Displaying 1-10 letters out of 381 published
Censorship of media and scholarly debates and avoiding collateral damage to public confidence in organ donation
We read with great interest Daoust and Racine's contribution to the ongoing debate about brain death and its ethical and medical implications . The authors argue that little is known about how the public understands the concept of death determined by neurological criteria (DNC). They set out to trace common sources of public confusion about DNC and seek to "better define the relationship between expert and lay views of death". We wish to comment on the issue of whether or not public confusion "reflects public confusion in the media or perhaps a more profound insight into the nature of academic debates among experts". Although the authors recognize that "recent critiques have made any clear meaning of DNC more challenging and even counterintuitive", they position themselves, with no further explanation, on one side of the debate by stating that "landmark contributions and guidelines of professional societies have brought clarity and credence to the standard definition of DNC". With that, they imply that current determination of death and organ transplantation practices are rigorous and that media coverage distorts the actual process of declaring a person dead based on neurological criteria.
The two premises-- that the standard of DNC has clarity and credence and that producing a clear meaning of DNC is both challenging and counterintuitive-- are logically irreconcilable. The authors, nevertheless, conclude that all discussions in the media and with patient- families should "reinforce the genuine nature of neurological determination of death as a criterion to establish death...". Either (a) the philosophical rationale proposed in the President's Council on Bioethics "White Paper"  seeking to validate the concept of DNC, and the criteria and tests for determining DNC outlined in the guidelines by professional societies, definitively settled the issue, or (b) the critics have been raising legitimate concerns and have successfully challenged the validity of this concept. Regarding the President's Council of Bioethics' philosophical validation of DNC, the debate is ongoing and indeed has intensified [3-5]. In regard to professional societies' guidelines, the American Academy of Neurology has assigned level "U" (i.e., unknown, conflicting or insufficient evidence) to several recommendations in the DNC . Generally, for clinical practice guidelines to be trustworthy, the Institute of Medicine requires the recommendations to be supported by a much higher level of evidence than "U" .
The authors also mention that some articles refer to the brain-dead patient as being "kept alive" by artificial methods rather than as being dead. Yet this brings out the fact that it is odd to declare an individual with functioning circulation and respiration (in the sense of cellular exchange of oxygen and carbon dioxide-- ventilator-dependence is irrelevant to the issue of whether a person is alive or dead) dead as is done in brain-dead patients. Even though the authors ostensibly acknowledge the academic debate about the validity of brain-death criteria, de facto they ignore it, claiming (though not arguing) that both discussions between the patient's family (note the use of the word "patient," which does not make sense if the patient is dead) and information shared with the general public should reflect the view that brain death criteria are "genuine". Therefore, Daoust and Racine's recommendation to reinforce the genuine nature of neurological determination of death is not only premature but, if followed through, would deprive the public of informed decision making about organ donation following DNC. More importantly, merely repeating the claim that brain- death criteria are "genuine" does not make them so.
Maintaining the professional integrity of medicine and public trust is a responsibility shared by the global medical community. This responsibility demands honesty, truthfulness and transparency with the general public regarding healthcare issues (e.g., organ donation at the end of life). Daoust and Racine report that critics of DNC have argued that DNC "merely represents a convenient 'redefinition' of death solely for the purpose of transplant medicine." Many in the medical community would agree with the critics. After several decades, the cumulative clinical experience with many kinds of brain-dead patients over decades, combined with logic has disproved the neurologic criterion of death. Persistent denial of caveats that donors are not certainly dead may be leading to grievously unethical medical practice namely: (1) the lack of truly informed consent in the donation process, (2) the strategic campaign of rhetoric, partial information, and misinformation designed to induce people to check the donor box on drivers licenses and to induce families to authorize donation from a "brain-dead" loved one, (3) the nondisclosure of financial conflict of interest on the part of organ procurement representatives whose job is to convince grieving families to donate.
The media have been fulfilling their primary duties of disclosing to the general public scientific, ethical and cultural controversies about neurologic criteria [8,9]. The conclusion of Daoust and Racine that "public discussions should reinforce the genuine nature of neurological determination of death as a criterion to establish death" and "scholarly debates need to be contextualized to avoid undue collateral damage to public confidence in DNC and organ donation practices" can also be construed as a call for censorship of media and suppression of scholarly debates. Costas-Lombardia and Castiel have criticized the control of information in Spain by the transplantation industry: "disinformation of society is an indispensable condition for the success of the 'Spanish Model'" . Organ procurement and transplantation practice generate billions of dollars in a commodified US health care system annually . The call for control of media and scholarly debates to avoid collateral damage to organ transplantation practice may indeed violate public trust in the medical profession and the First Amendment of the United States Constitution.
Michael Potts, Ph.D., Department of Philosophy, Methodist University, Fayetteville, North Carolina, USA
Joseph L. Verheijde, PhD, MBA, PT, Department Physical Medicine and Rehabilitation, Mayo Clinic, Phoenix, Arizona, USA
David W. Evans, MA, MD, FRCP, Queens' College, Cambridge, UK
Mohamed Y. Rady, MB BChir MA MD (Cantab), Department of Critical Care Medicine, Mayo Clinic Hospital, Phoenix, Arizona, USA
D. Alan Shewmon, MD Olive View-UCLA Medical Center, Sylmar, CA, USA
1. Daoust A, Racine E. Depictions of 'brain death' in the media: medical and ethical implications. J Med Ethics.2013:Published Online First: 12 April 2013 doi:2010.1136/medethics-2012-101260
2. The President's Council on Bioethics. Controversies in the determination of death. A White Paper of the President's Council on Bioethics. 2008; http://bioethics.georgetown.edu/pcbe/reports/death/. Accessed 10 April 2013.
3. Shewmon A. Brain Death: Can It Be Resuscitated? Hastings Cent Rep.2009; 39(2):18-23.
4. Joffe AR. Brain death is not death: a critique of the concept, criterion, and tests of brain death. Rev. Neurosci.2009; 20(3-4):187-198.
5. Nair-Collins M. "Brain Death, Paternalism, and the Language of "Death"." Kennedy Inst Ethics J.2013; 23(1):53-104.
6. Wijdicks EF, Varelas PN, Gronseth GS, Greer DM. Evidence-based guideline update: Determining brain death in adults: Report of the Quality Standards Subcommittee of the American Academy of Neurology. Neurology.2010; 74(23):1911-1918.
7. Institute of Medicine (IOM) -National Academy of Sciences. Clinical Practice Guidelines We Can Trust. 2011; http://www.nap.edu/openbook.php?record_id=13058. Accessed 10 April, 2013.
8. Rady MY, McGregor JL, Verheijde JL. Mass media campaigns and organ donation: managing conflicting messages and interests. Med Health Care Philos.2012; 15(2 ):229-241.
9. Rady M, McGregor J, Verheijde J. Transparency and accountability in mass media campaigns about organ donation: a response to Morgan and Feeley. Med Health Care Philos.2013:Published online: 25 January 2013. DOI 2010.1007/s11019-11013-19466-11014.
10. Costas-Lombardia E, Fereres Castiel J. The Easy Success of the Spanish Model for Organ Transplantation. Artif Organs.2011; 35(9):835-837.
11. Bentley TS, Hanson SG, Hauboldt RH. Milliman Research Report. 2011 U.S. organ and tissue transplant cost estimates and discussion. 2012; http://publications.milliman.com/research/health-rr/pdfs/2011-us-organ- tissue.pdf. Accessed April 1, 2013.
