Mary Simmerling

When Duties Collide: Beneficence and Veracity in the Evaluation of Living Organ Donors

Purpose of reviewAlthough the medical excuse is routinely used by many transplant programs, ethical issues arising from its use have received little critical attention. The present review will define the medical excuse and briefly discuss its history, purposes, and use in the context of evaluating donor candidates, and will provide a framework for evaluating some of the ethical issues related to its use through consideration of, and comparison with, ethical issues arising from the use of deception in medical practice. Recent FindingsNo empirical evidence supports or contradicts claims about whether using the medical excuse in transplantation fosters the short-term or long-term benefits or harms commonly attributed to it. The literature on using deception in medical practice provides illustrative comparisons and suggests the medical excuse may have ramifications not yet well understood. SummaryThe medical excuse is used by many transplant programs to assist or usher donor candidates out of donation. The present review explores ethical issues that may arise from maintaining or abandoning this practice, and suggests that it merits further empiric and analytic attention from the transplant community.

The Commercialization of Human Organs for Transplantation: The Current Status of the Ethical Debate

Purpose of reviewWhether financial or other incentives for organs should be allowed or prohibited is one of the most challenging ethical issues facing the transplant community. This review provides an overview of the current status of the ethical debate on this issue. Recent findingsCurrently, the buying and selling of organs from either living or deceased donors is legally prohibited in many parts of the world in order both to prevent the commercialization of organs and to ensure some level of equity of access to organ transplantation. Still, a number of proposals have been put forth in recent years suggesting that some form of financial compensation (e.g. direct payment, reimbursement, tax credits) or other ‘moral’ incentives (e.g. honorary medals) should be permitted or explored. An emerging issue that has recently received considerable attention is public solicitation of organs from living and deceased donors through commercial venues, which is seen by some as a potential means for the wealthy to gain an unfair advantage in obtaining an organ. SummaryThis review tracks the ethical debate regarding the commercialization of organs along a ‘commercialization continuum’, with direct payment for organs at one end and public solicitation at the other.

Beyond scarcity: poverty as a contraindication for organ transplantation.

The organ transplantation system is viewed as one of our most equitable health care services, but poor patients are effectively excluded by policy that denies Medicaid coverage of post-transplant immunosuppressant medication. Virtual Mentor is a monthly bioethics journal published by the American Medical Association.

IRBs and Psychological Science: Ensuring a Collaborative Relationship

Institutional Review Boards (IRBs) are federally-mandated, locally-administered groups charged with evaluating risks and benefits of human participant research at their institution. To a greater or lesser extent, risks and potential benefits exist in virtually any research with human participants, including research in the behavioral/social sciences. Federal law and APA standards require IRB review of all human participant research projects. IRB review and approval will likely bring an investigator into contact with two in- ter-related groups: the IRB and the professional staff that administers IRB activities. Due to a variety of factors, including increased IRB and faculty workload and enhanced federal oversight, the potential for conflict among IRB members, IRB administrators, and investigators may be great. Indeed, anecdotal evidence suggests that this potential for conflict may be particularly high for behav- ioral scientists, and that dissatisfaction with IRB review may jeopardize compliance with federal regulations, research participant protection, and research itself. The purpose of this paper is to suggest specific strategies that IRB members, IRB administrators, and investigators can use to avoid potential conflict and facilitate human research participant protection. We contend that when these groups understand and face these responsibilities collaboratively, conflict will be minimized and safe, ethical, high quality research will flourish.

Disease Heritability Inferred from Familial Relationships Reported in Medical Records

Heritability is essential for understanding the biological causes of disease but requires laborious patient recruitment and phenotype ascertainment. Electronic health records (EHRs) passively capture a wide range of clinically relevant data and provide a resource for studying the heritability of traits that are not typically accessible. EHRs contain next-of-kin information collected via patient emergency contact forms, but until now, these data have gone unused in research. We mined emergency contact data at three academic medical centers and identified 7.4 million familial relationships while maintaining patient privacy. Identified relationships were consistent with genetically derived relatedness. We used EHR data to compute heritability estimates for 500 disease phenotypes. Overall, estimates were consistent with the literature and between sites. Inconsistencies were indicative of limitations and opportunities unique to EHR research. These analyses provide a validation of the use of EHRs for genetics and disease research.

Financial and Social Complications as Barriers to Satisfaction with Life Among Living Kidney Donors

This commentary and analysis focuses on financial and social complications as barriers to satisfaction with life among living kidney donors.

Normal Functioning and the Treatment/Enhancement Distinction: An Opportunity Based Assessment

As genome mapping technology uncovers the roots of pathologic and physiologic human functioning, important questions are brought to the fore concerning our conceptualization of ideas such as disease, treatment, and enhancement. In 1985, Norman Daniels proposed a normal-functioning model that expands John Rawls’ theory of justice to obligate the provision of health care based on the constraints disease places on individual opportunity, but also limits the commitment of the medical establishment by focusing on states that represent deviations from normal human function. While some argue that the boundaries of medical institutions’ commitment to provide services within a normal-functioning model are arbitrary, the degree to which these concerns truly threaten the framework is often exaggerated in special cases put forward in the literature. Furthermore, the normal-functioning model provides a comprehensive basis for agreement in discussions of medicine’s commitment to the demands of social justice where resources are limited and avoids the dangerous overextension of the healthcare system and medicalization to which more expansive models are exposed.