Ethical issues in living organ donation: donor autonomy and beyond

Aaron Spital

Ethical issues in living organ donation: donor autonomy and beyond

Abstract
Despite nearly 50 years of experience with living kidney donation, ethical questions about this practice continue to haunt us today. In this editorial I will address two of them: (1) Given the possibility of limited understanding and coercion, how can we be sure that a person who offers to donate an organ is acting autonomously? and (2) Do people have a right to donate? The universal requirement for informed consent is the traditional method for ensuring that a person is acting autonomously. But, while obtaining fully informed consent is desirable, it may not always be achievable or necessary. When the recipient is very dear to the potential donor, the donor may base his decision primarily on care and concern rather than on a careful weighing of risks and benefits. I will argue that consent that emanates from such deep affection should be considered just as valid as consent that is fully informed. But consent is not enough. There is no absolute right to donate an organ. If there were such a right, then some physician would be obligated to remove an offered organ upon request, regardless of the risks involved. I do not believe that physicians have such an obligation. Physicians are moral agents who are responsible for their actions and for the welfare of their patients. Therefore, while the values and goals of the potential donor should be given great weight during the decision-making process, physicians may justifiably refuse to participate in living organ donation when they believe that the risks for the donor outweigh the benefits..


Spital A. Ethical issues in living organ donation: donor autonomy and beyond. Am J Kidney Dis. 2001 Jul;38(1):189-195.

(Correspondence) The abortion issue

Patrick G Coffey

Canadian Medical Association Journal, CMAJ
Canadian Medical Association Journal

Extract
Having read the well-written article by Laura Eggertson, I feel that her thrust (and that of Planned Parenthood, the Canadian Abortion Rights Action League, Health Minister Allan Rock, etc.) is that it is a scandal and surprise that a “medically necessary” operation — abortion — is not universally accepted like other procedures You do not hear most of the old debating arguments about abortion any more, but the one that will not go away concerns whether abortion is a medically necessary operation. . . .Abortion is both a moral and a medical issue, and we should not be surprised if people do not regard it as a necessary procedure in the same way they view other operations.


Coffey PG. (Correspondence) The abortion issue. Can Med Assoc J. 2001 Jul 10;165(1):14-15.

(Correspondence) The abortion issue

Will Johnston

Canadian Medical Association Journal, CMAJ
Canadian Medical Association Journal

Extract
Your homey analogy of abortion as a patchwork quilt — a warm, comforting and maternal object if ever there was one — furthers the dishonourable tradition of euphemizing the medicalized killing of small human beings. . . CMA members remain deeply divided on these issues. An even-handed editorial and reporting style would show respect for this diversity of opinion.


Johnston W. (Correspondence) The abortion issue. Can Med Assoc J. 2001 Jul 10;165(1):15.

Private Religious Hospitals: Limitations Upon Autonomous Moral Choices in Reproductive Medicine

William W Bassett

Journal of Contemporary Health Law and Policy
Journal of Contemporary Health Law and Policy

Extract
“Conscience clauses,” protecting the free exercise of religion in ethical decision-making by religiously affiliated hospitals, I believe, should continue to be absolute in reproductive medicine where the hospitals are clearly and unmistakably religious and patient choices of providers are free and fully informed. This conclusion is compelled by the free exercise clause of the First Amendment, as well as by the national interest in preserving and promoting diversity in the voluntary health care sector.


Bassett WW. Private Religious Hospitals: Limitations Upon Autonomous Moral Choices in Reproductive Medicine. J Contemp Health Law Policy. 2001;17:455-583.

Moving From Compliance to Conscience: Why We Can and Should Improve on the Ethics of Clinical Research

Jeffrey P Kahn

JAMA Internal Medicine
JAMA Internal Medicine

Abstract
. . . an emphasis on oversight and compliance misses the point. By overly focusing on making sure that rules are followed, we push researchers away from a real appreciation for issues and into doing whatever it takes to expedite the oversight process. This approach can cause researchers to quickly lose sight of the point of research protections – the rights and interests of the subjects themselves.


Kahn JP. Moving From Compliance to Conscience: Why We Can and Should Improve on the Ethics of Clinical Research. Arch Intern Med. 2001 Apr 09;161(7) 925-928.

Limiting Access to Medical Treatment in an Age of Medical Progress: Developing a Catholic Consensus: A Response from Jewish Tradition

Laurie Zoloth

Christian Bioethics
Christian Bioethics

Extract
The efforts of Christian colleagues to articulate a clear framework of specific Christian moral values to assess clinical treatments are a necessary contribution to the debates about justice and resource allocation in health care. Such efforts not only make clear the way in which all such judgement is located, understood and interpreted from a particular social venue and from a particular ethical stance; finding one’s moral location is the first task of critical theory and concomitant practice. The clinical epistemology required in medical resource allocation is framed by cultural and theological stance just as surely as any knowledge, and Christians must be fully responsible for making overt the often covert assumptions that undergird such work. I have been asked to respond to the Consensus Statement by Catholics as a Jewish ethicist.