Conflict of Interest:
Beyond the half-truths about placebos and placebo effects
We would like to thank Professor Stewart Justman for his thoughtful paper "Placebo: the lie that comes true", in which he highlights the often neglected deception in research on placebos and points out the potential harms related to half-truths or exaggerated claims about the "power of the placebo" (1). We agree strongly with his conclusion that "it is necessary to root the placebo effect in the attentive practice of medicine itself". We also agree with his other conclusion that the "appropriate response to this dilemma is first of all to consider the placebo effect as a therapeutic benefit arising from the conscientious performance of the rituals of good medicine, and not as a resource to be tapped by the use of trickery (with equivocations counting as trickery) or dispensed in the form of pills."
As Justman also remarks, much of the confusion related to placebos and placebo effects is related to the ambiguous nature and many understandings of these concepts. We'd like to develop this point further and repeat our earlier suggestion to replace the ambiguous "placebo effect" with a new term "care effect" in the clinical context (2). In the research context, the term "placebo effect" could be replaced by the expression "the effect in the control group" when the outcome of the research is discussed. The equivocal concept "impure placebo" confuses more than it clarifies and should be abandoned totally. If a method of treatment is ineffective in its own right, it should be called an ineffective treatment for a particular patient or problem.
References: 1. Justman S. Placebo: the lie that comes true. J Med Ethics 2013;39:243- 248. 2. Louhiala P, Puustinen R. Rethinking the placebo effect. J Med Ethics; Medical Humanities 2008;34:107-109.
Authors: Pekka Louhiala, Hjelt Institute, University of Helsinki, Finland, firstname.lastname@example.org Raimo Puustinen, Medical School, University of Tampere, Finland, email@example.com
Conflict of Interest:
Do Bioconservatives Really Have an "Untenable Ambiguity" Regarding Human Perfectibility?For full disclosure, I should begin by saying that I read this paper because I am personally acquainted with one of the authors, Johann Roduit, with whom I had a brief exchange about the paper and who encouraged me to submit my few critical thoughts to this site. Also, I should say that I am not an expert in bioethics, but simply an interested layman.
As a layman, I read the paper with pleasure. The thoughts were clearly articulated, and I learned something about the current debate within this particular field of ethics. The paper does a good job at laying out the respective positions of bioconservatives and bioliberals and pointing out "the crucial question of the ultimate goals of biotechnological interventions."
In our exchange about the paper, Mr. Roduit told me that his main criticism is directed against people who "refuse to speak of an ideal at all," although they "cannot avoid having an ideal influencing the way they wish to enhance." This point is well taken, but in my view, the paper goes too far in charging bioconservatives with an "untenable ambiguity between criticising and endorsing ideas of human perfection" (p. 1). I am also inclined to think that the paper goes too far in charging bioliberals with an "unconvincing" denial of the relevance of perfection, but here I will restrict my comments on the criticism of bioconservatives.
Of course, the authors of the paper are right that anyone who makes any kind of proposition in regard to human behavior has some kind of ideal in mind. Otherwise the person would not make a proposition at all. People who say that everyone should do as they please have the ideal of individual autonomy in mind. People who say that human perfectibility is not desirable thereby say that another human state is more desirable and hence, in a certain sense, more perfect.
But this observation, as true as it is, seems to me little more than a tautology. It says little more than, "People who make a normative statement, no matter of what kind, have a certain norm in mind." Naturally. But does that merit the charge that certain bioconservatives have an "untenable ambiguity" in regard to human perfectibility? I doubt it.
To make clearer why I doubt the merit of this charge, let me use a few examples from other fields. Take political philosophy, for instance. According to the thinking of the paper, one may charge Machiavelli's realpolitik with the same kind of "untenable ambiguity" as the authors charge bioconservatives, because Machiavelli makes the prescriptive (=idealistic) statement that a ruler should not be too idealistic but rather use whatever methods work to maintain order and keep society running in a reasonably safe state. One could then take the criticism of Machiavelli's ambiguity further and claim that his Prince is really just as idealistic as Plato's Philosopher-King, because he makes just as many normative statements about him as Plato does about his explicitly ideal ruler. Therefore, one might say, Machiavelli should bring his implicit idealism into the light of explicit discussion instead of pretending that he is abandoning the political idealism of the likes of Plato.
However, to my mind, such a charge is more sophistic than helpful and blurs the very important distinction between the idealism of Plato's Philosopher-King and the realpolitik of Machiavelli's Prince. Plato is clearly an idealist, and Machiavelli is clearly a realist, and making normative statements about being flexibly realistic does not turn him into an idealist.
To give another example, this time from the earliest literature we possess, which already deals with the big themes of the human condition and the ideal human life, let us take the Epic of Gilgamesh. Gilgamesh, an ancient king of Uruk (modern-day Iraq), loses his best friend and realizes that he, too, shall one day die. Hence, he goes on a quest to find immortality, but in vain. Not only does he learn that immortality is reserved for the one couple that survived the Great Flood in a boat, because it was a unique situation that led the gods to bestow immortality on them, but the rejuvenating Plant of Life is also stolen from Gilgamesh by a serpent. Gilgamesh therefore has to accept his mortality, and he proceeds to engage in great building projects in order to make a lasting name for himself in that way.
The Epic of Gilgamesh seems to make the point that, in order for a human to flourish, he or she needs to accept their mortality. In other words, the story can be said to set up a kind of ideal of what the good life is, but at the same time the story conveys the strong message that the good human life is far from perfect. "Ideal under the very imperfect circumstances" is not the same as perfection.
To give third and last example, the Greeks were instructed to "know thyself," that is, to know the limits of the human condition, and this self-knowledge can be said to have been an ideal. But the ideal consisted precisely in the acknowledgment that, under the circumstances, humans are not and can never be perfect.
In my view, it would be confusing to say that recognizing the existence of imperfection as a precondition for many good things is to erect another standard of perfection, as the paper seems to charge certain bioconservatives with doing. It is not another standard of perfection but simply the recognition that certain good things hinge on the existence of imperfection.
That's the two cents from a layman for now, written with much ignorance about the details of today's bioethical debate.
Conflict of Interest:
Re:"Ahsan v University Hospitals Leicester NHS Trust" does not legitimize antemortem organ preservation in end-of-life care.
I am grateful for the response to my paper.
For clarity's sake, however, I would like to point out in reply that I do not cite Ahsan to 'legitimize' any claim. Rather I present it as legal authority for a claim about legal principle. The principle is clear, though the respondents to my paper seem not to understand it quite.
I would therefore emphasise that the idea of best interests applies to patients individually, and thus necessarily varies from patient to patient. I do not for a moment consider that best interests supports the measures discussed in the paper for all patients; rather I suggest that it does so in some cases.
The respondents to my paper seem to suggest that a preponderance of relgious opinion renders my interpretation of the law impossible.
Their argument rests on a fundamental failure to appreciate that the law respects a plurality of distinct values. Many systems of beliefs are respected.
It would not be true that it would be in everyone's best interests, as that idea is understood in English law, to become organ donors. But it is wrong to suggest that this means that it can be in no-one's best interests.
Conflict of Interest:
Acceptable Murder, Excusable Conscience.
