 section 4 Prohibition of commercial dealings in human organs illegal! 1. Preservation of life and patient's
beneficence 2. Safety Step 9: Human values 4. Justice Step 9: Human values 5. Human dignity Step 9: Human values trample human dignity improved after liver transplantation
hope of receiving liver transplantation
hope of maintaining life Step 9: Human values
love each other
Judy wants to donate part of her liver to patient (her mother) Step 10: Relevant ethical principles No.4 :
Principle of autonomy (Daughter)
Daughter also has the right to make decision Step 11: Evaluation and prioritization of all factors and guiding principles No. 1:
Principle of non-maleficence (daughter)
Do no harm to daughter Step 11: Evaluation and prioritization of all factors and guiding principles No. 3:
Principle of beneficence (patient)
Do good to patient
No.2:
Principle of autonomy (patient)
Patient has the right to make decision Step 12: Plan of action and alternatives Balance between patient’s beneficence and Judy’s non-maleficence.

Balance between Judy’s autonomy and her non-maleficence

Balance between paternalism and patient’s autonomy Now,
Patient’s condition: urgent Step 12: Plan of action and alternatives Step 12: Plan of action and alternatives


suggest patient to continue queuing at the HKMA organ donation registry
close monitoring e.g. regular blood taking
provide pros and cons of donation of organ from genetically-related person
explain possible actions taken in a life-threatening condition


violating law in Hong Kong and China
different medical system in China
human being should not be sold as goods Under a life-threatening condition Step 12: Plan of action and alternatives

seek court’s approval if Judy is under 18
psychological counseling to reassure patient though there are risks in surgeries, it may not affect Judy’s health a lot Q & A 2. Judy’s Autonomy VS Judy’s non-maleficence Doctor’s values:
Judy’s non-maleficence > patient’s beneficence
Hesitate about the donation of Judy’s liver to the patient Step 2:
Medical context from caregiver's perspective Step 7: Missing information 1. Judy’s physical well-being

2. Relationship between Judy and her parents

3. Does the patient have other children or relatives who are capable of donating their liver?

4. The surgery of liver transplant from a living donor performed in HK or mainland?

5. Does the doctor know about the patient’s idea of paying a living donor in mianland and what is the doctor’s stance if he/she is notified? 6. Does the patient understand the risks of receiving liver and having transplantation surgery in mainland? (E.g. sterility of operation; Is the donor a carrier of blood-borne disease such as Hepatitis B or AIDS? Law of Hong Kong and mainland related to organ selling and transplant)

7. Does Judy’s blood group matches her mother’s?

8. Does Judy understand the risks of donating her liver?

9. Is Judy mentally competent?

10. Any religious belief? Missing information Assumption Step 8: Assumptions made Missing information Assumption 1. How's Judy’s physical well-being? 2. Does the patient have other children or relatives who are capable of donating their livers? 3. Will the surgery using the liver bought from a living donor, be performed in HK or mainland? 4. Does the doctor know about patient’s idea of paying a living donor in mainland and what is the doctor’s stance if notify? Physically well No Mainland No. The doctor must not support this idea if he or she knows. 5. Does the patient understand the risks of receiving liver and having transplantation surgery in mainland? Not fully understand. Yes 6. Is Judy mentally competent to understand the risks of donating her liver?? 8. Any religious belief? Medical diagnosis: end-stage liver cirrhosis
Treatment: Liver transplant
50% chance to survive while waiting in 12 months Doctor’s considerations:
Judy is below the legal age (18) for transplant
--> need to seek court approval
Patient do not require transplant immediately (50% to survive in 12 months)
Surgery will do harm on Judy’s health
Don’t know the matters about paying a living donor Self understanding: end-stage liver cirrhosis and require liver transplant Expectation: liver transplant surgery as soon as possible to save her life Do not want Judy to take the risk of surgery consequences and think that the surgery will harm on Judy Understanding: same as patient Under the influence of Confucianism,
Filial piety:
Sacrifice for her mother
Take care of her mother by showing love, respect and support Judy’s view: Hierarchical structure of Chinese society
Children should respect parents’ decision
Judy, under 18, is not mature enough for decision making on medical issues Judy’s parents’ view: =>Low rate of organ donation in Hong Kong Traditional values in Chinese society: With court order Gillick competent HONG KONG HUMAN TRANSPLANT ORDINANCE In China, under provide best treatment
maintain life increase risk of tissue rejection and infection
risk of undergoing surgery in mainland
organ shortage--> distributive justice

