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CURRENT CONTROVERSIES IN CRITICAL CARE |
The recent death of Mike Hurewitz, age 57, who died after donating a portion of his liver to his brother, raises new ethical questions about institutional and societal obligations for protecting the vulnerabilities of the living donor insofar as possible. The untimely death of Mr Hurewitz now becomes a part of the continuing debate on the ethical issues surrounding the donation of organs by living donors. The brother-recipient is out of the hospital and reportedly doing well. Though, one can only surmise that his recovery is impacted by grief over the loss of his brother’s life.
According to the New York Times, Mr Hurewitz, a reporter for the Times Union of Albany, choked to death at 3:40 pm on January 13, 3 days after donating a portion of his liver to his physician brother. Mr Hurewitz was in a transplant unit in which 34 patients were being cared for by an inexperienced resident. The New York Times omits any information about the nursing staffing on this day. Unanswered in the news reports are questions about the level of staffing of nurses, and why the level of attentiveness fell so low that signs of bleeding and the dangers of aspiration were not averted by attentive and expert nursing and medical care. The state commissioner, Antonia C. Novello, announced that the state of New York is "holding Mt Sinai accountable" for inadequate care and that any operations in which living donors are used to provide liver transplants will be banned for 6 months.1
The ethical concerns for living donors include concern over the unavoidable risks of an otherwise unnecessary surgical procedure and the subsequent potential risks that may be associated with their own possible current and future diminished organ capacity. These are substantive ethical concerns about moral boundaries and reasonable risks of offering a gift of life for another. Often, these substantive ethical issues around living donors are discussed in procedural terms related to informed consent. Does the living donor understand the risks to health, longevity, comfort, and life incurred by the organ donation? The problem of informed consent is that giving the factual information does not necessarily mean that the risks are understood by the donor. It is difficult for the person to figure out the meanings of potential risks stated in statistical terms for his or her particular case. If one has never had major abdominal surgery, it is difficult to understand or imagine the postoperative course and potential residual effects of the surgery on general health and well-being.
The strongest meaning of autonomy drawn from Kant’s moral theory calls for people to be treated as a "kingdom of ends" and never as a mere means.2 Being a kingdom of ends requires that one choose or endorse one’s own ends in terms of living what one considers to be a good life. On the one hand, one must never be required to be treated as a means to another’s good ends unless it is a clearly chosen end to sacrifice some measure of safety for the good of another.
The choice to donate the organ must be free of coercion or manipulation, either social or financial. Nancy Scheper-Hughes,3 an anthropologist at University of California, Berkeley, who has interviewed living donors in other countries, concludes that coercion due to poverty is almost always involved and finds that the donors often express remorse over their less than optimal "choice" to donate an organ to alleviate their poverty. The World Medical Association Statement on Human Organ & Tissue Donation and Transplantation,4 adopted by the 52nd WMA General Assembly in Edinburgh, Scotland, during October 2000, states:
Payment for organs and tissues for donation and transplantation should be prohibited. A financial incentive compromises the voluntariness of the choice and the altruistic basis for organ and tissue donation. Furthermore, access to needed medical treatment based on ability to pay is inconsistent with the principles of justice. Organs suspected to have been obtained through commercial transaction should not be accepted for transplantation. In addition, the advertisement of organs should be prohibited. However, reasonable reimbursement of expenses such as those incurred in procurement, transport, processing, preservation, and implantation is permissible.4
Within the United States, so far, society and policy makers have held the line that organ donation can only be given as a gift and not for coercive financial incentives.
Organ donation must be deemed to be a reasonable risk on the part of the donor. If there are extenuating circumstances, for example, possibilities of genetic predispositions to future diseases that would increase the risk of organ donation, the offer to donate should be declined because of the excessive risk to the donor’s life. For example, in a widely publicized case of an imprisoned father who volunteered to donate his second kidney to his daughter, the father was denied the opportunity because it was considered morally unacceptable to use his body as a sacrificed means to save his daughter’s life.5
The death of Mr Hurewitz raises questions about what are reasonable societal and institutional safeguards for the potential living organ donor. If living organ donation is a practice that the society and medical establishments want to support, do they not have special obligations to ensure the safest possible passage for the living organ donors? In the case of Mr Hurewitz, it appears that there was inadequate postoperative supervision. His symptoms of nausea and hiccups began in the morning, and even though another more senior physician was called in to check on Mr Hurewitz at 1:00 pm when he began to vomit blood, the physician did not actually examine him. By 2:00 pm, Mr Hurewitz required an oxygen mask because his blood oxygen was low. At 3:10 pm, he lost consciousness and resuscitative efforts to revive him failed. Mr Hurewitz died at 3:40 pm.1
Currently, the United States does not require the level of record keeping for living donor transplantations that is required for cadaver organ donation. And we do not have a cumulative or collective record of the experiences of the living donors. Can we proceed with good ethical deliberations about the reasonableness and efficacy of living organ donations without such records? Can we proceed without providing additional assurances and safeguards for the most optimal recovery caregiving provided to living organ donors? Do medical institutions and society have special obligations, given that living organ donors have already assumed a greater than usual burden in subjecting themselves to an otherwise unnecessary surgery?
All postsurgical patients share certain vulnerabilities and risks, and equity demands that the institutions protect all patients during the vulnerable period of postoperative care. Such protection requires adequate numbers and kinds of staff who are well trained and committed to pay attention to the potential complications of the patient’s postoperative course, even though, most of the time, postoperative complications do not occur. Thomasma6 and Goodin7 point out that it is the vulnerability of the beneficiary (the patient) and not the voluntary commitment of the healthcare worker that constitutes the fiduciary responsibilities of the healthcare worker. In the case of Mr Hurewitz, it appears that the special vulnerabilities incurred by his postoperative course were not adequately protected.
Maurice Godelier8 points out in his book, The Enigma of the Gift, that in capitalistic societies driven by impersonal markets, the continuance of society no longer appears to be dependent on gift exchange. Gift giving now lies beyond the market and the state. However, in France (and, I would add, in large proportions of American society), gift giving is still a felt bond and obligation between family members and close friends. Family relationships and friendships lie beyond calculation, and treating others as a means to an end violates the relationship. Charles Taylor9 points to the essential functions of the non-market aspects of a market society that are required for the market to work. Certainly, without a measure of trust and even some solidarity, the market will not work. Godelier, referring to France, states:
In our culture, gift-giving thus continues to partake of an ethic and a logic which are not those of the market and of profit, which are even opposed to them and resist them.... The boundaries of social negotiation are nevertheless clear. Can one imagine a child making a contract with its parents to be born? The idea is absurd. And its absurdity shows that the first bond between humans, that of birth, is not negotiated between the parties involved. And yet it is just such inescapable facts that our society tends to pass over in silence.8
Mark Linthicum, age 27, donated 60% of his liver to his 55-year-old mother, who needed a liver transplant as a result of hepatitis C. Regarding this gift of life, he states: "It wasn’t a question, in my mind. Anything for Mom. She gave me life. I’m lucky enough to get a chance to give it back."10 Mark Linthicum captures the non-market, gift side of our social world. Without it, we would have neither society nor markets. We must ensure that the market side of our society does justice to the solidarity and gift side by ensuring that our healthcare institutions invest enough good planning and money to ensure high quality, safe care to all postsurgical patients. No living donor’s risks should be made greater by lack of adequate care and respect for his or her gift of life.
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This article has been cited by other articles:
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  A. S. Iltis Reviews in medical ethics. J. Law Med. Ethics, June 1, 2008; 36(2): 419 - 424. [PDF]
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