I find it difficult to believe that this article was written by thoughtful, intelligent persons who participate in our society on any level.
as an argument in logic, this article hangs together with the "abortion which would be sought before the fetus was born with abnormalities, makes it natural to seek after-birth abortion." Apart from the logic of that argument, the article is a desire to allow excusable murder into our society
Abortion, in itself, is the killing of persons who would contribute to society, no matter what their level of intellect or physical ability and form. Murdering infants after they are born is just that - murder. Others would like to hide behind titles such as "after-birth abortion" or "euthanasia" but it is murder, just the same. Yes, raising a child with any type of disability is a huge responsibility and puts tremendous burdens on parents but that does not give parents the right to only choose who they deem to be "acceptable" and "worthy" of living. The real argument put forth in this article is whether or not people should be "forced to endure hardship" (hardship as defined by the authors - raising children with deformities and/or other abnormalities). The article presented would at least have some shred of dignity due to the honesty or the authors. Trying to clean up their immoral and heinous thoughts makes this article a travesty of any professional in the medical field.
Conflict of Interest:
What's wrong about "what makes killing wrong?"
In a recent article by Walter Sinnott-Armstrong and Franklin G. Miller, the argument is made that ability should be the metric of value among human life and thus the determining factor on what constitutes moral harm when killing. Someone who has permanently lost all abilities no longer has value and killing them would not only fail to add more harm and it would also fail to take away any more value.
In the authors' case, to say that "Betty is not worse of dead" is to presume knowledge about death. It's taken for granted what the authors believe about death is true: a descent into non-existence and nothingness. However, we cannot say whether it is better to become nothing than to be conscious and totally and irreversibly disabled mainly because we have experienced neither, and we have no ability to comprehend what it would be like to "be nothing" (a contradictory phrase, but one that captures the farce in making the claim that someone is "not worse off dead" if one presupposes nothing after death). I certainly don't believe that we descend into nothingness when we die, and indeed the things that happen after we die could be much worse than our present life, but I'm only using the authors' own views to determine that they aren't justified to say that Betty is not worse off dead; even if she were, it would be a matter of personal preference toward either nothingness or total and irreversible disability.
Furthermore, the authors divorce morality from truth when they say "one advantage of this position is that it simplifies the structure of morality." Either that which is most simple is always true, or else morality and truth have no relationship and we pursue that which is most useful to us, regardless of its veracity. Why should simplicity win on the merit of simplicity alone? The authors identify the simplification of morality as an advantage of this perspective, regardless of whether that simplification is born out of truth: is it actually true that it is wrong to kill a universally and irreversibly disabled person? The truth, it seems, doesn't matter as much as the simplicity of the moral system.
The authors also assume that it is worse to cause a person to be deaf and blind rather than only blind. However, this begs the question, for this is only worse in their system of morality in which abilities are the metric of value. In that system, it makes sense that it is worse to deprive a person of two abilities rather than one. However, in other systems, depriving a person of any abilities ("without adequate reason") reaches maximum heinousness and to add increasing quantities of ability deprivation to that doesn't make it any more wrong, but only more tragic. The authors' example here, then, isn't helpful to them because it assumes the system of value they're trying to establish.
The rebuttal to the objection regarding God's commandment is superficial. First, it assumes that the strength of God's commandment is in the reason that justifies his commandment and not the command itself. This is not evidenced throughout Judeo-Christian theology, the theology that I would be prepared to assert and defend; instead, God should be obeyed because he is God. This is why Lot's wife was turned into a pillar of salt: because she disobeyed God. It doesn't matter what God's reasons were for commanding her not to look back on the destruction of Sodom and Gomorrah. What matters is that he commanded it at all and his commands are self-justifying because he is God. This leads us into a discussion regarding the sovereignty of God and epistemology, which isn't the main topic at hand, but suffice it to say that the authors dismiss this objection without actually rebutting it.
The authors go on to further establish, in their rebuttal of the anticipated objection by secular theorists, how they are begging the question in their argument. The main question of their paper may be, "Why is life valuable in this extreme case when it includes no ability?" They're trying to show in their argument that killing people in this state is not wrong because lack of ability constitutes total loss of value. To dismiss this objection by assuming that the metric of value is ability is to beg the question in the rebuttal.
They reduce moral theory to a matter of preference when they write, "these arguments will have no force at all for those of us who prefer our moral theories to be independent of religion." Therefore, it doesn't matter what is actually true; what matters is what one prefers. They further support this idea by stating that it is problematic to depend on religious belief in philosophical theory as well as public policy. They imply that what is good is an agreeable solution for all, even if that means that the agreeable solution isn't what's actually true. Is this right or even good? Unfortunately that small question alone is irrelevant to those who do not care about what's right but instead only what serves their preferences! Thus this discussion cannot even begin until we deal with moral relativism, a discussion unto itself.
They go on to nearly refute their entire argument when addressing concerns regarding whether using ability as the metric of value would lead to the assignment of variable values to humans with non-zero quantities of ability.
For their first response regarding possession of abilities greater than plants, why would that be the case? Why plants in particular? If one is going to hold the "minimal ability threshold" stance, does that mean a human with, say, one ability is equivalent to a chimpanzee with one ability? Indeed, under this view, why aren't chimpanzees and humans equivalent, or any non-plant life? The authors fail to flesh out this rebuttal to make it consistent with the rest of their argument. Furthermore, they establish earlier in their argument that if it is wrong to remove one ability, it is more wrong to remove two, and maximally wrong (indeed, equivalent to murder) to totally and irreversibly disable someone. Their argument cannot be paired with this objection because this objection assumes that abilities do not have individual value but only the trait of "ability possession" (in which a person may only possess one ability) is what actually grants value.
Their second response (that it would be morally wrong to treat people differently based on their different abilities) does a good job of overturning the argument for which the paper was written. Are we not treating the totally and irreversibly disabled person differently based on their lack of ability? Yet the authors argue that one could rebut the aforementioned objections by declaring that it's wrong to do just that.
The third response is antiquated: quality- and disability-adjusted life years (QALYs and DALYs) are already used to compare people with different disabilities and sets of abilities. This is not a perfect system, but it's what's being used for any number of purposes now. If one is going to respond in this way, one would have to make the point of doing away with QALYs and DALYs.
The fourth response is essentially what the authors are doing in this paper. They're insisting that ability should be the metric of value, yet they haven't established why that should be the case and they've done a poor job of dealing with the anticipated objections. Indeed, if ability is the metric of value, then a myriad of questions are raised that the authors don't address: for someone who is reversibly disabled, how many abilities must they recover to gain value again and thus pull themselves from the chopping block? What if they can follow simple commands? Write their name? Speak? Maintain urinary and bowel continence? Do abilities differ in value, as this would become a real concern in determining whether to harvest someone's organs? If not, would it be accurate to say all who are disabled at all are equally disabled?
The fifth and final response is essentially selling the agenda; somehow get people to believe that what is wrong isn't that wrong, or what is wrong is actually good. When variable value is assigned to humans, such that some are worth less than others, that is the stuff out of which tyrannies, discrimination, eugenics and persecution are made. It is not hyperbole to indicate this because that is precisely the philosophy of historical figures like Adolf Hitler: some people were worth more than others during the Third Reich and some people were worth so little and so detrimental to society that they were better off exterminated. This, of course, is the extreme conclusion of the authors' argument, but the authors' argument sets the precedent for it; it paves the way for other arguments to march, one step at a time, toward that conclusion.
