Saturday, January 08, 2005


Protocols and Ethics

There are two combatting trends in ethics going on. There are those of us who espouse the "Culture of Life" viewpoint, that says life is something to be cherished from conception to death, even if it's inconvenient, and worth respect and dignity, versus a view that heightens view of life with dignity to the point that sometimes life is taken because, in the views of other people the suffering is too great, or the quality of life as they determine it is so bad that the persons might as well "be put out of their misery." It starts with humane goals, and sometimes slips over to ta point that seems to say at times, death is to be preferred over life. Between the view of life at any cost (an extremist view that would require people to take treatment that they could refuse, or ignoring all cases of do not ressusitate, etc.- not at all where I personally stand) to the latest idea floated in the Netherlands that euthanasia should be available for those who are sick of life, there are many gray areas where decisions have to be made, and often under stress, short time, and a veil of grief.

One thing that is beginning to happen is a new tupe of protocol for organ donation.

Organ donation to begin with is almost always decided at a time of great sorrow for the loved ones involved. In the past, the organs were removed after the patient was declared brain dead. The new protocol is called non-heart beating organ donation.
It can be described as: the potential NHBD patient does not meet the brain death criteria but is termed "hopeless" or "vegetative" soon after suffering a devastating condition such as a severe stroke or trauma, and while still needing a ventilator to breathe...families or other surrogates then agree to have the ventilator turned off, a "do not resuscitate" order is written, and when the patient's breathing and heartbeat stops, the organs are removed.. This may be a perfectly valid situation. The real problem, as far as I can see is the subjectiveness of the diagnosis.

According to an article on this by George Isajiw, there is a lack of hard guidelines about this, and it is often up to the subjective diagnosis of the doctor that the patient is in a vegetative or terminal, hopeless state. He goes on to note:

A recent article in the New England Journal of Medicine illustrates the disturbing lack of objective medical standards for withdrawal of ventilators. This article, published in September of 2003, admits that no study was done to "validate physicians' predictions of patients' future functional status and cognitive function", and the researchers did not ask doctors to "justify their predictions of the likelihood of death or future function."

With such subjective standards being used for withdrawal of ventilators, it should not be surprising that the potential NHBD patient will unexpectedly continue to breathe for longer than the usual one hour time limit required for the organ transplant to be successful. In these cases of failed NHBD, the transplant is then cancelled but, rather than resuming care, the patient is just returned to his or her room to eventually die without any treatment or further life support.

There are some ethical questions here that need to be addressed. Is there a way to deal with incidents when the doctor guesses wrong and the person, who is horribly injured is refused treatment, but might have survived, is refused treatment after they don't die on schedule? Should there be a "provisional" do not ressucitate order? Is there a way to make a rational, non-subjective protocol on how to decide these cases? And how do we prevent the creeping movement to losen the standards to find more and more people usable for organ donorship?

Interesting area of ethical discussion - and one which needs real answers set up in advance, based on good science and ethical considerations, and not one meant to prey on the sorrows and weaknesses of family members at their most vunerable time.

Comments: Post a Comment

<< Home

This page is powered by Blogger. Isn't yours?