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 clearl...
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.
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...
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.
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 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.
"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 [1]. Elective mechanical ventilation
alone does not preserve organs in donors for transplantation without
performing ad...
"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 [1]. 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 [1]. 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"
[4].
In Ahsan v University Hospitals Leicester NHS Trust 2006 [5],
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" [5]. 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"[5]. 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 [11].
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 [2].
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 [12]. 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 [13]. 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 [16]. 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 [17],
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 [18]. 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 [19]. 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.
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
References
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public ethics. J Med Ethics.2012:Published Online First: 7 December 2012
doi:2010.1136/medethics-2012-100992
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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 [2006] EWHC 2624 (QB). 2006.
6. The Lancet. Religion, organ transplantation, and the definition of
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As a layman, I read the paper with pleasure. The thoughts were clearl...
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...
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 author...
"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 [1]. Elective mechanical ventilation alone does not preserve organs in donors for transplantation without performing ad...
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