In stating that it is bad to shorten life and thus worse to shorten it more in killing younger or healthier individuals, the authors assume that quantity is what gives life value; in this particular point, not just quantity of abilities, but quantity of years left to live. They neglect the possibility that life, regardless of the quantity remaining, maintains maximum value until death. An analogy would be currency: whether you have $1000 or $1, a dollar is still worth a dollar (putting aside inflation and other economic confounders). Thus, as you spend your money, your money doesn't lose value. By the time you're down to your last dollar, it's not worth $0.10 or some other amount; it's still worth a dollar. The subjective value of that dollar to its owner may be greater (it becomes more precious to its owner because the owner does not have the other $999), but the objective worth of it is still one. If anything, as life shortens, it becomes more precious (particularly for the atheist, who believes that this is all we get!), so it may be more wrong kill people with less time left to live.
In discussing violations of the dead donor rule, the authors miss the mark in clearly establishing what death is. Brain death is merely a surrogate marker for determining death proper. What we actually care about is whether the organism itself, the person, is dead. We use brain death as a marker for the organism's inability to maintain cohesion of its various systems to the benefit of itself. According to Maureen Condic, a neurobiologist at the Universty of Utah, when an organism can no longer "act in a coordinated manner for the continued health and maintenance of the body as a whole," it's considered dead (Condic, M. Life: Defining the Beginning by the End. First Things. 2003). This appears to be the most intuitive, holistic definition of death. The reason why we look for brain death is because we care whether we're using machines to artificially prolong the survival of an organism that can no longer perform this fundamental function; it is not strictly to determine whether higher-order brain function is lost. Thus Condic explains:
"It is often asserted that the relevant feature of brain death is not the loss of integrated bodily function, but rather the loss of higher- order brain activities, including consciousness. However, this view does not reflect the current legal understanding of death. The inadequacy of equating death with the loss of cognitive function can be seen by considering the difference between brain death and "persistent vegetative state" or irreversible coma. Individuals who have entered a persistent vegetative state due to injury or disease have lost all higher brain functions and are incapable of consciousness. Nonetheless, integrated bodily function is maintained in these patients due to the continued activity of lower-order brain centers. Although such patients are clearly in a lamentable medical state, they are also clearly alive; converting such patients into corpses requires some form of euthanasia."
Therefore if one is brain dead, one is properly dead because brain death is a marker for the organism's permanent inability to coordinate the maintenance of all its various sub-systems into a cohesive whole. The authors' ignore the implication that brain death is being used as a surrogate marker for the death of the organism in light of the fact that we can use machines to keep the cellular processes of the organism going without the organism ever being able to recover its coordinated manner by which it sustains its life. To procure organs from these individuals is not a violation of the dead donor rule; they're dead.
They raise a second example in which they believe the dead donor rule is violated, yet they fail to point out that the decision has been made to not resuscitate these individuals, just like anyone else with a "do not attempt resuscitation" order in their chart. Obviously it's philosophically inconsistent if a patient goes through vital organ donation but has an advanced directive still in place to attempt resuscitation. Irreversibility isn't included in the legal definition of death because plenty of people who die could be resuscitated but are not because of their advanced directive, yet we still declare them dead when they enter into that state because we will not prevent them from naturally progressing to the point at which their body loses the capacity to maintain cohesion amongst its sub-systems.
Interestingly, Dr. Miller co-authored a paper in the New England Journal of Medicine on the topic of the dead donor rule, and a point was made that seems to stand contrary to the central argument of the article in question (Truog and Miller. The Dead Donor Rule and Organ Transplantation. 2008. NEJM):
"At the dawn of organ transplantation, the dead donor rule was accepted as an ethical premise that did not require reflection or justification, presumably because it appeared to be necessary as a safeguard against the unethical removal of vital organs from vulnerable patients. In retrospect, however, it appears that reliance on the dead donor rule has greater potential to undermine trust in the transplantation enterprise than to preserve it. At worst, this ongoing reliance suggests that the medical profession has been gerrymandering the definition of death to carefully conform with conditions that are most favorable for transplantation. At best, the rule has provided misleading ethical cover that cannot withstand careful scrutiny. A better approach to procuring vital organs while protecting vulnerable patients against abuse would be to emphasize the importance of obtaining valid informed consent for organ donation from patients or surrogates before the withdrawal of life- sustaining treatment in situations of devastating and irreversible neurologic injury."
The question, it seems, is irrelevant as long as strict adherence to informed consent and the advanced directive of the patient (if present) is upheld. Those are our guiding principles in choosing to withdraw aggressive care, whether it be from the patient with multi-organ failure in the intensive care unit or the patient with metastatic cancer in the outpatient setting who just wants to live his last two weeks free from the burden of chemotherapy and other aggressive interventions. The valid concern is that organs would begin to be harvested from people who have reasonable chances of survival or are not even in imminent danger of death. Yet we seem to navigate this labyrinth fairly well when patients or their families request a cessation of aggressive care apart from concerns of organ transplantation; the additional piece that must be added to it in matters of transplantation is the avoidance of euthanasia and physician- assisted suicide, the ethics of which will not be discussed here, but for the sake of this discussion I take for granted as wrong. I suspect it would be very difficult to determine a general rule that could apply to all cases, but that each patient must be approached individually.
Interestingly, Dr. Truog and Dr. Miller identify that, at worst, "this ongoing reliance [on the dead donor rule] suggests that the medical profession has been gerrymandering the definition of death to carefully conform with conditions that are most favorable for transplantation." It seems that is exactly what is being done in this paper Dr. Sinnott- Armstrong and Dr. Miller have submitted to the Journal of Medical Ethics and the applications reach beyond the field of transplantation. The authors are trying to figure a way to broaden the population that would be available to donate their organs. With the precedent set, each following step becomes easier to take and before long we really are harvesting organs from people who are in no imminent danger of death. Indeed, the reductio ad absurdum would be the harvesting of organs from individuals who are disabled in some capacity and do not even want their organs harvested. The authors attempt to stave off this objection by stating, "We can hold the line for vital organ donation by continuing to restrict it to those in a state of total (universal and irreversible) disability. It is only these donors who would not be harmed or wronged by vital organ donation, since all other donors have abilities to lose." Yet they are not holding the current line (i.e., the dead donor rule). So the line is moved this time and, perhaps even after the authors themselves are dead, still others will desire to move the line and will make arguments in favor of it. And another argument will be made to move the line further. This is the power of precedent setting. Why should we trust those who move the line to hold the line?
"What makes killing wrong" is a transparent attempt to do what Dr. Miller denounces in his paper in the New England Journal of Medicine: "gerrymander the definition of death," or in this case, gerrymander those circumstances about which one might be declared suitable for transplantation. The scope of this argument extends beyond organ transplantation, however, and into the broader world of medicine. If adopted, this view would color for the worse how we perceive the weak, the sick, the aged and the unborn.
Conflict of Interest:
Who are you?
The proposal of the so-called post-birth abortion, in the article by Giubilini and Minerva, is astonishing but not surprising. As the journal editor pointed out, this issue has been largely discussed in the past, after it was formally advocated for the first time by Prof. Michael Toolan in 1972.