Zoloth L. Limiting Access to Medical Treatment in an Age of Medical Progress: Developing a Catholic Consensus: A Response from Jewish Tradition. Christ Bioet. 2001 Jan 01;7(2):193-201.

Bioethics for clinicians: 20. Chinese bioethics

Kerry W Bowman, Edwin C Hui

Canadian Medical Association Journal, CMAJ
Canadian Medical Association Journal

Abstract
Many of the assumptions implicit in a Western autonomy-based approach to bioethical deliberation may not be shared by Chinese Canadians. In traditional Chinese culture, greater social and moral meaning rests in the interdependence of family and community, which overrides self-determination. Consequently, many Chinese may vest in family members the right to receive and disclose information, to make decisions and to organize patient care. Furthermore, interactions between Chinese patients and health care workers may be affected by important differences in values and goals and in the perception of the nature and meaning of illness. Acknowledging and negotiating these differences can lead to considerable improvement in communication and in the quality of care.


Bowman KW, Hui EC. Bioethics for clinicians: 20. Chinese bioethics. Can Med Assoc J. 2000;163(11):1481-1485.

The scope and limits of conscientious objection

Bernard M Dickens, Rebecca J Cook

International Journal of Gynecology & Obstetrics
International Journal of Gynecology & Obstetrics

Abstract
Principles of religious freedom protect physicians, nurses and others who refuse participation in medical procedures to which they hold conscientious objections. However, they cannot decline participation in procedures to save life or continuing health. Physicians who refuse to perform procedures on religious grounds must refer their patients to non-objecting practitioners. When physicians refuse to accept applicants as patients for procedures to which they object, governmental healthcare administrators must ensure that non-objecting providers are reasonably accessible. Nurses’ conscientious objections to participate directly in procedures they find religiously offensive should be accommodated, but nurses cannot object to giving patients indirect aid. Medical and nursing students cannot object to be educated about procedures in which they would not participate, but may object to having to perform them under supervision. Hospitals cannot usually claim an institutional conscientious objection, nor discriminate against potential staff applicants who would not object to participation in particular procedures.


Dickens BM, Cook RJ. The scope and limits of conscientious objection. Int J Gyn Ob. 2000;71(1):71-77.

The First Ten Principles for the Ethical Administration of Nursing Services

Leah L Curtin

Nursing Administration Quarterly
Nursing Administration Quarterly

Abstract
At the dawn of the 20th century, postmodern academics stressed the cultural differences among human beings. Philosophers predicated differing value systems based on these cultural differences, and conflicts have arisen among those who hold distinctly different religious traditions. Many people believe there can be no universal system to explain reality and thus form the basis for norms in human behavior. However, at the close of the 20th century scientists and philosophers had come full circle: physics quite literally became metaphysics, and ethical systems made sense. Rush Kidder interviewed two dozen “men and women of good conscience” from around the world and asked them if there is a single set of values that wise people use to make decisions. They answered with a resounding YES! Thus, in addition to the customary principles of beneficence, nonmalfeasance, honesty, and so forth, the author proposes a set of ethical principles based on those universal values, adapted to fit nursing administrators’ dual responsibilities. Ethical decision making and behavior, the author contends, help to reconcile perspectives and interests and to keep values and mission uppermost in one’s mind. In the process, ethical behavior establishes long-term relations of trust and cooperation, which in turn promote consistency and stability in an unstable world..


Curtin LL. The First Ten Principles for the Ethical Administration of Nursing Services. Nurs Adm Q. 2000 Fall;25(1):7-13.

Informed Consent for Emergency Contraception: Variability in Hospital Care of Rape Victims

Steven S Smugar, Bernadette J Spina, Jon F Merz

American Journal of Public Health
American Journal of Public Health

Abstract
There is growing concern that rape victims are not provided with emergency contraceptives in many hospital emergency rooms, particularly in Catholic hospitals. In a small pilot study, we examined policies and practices relating to providing information, prescriptions, and pregnancy prophylaxis in emergency rooms. We held structured telephone interviews with emergency department personnel in 5K large urban hospitals, including 28 Catholic hospitals from across the United States. Our results showed that some Catholic hospitals have policies that prohibit the discussion of emergency contraceptives with rape victims, and in some of these hospitals, a victim would learn about the treatment only by asking. Such policies and practices are contrary to Catholic teaching. More seriously, they undermine a victim’s right to information about her treatment options and jeopardize physicians’ fiduciary responsibility to act in their patients’ best interests. We suggest that institutions must reevaluate their restrictive policies. If they fail to do so, we believe that state legislation requirng hospitals to meet the standard of care for treatment of rape victims is appropriate.


Smugar SS, Bernadette J Spina BA, Jon F Merz JD. Informed Consent for Emergency Contraception: Variability in Hospital Care of Rape Victims. Am J Public Health. 2000 Sep;90(9):1372-1376.