unfair to those waiting for liver transplant from the central registry 4. Principle of paternalism 3. Principle of non-maleficence (daughter) 1. Principle of autonomy (patient and daughter) 2. Principle of beneficence (patient) If patient still hesitates towards donation from her daughter Strongly discourage patient to pay for a living donor and transplantation in mainland china transplantation from Judy is recommended distributive justice Step 10: Relevant ethical principles organ shortage
not everyone who needs an organ transplant gets one
everyone have the equal access to receive an organ transplant Judy’s mother plans to pay a living donor for performing the transplant certainly breaks the fairness need to follow distributive justice criteria according to medical need and probable success of liver transplant NURS3200 Bioethics Judy's mother is a 47 years old housewife and was admitted to medical ward because of end stage liver cirrhosis. Judy does not want to see her mother's health deteriorates further by waiting the queue in the central registry for cadaver organ, as the past statistics shows that her mother will have 50% chance to survive while waiting for a cadaver liver transplant in 12 months. Judy offers to donate her liver. However, she is only 17 years old, a Form 6 student and unmarried. Judy seeks special permission of donating part of the liver to her mother. Yet, both the doctor and her parents show hesitation about her decision. Judy's parent are thinking of crossing the mainland border and pay a living donor for performing the transplant. Judy is very disturbed by this idea.
The doctor in -charge eventually suggest organizing a meeting with the health care team, including nurses and social worker before making any decision for this case. Group 6:
Chow Lai Ieng
Chu Yin Shan
Lam Chi Yuk
Lai Wai Nok
Lau Ching Man
Lee Yan Wing
Mok Pui Shan
Ying Wing Man
Yuen Chiu Ming In emergency situation A child (16-18yrs old) can gain the status of adulthood a competent child (under 18) is able to consent to his/her own medical treatment w/o parental permission illegal in Hong Kong and China Step 6: Legal Guides Is paying a living donor for liver transplant legal? 3. Patient’s/ Judy’s autonomy sell human organs 6. Quality of life 7. Hope 8. Love, sacrifice and filial piety Benefit to patient's health
Harm on Judy’s health Judy decided to donate part of her liver to her mother
Harm on her health Step 7: Missing information Step 7: Missing information COMPROMISED COMPROMISED NOT COMPROMISED NOT COMPROMISED The End Deemed as Gillick competence 7. Is Judy an independent person such as financially independent? No Hong Kong Human Transplant Ordinance Genetically related
18 or above (not applicable) (not applicable) 5. Principle of justice References: http://www.legislation.gov.hk/blis_pdf.nsf/6799165D2FEE3FA94825755E0033E532/9C78C1E7BF94FF05482575EF000A9DE2/$FILE/CAP_465_e_b5.pdf http://www.gov.cn/zwgk/2007-04/06/content_574120.htm No. Unlikely to be granted the status of emancipated minor by the court Step 9: Human values prioritization: At present stage:
Urgent condition
Doctor and parents: No. 1:
Principle of beneficence (patient)
Do good to patient's life No. 3:
Principle of autonomy (Daughter)
Daughter has the right to make her own decision Step 11: Evaluation and prioritization of all factors and guiding principles Step 11: Evaluation and prioritization of all factors and guiding principles NOT COMPROMISED No. 2:
Principle of paternalism
Act on patient’s best interest
Perform liver transplant immediately NOT COMPROMISED NOT COMPROMISED No.4:
Principle of autonomy (Patient)
Patient also has the right to make decision No.5:
Principle of non-maleficence (Daughter)
Do no harm to judy COMPROMISED COMPROMISED When in a life-threatening condition
patient's beneficence --> important Urgent Condition: LIfe-threatening Condition: Human organ transplant ordinance, the Central People's Government of the People's Republic of China Human Organ Transplant Ordinance, Chapter 465, HKSAR http://cinaps.co.uk/Gillick_Competent.html Gillick Competent, Cambridge Independent Neuroscience and Psychiatry Services, UK 1. not harm daughter's health --> important
2. respect the patient's autonomy
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