The option of killing the human fetus has been part of medical practice in most western countries over the past decades. As we agree with the authors that no substantial difference is present in the individual before and after birth, we recognize that killing babies 'after birth' only increases the total number of individuals being eliminated, but not the matter at stake. The authors are well aware of this, and conclude that since abortion is commonly permitted, even infanticide should be.
Our question for the authors is, who would be entitled to decree the death of an infant or any individual who 'might be an unbearable burden on the family and on society' (line 1, page 2) or is anybody at all entitled to make such a decision?
No one of us decided to be born, when to be born and where to be born, it happened in a specific time in history, in a precise geographical place, and in a family we did not choose. We are indeed confronted with an unavoidable question, who decided of our existence and who called us to existence? The fact of our own birth and our own life brings about, whether we like it or not, that we are not 'in charge' of our life and even less of the life of others. Life is given to us.
A famous Italian writer, Cesare Pavese, notes in his diary, after he had obtained the most highly prized Italian literary award, "You also have the gift of fertility. You are the master of yourself, of your fate ... yet all that will come to an end. This profound joy of yours, this glow of super-abundance, is made of things you did not take into account. It was given to you. By whom? Whom should you thank? Whom will you curse when it all disappears?" (*) The 'I', the human being, is that level of nature in which nature becomes aware of 'being made' and of 'not being made by itself', therefore this existential observation implies the presence of a mysterious relationship, what people historically call 'god'.
Thus, we hold that each individual has an untouchable value exactly in virtue of this mysterious relationship and no one, whether the person itself, the family and nevertheless the physician should be entitled to end their life.
Moreover, we argue that, since medicine was started in human history in order to heal illnesses, alleviate suffering and comfort patients, the answer to a present or future disability or to parents' anxiety should not be death but solidarity.
We propose that any patient, whether aware or unaware, capable or incapable, young or old, potentially disabled or chronically ill, even when incurable, holds an unconditional value and therefore should be object of profound respect and care.
(*) Cesare Pavese, The Burning Brand: Diaries 1935-1950, translated by A.E. Murch (New York: Walker & Company, 1961), 345
Conflict of Interest:
AS REGARDS THE ARTICLE ABOUT AFTER-BIRTH ABORTION
Giubilini and Minerva, in their article "After-birth abortion: why should the baby live?", have been trying to justify the moral legitimacy of the infanticide posing well-known theories in bioethics and bringing out the analogy with abortion. Such intention has raised reactions of protest and disagreement coming from different sides. Criticisms have been sometimes uttered in the deprecable forms of threats and insults, which is surely not suitable to rational confrontation and scientific research. However if we reckon that the civilization and justice rate of a society can be measured in the way its children are treated and welcomed, this bewilderment, in its peaceful statements, is significant and can be shared and vindicated through considered judgments and rational argumentation. In fact the "children" of a society, being totally helpless and vulnerable, need someone who, especially in the first days of life, takes care of them so that they can survive. Consequently the way they are treated becomes paradigmatic because it represents a precious index to understand in what extent a society respects human beings in every phase of their existence, since every man is first of all "child". Anyway, referring to the article at issue it is noteworthy to recall Michael Tooley and Peter Singer?s well-known contributions. Although they were the first to advocate the moral legitimacy of infanticide in bioethics, a twofold originality is ascribable to the two Italian authors in facing this issue. On the one hand, although admitting its contradictoriness, they have coined a new term i.e. "after-birth abortion" to distinguish the action they attempt to legitimate from infanticide. The term is actually an oxymoron, because for "abortion" we understand an interruption of pregnancy and consequently it is easy to understand that we cannot talk of "abortion" in the case of a newborn. Notwithstanding it is still to prove if the action defined "after-birth abortion" is really a different practice than infanticide or if it is just a linguistic legerdemain to legitimate an old discriminatory one. On the other hand they structure their argumentation maintaining that if the baby is "unwelcome" after-birth abortion would represents a better solution compared to a possible baby's adoption - albeit this assertion seems to be confirmed by psychological studies, it certainly needs to be discussed again. However these two new elements have as their premiss a functionalist concept of person, not at all new. According to this notion a person can be considered such and consequently a moral subject having right to life, only when he/she is able to recognize some sort of value to life that would lead him/her to perceive the own existence deprivation as a loss. Only by beginning with a similar concept - which is clearly restrictive of human being - they can argue, with a coherence that has to be unquestionably acknowledged, the legitimacy of abortion before and after birth and lean toward the killing the baby instead of the possibility of adoption. Nevertheless before considering the conclusions it is interesting to analyze how Giubilini e Minerva develop their argumentation and to value its foundation. The article begins giving for granted that voluntary abortion is a morally acceptable practice since if carried out under certain conditions it is legally allowed in many countries. Fortified by this concept, the two authors don?t waste a word to argue the legitimacy of voluntary interruption of pregnancy. They should have at least partially explained the notion, since it is the premiss from which their following argumentation is structured. Beginning with the observation that abortion can be justified when a baby's birth can cause physical or psychical impairments to a woman, the two authors wonder if these factors, remaining undetected until the delivery, can be equally valid to justify killing a baby once he/she is born. The cases they cite as an example are those in which some delivery complications intervened, from not diagnosed pathologies to the ones not diagnosable before the delivery, from changes of both sentimental and economic situation of the parents, who will condemn them to be responsible of "an unbearable burden" they are not able to carry: the offspring in a not desirable condition. Their answer is affirmative: a child can be killed both before and after his/her birth as he/she is not a person yet, but just a potential person who is not able neither to attach value to his/her own life (being unaware of it), nor to express desires nor to make plans for the future. In this way the analogy between abortion and what they name "after-birth abortion" is easily accepted as valid in order to legitimate the second term of the same analogy according to a sort of "transitive property". Often analogies entail the risk to stress common elements of the compared terms, hiding those aspects which differentiate the two categories. Instead in this case the analogy is perfectly structured. However if we question the concept of person at the bottom of their reasoning and consider it in the most proper manner, this analogy cannot lead us but to the diametrically opposed conclusion. In fact it is not difficult to find also among the argumentations of those who deem abortion as illegitimate, the reasoning which stresses the similarities between abortion and infanticide, taking into account that the letter is an action considered shameful by most people. Nevertheless Giubilini and Minerva's article is basically coherent in its reasoning, except for some details. Yet it is based on a notion of person that has to be necessarily discussed if we want to analyze the conclusions to which it leads with intellectual honesty. The definition of person proposed by the two authors has to be rejected not because of a "bottom option" which on the contrary would aim at protecting every person they consider potential, but because it is not able to catch in every possible facet what is specific of the human person. In fact a person is such because needs time to develop, i.e. needs some conditions to express at its fullness the qualities and abilities recognized and empathized by the two authors as necessary to acknowledge the right to life to an individual. The ability to be self-aware, to relate to others, to communicate through a language, to make plans for the future are surely qualities which reveal us the human value and which give reasons for its protection. However a similar protection takes root in the ontological condition that allows such exceptional expressions and that characterizes every human being. In fact such ontological condition distinguishes every man in every stage of growth and represents the not sufficient but necessary condition of those abilities so much stressed by the two authors. Consequently in order not to give an arbitrary definition of person, which puts Giubilini and Minerva in the uncomfortable position of "exactly determining when a subject begins or ceases to be person" and that leads them to unsolved problem of identifying an age until which after-birth abortion can be performed, the only alternative is to grant to human beings the right to life so as they are as such. Furthermore relating the protection of a human being to the quality/quantity of his interests appears restrictive and letting the adults' interests prevail on the repeatedly underestimated newborn's ones represents an arbitrary decision. What's more the two authors don't precisely explain the concept of "interest" which they continually refer to. Nevertheless we can accept that adults' interests have a wider significance but it is undeniable that a newborn has interests too. Although these are not verbalized, they become apparent in his vital dynamism, in his request for food and in the interaction with those who take care of him since the first days of life. Although interests are obviously proportional to the individual's stage of growth, the infant' s ones deserve a special consideration also because the satisfaction of the most fundamental interests, such as those emerging in the first weeks of life, represents the necessary condition to facilitate the expressions of more complex interests in the future. Going back to the analogy of fore and after-birth abortion: they are both morally equivalent since newborn and fetus are ontologically equivalent, but consequently these actions have to be claimed as illegitimate because interrupting the life of the involved subject - a human being - they are prejudicial to the right to life. Such conclusion is fundamental not just because this right represents the basis for all the others, but also because its acknowledgement in these terms avoids every kind of discrimination towards human beings: either they are protected in every condition or they are inevitably at the mercy of the strongest. In fact Giubilini and Minerva deem that the moral status of the unborn child or of the newborn depends on the value assigned by the mother, i.e. an adult human being, who has as such an absolute power on the individual who totally depends on her. If these are the terms through which the human procreation is connoted, the meaning of relationship parents-children is twisted because in this way the child is conceived as an object whose value (understood in purely utilitarian terms) depends on the interest of the people who brought him into the world. Parents should take care of their own child abiding by what they "have started", whether one likes it or not, instead of claiming the right to life or death over him. Such a duty is rooted "in the total absence of self-sufficiency of what is begotten [in which] it is ontologically programmed that the begetters protect him from the risk of falling back into nothing and look after him in his further becoming" like Jonas writes about the "figure" of the newborn. Giubilini and Minerva try to defend their thesis affirming that it cannot be talked of a damage towards someone if this someone is not able to perceive the action as a damage. The concept of damage that they use is not proper: in order to carry on a damage it is not necessary that the damaged person realizes it, but it is necessary that one of his/her interests is harmed. Such interest does not have to be intended as something emotionally perceived by the subject, but as the objective relation between the subject and a goods that belongs to him/her. In the case of abortion or after-birth abortion the goods which is not only damaged but even destroyed in a not-reversible way is that of life. This is the necessary condition for every other goods so its liquidation cannot but be a severe damage. In order to better understand the existence of a damage despite a person's unawareness, it is useful to cite as example the condition of a person whose human rights are offended without he/she realizes it. This happen because of a particular psychic or socio- cultural condition which doesn't permit the person to be aware of his/her human stature and consequently of his/her rights: if such rights are offended the damage exists anyway. The two authors go on with two terminological clarifications. First of all they specify that they use the term "after-birth abortion" and not "infanticide" to stress that the killed person's moral status is more comparable to the fetus' one that to that of a child. Consequently they ask to legitimate the killing of a newborn in all the cases in which abortion is permissible. Such "request" cannot be accepted since the human being's growth process is not characterized by qualitative differences and therefore it cannot be affirmed that a fetus-newborn-child have a different moral status. As a result it has to be granted them the same moral protection since these definitions don't identify distinct entities, but are just denominations indicating different growth stages of the same human being, who deserves always protection. Second of all they admit to have chosen the term "after-birth abortion" to distinguish the action identifiable through such expression from the one identifiable with "neonatal euthanasia" so to stress the fact that the interest of who dies is not necessarily the first choice criterion. The latter is basically represented by the protection of adults' interests which can be jeopardized by the baby's existence. The strategy of solving problems resorting to redefinitions rarely works and the arbitrary decision to name differently same actions does not succeed in backing a praxis averting its connection with an expression: "neonatal euthanasia"; a problematic practice for the public opinion. Even though both actions could be carried on for the sake of different reasons, such goal is not met because they remain illegitimate as they equally pursue the killing of a human being during the days following his/her birth. The two authors end their article upholding an innovative thesis: after- birth abortion would be preferable than the option of giving an undesired baby in adoption since it would be less traumatic for the mother. In what extent the own child's voluntary killing, whether the baby is considered a person or just a potential person, could be thought as a better choice than the adoption also from the point of view of emotional impact on a person's psychical balance, is a mystery that could maybe being clarified only by the deepening of psychological studies the two authors appeal to. From a moral point of view a similar practice cannot certainly be accepted as legitimate and results out of proportion because, although according to the two authors the newborn's life enjoys a low reputation, it is surely not so worthless to let prevail the egoism of the strongest on the life of the weakest. The events following the publication of this article deserve to be mentioned. The two Italian authors, surprised by the outcry caused by their words, explained on the blog of the "Journal of medical ethics" that their intervention is not to be intended as a draft bill but as a "pure exercise of logics". Moreover they affirmed that it is necessary and right to distinguish among what can be object of academic discussion and what can be legally permitted. The scientific community's obtained outcomes will surely be communicated to the "great public" through proper language and proportional to the comprehension skills. However this statement cannot be supported because of two reasons: first of all because it would provoke a retrenchment of the Academy's conception and of its task and of its role in the society. It is not a merely gathering of intellectuals, who, pour parler, play to sharpen their argumentative skills analyzing the most paradoxical and provocative issues. On the contrary the Academy is a place where the culture of a society should (at this point the conditional is obligatory) flourish and where reasoning should find its fully development in order to be in service of the scientific and civil community. Second of all the restrictive way to consider the work carried out in the bosom of the University appears naive, because it does not take into account that, owed to quicker and quicker means of communication, what is "produced" inside it reaches more easily the wide public. Henceforth the academical impact on the society is greater and requires more responsibilities as the academical debate often prepares the public one even without wanting to and consequently could create the presuppositions for a possible legislative intervention.
1 Tooley M., Abortion and infanticide, Philosophy & Public Affairs, Vol. 2, No. 1 (Autumn, 1972), pp. 37-65. 2 Singer P., Practical Ethics, Cambridge University Press, 1979. 3 Jonas H., Il principio responsabilit?. Un'etica per la civilt? tecnologica, trad. it. Einaudi, 2009, p. 167.
Conflict of Interest:
"Ahsan v University Hospitals Leicester NHS Trust" does not legitimize antemortem organ preservation in end-of-life care.
"Ahsan v University Hospitals Leicester NHS Trust" does not legitimize antemortem organ preservation in end-of-life care.
Coggon cited Ahsan v University Hospitals Leicester NHS Trust to legitimize elective mechanical ventilation and preservation of organs in dying patients for transplantation . Elective mechanical ventilation alone does not preserve organs in donors for transplantation without performing additional medical procedures. We have discussed elsewhere several antemortem medical procedures for organ preservation that included, but not limited to,: 1) endotracheal intubation, 2) invasive positive pressure ventilation, 3) pharmacological and/or mechanical support of the circulation, 4) invasive instrumentation of blood vessels and body cavities, and 5) use of antemortem preservative drugs such as anticoagulants and vasodilators [2,3]. Coggon cited Ahsan v University Hospitals Leicester NHS Trust to argue in favor of the permissibility of elective mechanical ventilation in end-of-life care of dying patients for the specific purpose of organ preservation and donation . We disagree with Coggon's interpretation of the 2 standards applied in Ahsan case: (1) patient's best interests; and (2) reasonableness of the proposed care regime.
(1) The standard of patient's best interests
Section 4(6) of the UK Mental Capacity Act of 2005 states that in determining what is in a person's best interests one "must consider, so far as is reasonably ascertainable-- (a) the person's past and present wishes and feelings (and, in particular, any relevant written statement made by him when he had capacity), (b) the beliefs and values that would be likely to influence his decision if he had capacity, and (c) the other factors that he would be likely to consider if he were able to do so". Furthermore, section 4(7) (b) of the Act affirms that one "must take into account, if it is practicable and appropriate to consult them, the views of-- anyone engaged in caring for the person or interested in his welfare" .
In Ahsan v University Hospitals Leicester NHS Trust 2006 , familial, cultural and religious considerations were significant factors in determining the patient's best interest regarding what, where, when and how to provide end-of-life care in the event of mental incapacity. Although medical experts made the case "to disregard any familial, social, cultural, religious or spiritual considerations in addressing" an incapacitated person's best interests, Judge Hegarty QC came to a different conclusion. Judge Hegarty QC stated in the final ruling: "[o]n the contrary, I would have thought that most reasonable people would expect, in the event of some catastrophe of that kind, that they would be cared for, as far as practicable, in such a way as to ensure that they were treated with due regard for their personal dignity and with proper respect for their religious beliefs" . In accordance with the UK Mental Capacity Act of 2005, cultural and religious values and beliefs must be considered and respected in end-of-life care. In the case of Ahsan, a Sunni Muslim, the values, beliefs and rituals of the Islamic faith determined the "best interests" in end-of-life care.
Coggon extrapolated from the Ahsan case, to argue that the person's (donor) "best interest" in end-of-life care should include supplying transplantable organs to a third party (recipient). However, if the preparation and execution of procurement of transplantable organs directly collide with the values, beliefs and rituals of a person's faith about end -of-life care, then Coggon's argument is bound to fail. Indeed, most world religions would nullify first-person consent to become an organ donor if the process of donating transplantable organs is believed to constitute a violation of enshrined faith-based values and beliefs about caring for dying individuals [6-10].
(2)The standard of reasonableness of the proposed care regime
There are several practical deficiencies in Coggon's claim that elective mechanical ventilation meets the standard of "reasonableness of the proposed care regime". The proposed elective mechanical ventilation is only one step of multiple sequential medical procedures that must be performed successfully to preserve organs for transplantation. Cardiovascular support is essential following elective mechanical ventilation to perfuse and preserve transplantable organs. Acute resuscitation and stabilization of both cardiac and circulatory functions are generally required after invasive positive pressure ventilation . If elective mechanical ventilation induces an acute cardiovascular collapse in dying patients, that is refractory to cardiopulmonary resuscitation, extracorporal membrane oxygenation (artificial heart-lung machine) will have to be introduced so as to preserve organs for transplantation .
Following elective mechanical ventilation, most donors who are dying from neurological injuries fail to progress to the neurological criterion of death to enable heart-beating organ donation . In this situation, elective withdrawal of mechanical ventilation is medically required to induce arterial pulselessness (cardiac mechanical asystole) and meet the circulatory criterion of death in controlled non-heart-beating organ donation . Almost 50% of potential donors, however, fail to progress to arterial pulselessness within 60 minutes after withdrawing mechanical ventilation [14,15]. Organs procured after 60 minutes generally sustain warm ischemic injury and recipients are likely to develop primary nonfunction or delayed function of the transplanted allografts . This raises additional practical questions about the end-of-life care of potential donors who undergo elective ventilation. If they fail to die within the required time to donate transplantable organs, what happen to the still living but dying patients? Furthermore, considering that potential donors should be transferred to the intensive care unit for elective mechanical ventilation and antemortem organ preservation, should this scarce resource be prioritized to potential donors rather than to critically ill patients who are in need of life-support? Alternatively, should potential donors be transferred to separate procurement units especially designed for elective mechanical ventilation and antemortem organ preservation?
In conclusion, we disagree with Coggon's interpretation of patient's best interests and reasonableness of the proposed elective mechanical ventilation in end-of-life care for the specific purpose of organ preservation and donation. As other commentators have done earlier , Coggon has mistakenly used the decision in Ahsan v University Hospitals Leicester NHS Trust to support his position on the legal permissibility of antemortem organ preservation in controlled heart-beating donation. Others have mistakenly generalized that antemortem organ preservation upholds human dignity and beneficence . We assert that beneficence, compassion, and human dignity in end-of-life care mean upholding and respecting the cultural and religious values of dying patients . We think that the standards of person's best interests and the reasonableness of proposed care invoked in Ahsan case can, instead, be a ground to legitimately, even mandatorily revoke or overrule a prior first-person consent if the process of organ donation is believed to constitute a violation of the religious values and beliefs of the potential donor or the surviving family.
Mohamed Y Rady, B.Chir, M.B (Cantab), M.A , M.D (Cantab), FRCS (Edin. & Eng.), FRCP (UK), FCCM
Professor, College of Medicine, Mayo Clinic
Consultant, Department of Critical Care Medicine, Mayo Clinic Hospital, Phoenix, Arizona, USA
Joseph L. Verheijde, PhD, MBA, PT
Associate Professor, Biomedical Ethics, College of Medicine, Mayo Clinic
Department of Physical Medicine and Rehabilitation, Mayo Clinic, Phoenix, Arizona, USA
1. Coggon J. Elective ventilation for organ donation: law, policy and public ethics. J Med Ethics.2012:Published Online First: 7 December 2012 doi:2010.1136/medethics-2012-100992
2. Rady MY, Verheijde JL, Johnstone M-J. The general public is ready for transparency about organ donation at the end of life. Em Med J.2012;29(10):858-859.
3. Rady MY, Verheijde JL, McGregor JL. Scientific, legal, and ethical challenges of end-of-life organ procurement in emergency medicine. Resuscitation.2010;81(9):1069-1078.
4. The National Archives on behalf of HM Government. Mental Capacity Act 2005. http://www.legislation.gov.uk/ukpga/2005/9/contents.
5. The High Court of Justice Queen's Bench Division. Ahsan v University Hospitals Leicester NHS Trust  EWHC 2624 (QB). 2006.
6. The Lancet. Religion, organ transplantation, and the definition of death. Lancet.2011;377(9762):271-271.
7. Rady MY, Verheijde JL. Brain-dead Patients Are Not Cadavers: The Need to Revise the Definition of Death in Muslim Communities. HEC Forum. 2012:Published online: 28 September 2012, DOI: 2010.1007/s10730-10012- 19196-10737. http://dx.doi.org/10.1007/s10730-012-9196-7.
8. Jones DA. Loss of faith in brain death: Catholic controversy over the determination of death by neurological criteria. Clinical Ethics.2012;7(3):133-141.
9. Sanchez GM. Objections to Donation after Cardiac Death. A Violation of Human Dignity. Natl Cathol Bioeth Q.2012;12(1):55- 65.
10. Shewmon DA. You only die once: why brain death is not the death of a human being. A Reply to Nicholas Tonti-Filippini. Communio: International Catholic Review.2012;39(Fall issue):422-494.
11. Watkinson P, McKechnie S, Wilkinson D, Salmon J, Young D. Actively delaying death to increase organ donation. BMJ.2012;344:e1179
12. Kompanje EJO, de Groot YJ, Bakker J. Is Organ Donation From Brain Dead Donors Reaching an Inescapable and Desirable Nadir? Transplantation.2011;91(11):1177-1180
13. Bernat JL, Capron AM, Bleck TP, et al. The circulatory- respiratory determination of death in organ donation. Crit Care Med.2010;38(3):963-970.
14. de Groot YJ, Lingsma HF, Bakker J, Gommers DA, Steyerberg E, Kompanje EJO. External validation of a prognostic model predicting time of death after withdrawal of life support in neurocritical patients. Crit Care Med.2012;40(1):233-238
15. Rabinstein AA, Yee AH, Mandrekar J, et al. Prediction of potential for organ donation after cardiac death in patients in neurocritical state: a prospective observational study. The Lancet Neurology.2012;11(5):414-419.
16. Dominguez-Gil B, Haase-Kromwijk B, Van Leiden H, et al. Current situation of donation after circulatory death in European countries. Transpl Int.2011;24(7):676-686.
17. Price D, Samanta J. Supporting Controlled Non-Heart-Beating Donation. Camb Q Healthc Ethics.2013;22(01):22-32.
18. De Lora P, P?rez Blanco A. Dignifying death and the morality of elective ventilation. J Med Ethics.2013:Published Online First: 8 January 2013 doi:2010.1136/medethics-2012-100995
19. Rady MY, Verheijde JL. Comfort Care, Withdrawal of Life-Support Treatment, and Nonconsensual Euthanasia in the ICU. Crit Care Med.2013:DOI: 10.1097/CCM.1090b1013e31827c31803ac.
Conflict of Interest:
Conscientious objection by Muslim students to the cross-gender consultation startling
I read Robert Card's recent paper entitled "Is there no alternative? Conscientious objection by medical students" with great interest.1 That Muslim students in America are able to conscientiously object (and this was entertained) to the cross-gender consultation is somewhat startling. I have just left the Middle East, where I worked as a medical educator for five and half years (2006-2011), and, to the best of my knowledge, even in the conservative, gender-segregated traditional Muslim culture of the United Arab Emirates, not once did a male or female student refuse to examine a patient of the opposite sex.
Several issues, many of which have been described by Padela and del Pozo,2 should be taken into consideration in relation to Muslim students' conscientious objection to the cross-gender consultation on religious grounds. Although Islam prohibits touching or physical contact by the opposite gender, unless appropriate (e.g. by a spouse), in some circumstances, the "prohibited becomes permissible".3 Medicine is one such circumstance. Islam does not preclude a doctor from examining the opposite gender where a same gender physician is not available or in life and death situations.2-6 Islam recommends first a same gender Muslim physician, followed by a same gender non-Muslim and, failing their availability, a Muslim of opposite gender, and lastly an opposite gender non-Muslim doctor. 3,5 In cross-gender consultations, however, Muslim women generally need to be accompanied by a same gender third party.3-5 The ancient literature on medical care attests to the possibility of and necessity for cross-gender examinations. In the eighth century, Ibn Quaddama wrote that it was permissible for a male doctor to inspect whatever parts of the woman's body warranted during the medical examination.4 Similarly, Ibn-Muflih stated that "A man doctor may inspect the awra of a women's body as far as the medical examination warrants if only a male doctor is available to treat her, even if he has to look at her private parts. The same would be true if a man is ill and there is but the woman doctor to treat him. She may inspect his body even his private parts" (p. 3).4 Furthermore, this literature attests to the need for Muslims to seek the most qualified practitioner for their medical treatment. Some 600 years ago, Ibn Qayyim Al Jawziyya wrote in The Prophetic Medicine that Muslims should seek the best authority in each matter and field because such expertise will ensure that the task is done with excellence.7 Implicit in this hadith (narrative originating from the words or deeds of Prophet Muhammad) would be the need to consult an opposite gender physician if he or she was the most qualified. The insistence of modern Muslim patients for the same gender physician or for Muslim medical students conscientiously objecting to the cross-gender consultation is interesting considering the Islamic history of medicine during Prophet Muhammad's life. During that time, the medical corps comprised "lady healers" or asiyaat, who were responsible for treating wounded soldiers, irrespective of the injuries. Cross-gender medical care was established during the battles of Badr and Uhud, and so according to the Prophet's tradition, the rule governing covering of areas of the body was waived in the interest of medical treatment.3,4
During interviews with final year male and female clerks about the cross-gender consultation in a society (United Arab Emirates) where women are generally not free to travel without a member of their mahram (non- marriageable male chaperone), some female students (more so than their male colleagues) had initially been apprehensive about touching a male body. Their mutawa (religious leader) reassured them that as medical students, they had to treat both male and female patients and were therefore allowed to touch males. From this study, it also emerged that although students became more "comfortable" with cross-gender touching in the clinical consultation, Emirati female patients in Obstetrics and Gynecology and Emirati male patients in Urology often refused male and female students, respectively. As little has been published in this regard, a group of local female students surveyed Emirati women's attitudes towards male and female medical students as well as canvassed their physician preference. While their general preference was for a female student or physician, other factors such as physician certification and patient education impacted on what parts of the body the women would or would not allow a male student or physician to examine.8,9
As I indicated at the start of my response, it was startling that Muslim students in America could conscientiously object to the cross- gender consultation. This is difficult to reconcile how Muslim students living in a conservative, gender-segregated and traditional Middle Eastern society were able to accept that in Islam medical care should supersede religious teachings and how Muslim students living in a Western country do not share the same understanding.
References 1. Card RF. Is there no alternative? Conscientious objection by medical students. J Med Ethics 2012;38:602-4. 2. Padela A, del Pozo PR. Muslim patients and cross-gender interactions in medicine: an Islamic bioethical perspective. J Med Ethics 2011;37:40-4. 3. Aldeen AZ. The Muslim ethical tradition and emergent medical care: An uneasy fit. Acad Emerg Med 2007; 14(3): 277-8. 4. Hathout H. The male gynaecologist. Medical examination of the other sex. 1986. http://www.islamset.org/bioethics/obstet/examin.html (accessed 21 November 2012). 5. Hedayat KM, Pirzadeh R. Issues in Islamic biomedical ethics: A primer for the pediatrician. Pediatrics 2001;108: 965-71. 6. Hammoud MM, White CB, Fetters MD. Opening cultural doors: Providing culturally sensitive healthcare to Arab American and American Muslim patients. Am J Obstet & Gynecol 2005;193: 1307-11. 7. El-Qadar A. trans. Ibn Qay'em El-Jozeyah on The Prophet Medicine, 2007. http://www.islamhouse.com/p/51834 (accessed 21 November 2012). 8. McLean M, Al Ahbabi S, Al Ameri M, Al Mansoori M, Al Yahyaei F, Bernsen R. 2010. Muslim women and medical students in the clinical encounter: A United Arab Emirates study. Med Educ 44:306-15. 9. McLean M, Al Yahyaei F, Al Mansoori M, Al Ameri M, Al Ahbabi S, Bernsen R. 2012. Muslim women's physician preference: Beyond Obstetrics and Gynecology. Health Care Women Internat 2012;33:849-76.
Conflict of Interest: