Robert M. Veatch

Models for Ethical Medicine in a Revolutionary Age

9JL/tJT by ROBERT M. VEATCH ost of the ethical problems in the practice of medicine come up in cases where the medical condition or desired procecture itself presents no moral problem. Most day-today patient contacts are just not cases which are ethically exotic. For the woman who spends five hours in the clinic waiting room with two screaming children waiting to be seen for the flu, the flu is not a special moral problem; her wait is. When medical students practice drawing bloods from clinic patients in the cardiac care unit-when teaching material is treated as material-the moral problem is not really related to the patients heart in the way it might be in a more exotic heart transplant, Many more blood samples are drawn, however, than hearts transplanted. It is only by moving beyond the specific issues to more basic underlying ethical themes that the real ethical problems in medicine can be dealt with. Most fundamental of the underlying themes of the new medical ethics is that health care must be a human right, no longer a privilege limited to those who can afford it. It has not always been that way, and, of course, is not anything near that in practice today. But the norm, the moral claim, is becoming increasingly recognized. Both of the twin revolutions have made their contribution to this change. Until this century health care could be treated as a luxury, no matter how offensive this might be now. The amount of real healing that went on was minimal anyway. But now, with the biological revolution, health care

The nondirected live-kidney donor: ethical considerations and practice guidelines: A National Conference Report.

Background. The success of kidney transplantation from a genetically unrelated living spouse or friend has influenced transplant physicians to consider the requests of individuals wishing to volunteer to be a kidney donor who have no intended recipient specified. Representatives of the transplant community gathered in Boston, MA, on May 31, 2001, to deliberate on the experience of live kidney donation from such volunteers, currently termed nondirected donors (NDD). Objective of Conference Participants. The objective of the conference was to recommend ethical and practice guidelines for health care professionals considering the transplantation of a kidney from a live NDD. Conference Participants. This conference was convened under the sponsorship of The National Kidney Foundation, with representation from The American Society of Transplantation and The American Society of Transplant Surgeons, The American Society of Nephrology, The United Resource Networks, The United Network for Organ Sharing, The Association of Organ Procurement Organizations, The National Institutes of Health, and The Division of Transplantation of the Health Resources and Services Administration (see Appendix). Conference Report. The suggested content of screening interviews, which provide information regarding the donation process, elicits pertinent medical and psychosocial history, and assesses NDD motivation are presented in this report. Approaches to identifying the center that would evaluate the suitability of the NDD, to performing the kidney recovery, and to selecting the NDD recipient are also proposed. Other ethical issues such as the use of prisoners as an NDD, compensation for the NDD, media involvement, and communication between the NDD and recipient are discussed. Conclusion. The willingness of health care professionals to consider NDD volunteers is driven by the compelling need to provide organs for an ever-expanding list of patients awaiting a kidney transplant. However, the psychological impact and emotional reward of donation has yet to be determined for NDD who may not have any relationship to the recipient or knowledge of the recipient’s outcome. Transplant centers that accept NDD should document an informed consent process that details donor risks, assures donor safety, and determines that the goals and expectations of the NDD and the recipient can be realized.

The Care of the Terminally Ill: Morality and Economics

Are current expenditures on dying patients disproportionate, unreasonable, or unjust? Although a review of empirical data reveals that care for the terminally ill is very costly, it is not appropriate to conclude that such expenditures represent a morally troubling misallocation of societal resources. Moreover, though efforts to reduce the costs of caring for the dying are not unreasonable, they must be undertaken with great caution. At present, such efforts should concentrate on three basic goals: development of better criteria for admission to intensive- and critical-care units; promotion of patient and family autonomy with regard to decisions to stop or refuse certain kinds of treatment; and promotion of alternative forms of institutional care, such as hospice care. The most difficult moral problems will arise when patients and their physicians seek access to therapies judged only marginally useful. There may be conflict between administrators with broad institutional responsibilities and clinicians committed to particular patients.

Donating Hearts after Cardiac Death : Reversing the Irreversible

Under current law, it is not possible to procure a transplantable heart after cardiac death. Robert Veatch discusses two possible ways out ofthis dilemma.

Why Liberals Should Accept Financial Incentives for Organ Procurement

Free-market libertarians have long supported incentives to increase organ procurement, but those oriented to justice traditionally have opposed them. This paper presents the reasons why those worried about justice should reconsider financial incentives and tolerate them as a lesser moral evil. After considering concerns about discrimination and coercion and setting them aside, it is suggested that the real moral concern should be manipulation of the neediest. The one offering the incentive (the government) has the resources to eliminate the basic needs that pressure the poor into a willingness to sell. It is unethically manipulative to withhold those resources and then offer payment for organs. Nevertheless, the poor have been left without basic necessities for 20 years since the passage of the prohibition on incentives. As long as the government continues to withhold a decent minimum of welfare, liberals should, with shame, cease opposing financial incentives for organ procurement.

The nondirected living donor program: A model for cooperative donation, recovery and allocation of living donor kidneys

We describe an altruistic nondirected (ND) and live donor/deceased donor list exchange (LE) donor program administered by an organ procurement organization (OPO) in the Washington, DC area. Screening eliminated 25 donors (17 NE; 8 LE) from the 97 donor applications (62 ND; 35 LE) completed. Twenty‐one donors (16 ND; 5 LE) failed to follow through with the psychiatric evaluation, which eliminated 13 donors (9 ND; 4 LE). Two donors dropped out and 12 (9 ND; 3 LE) were medically unsuitable after final clinical evaluation. Twenty donor procedures were performed (10 ND; 10 LE) with four pending (2 ND; 2 LE). This resulted in a modest 3–5% increase in the OPO‐procured kidney organ pool. The average cold ischemia time of the grafts not transported between transplant centers was 205 ± 66 min compared with 243 ± 48 min for transported grafts. With no documented adverse outcomes, donors had a hospital stay of length 2.9 days and at home recuperation of 12.3 days. Three‐ and 6‐month creatinines were 1.44 ± 1.36 and 1.68 ± 0.61 for grafts not transported between transplant centers, and 1.6 ± 0.27 and 1.6 ± 0.44 for transported grafts. An OPO‐administered altruistic donor program can serve as a model for cooperative donation, recovery and allocation of living donor kidneys.

Abandon the Dead Donor Rule or Change the Definition of Death

Research by Siminoff and colleagues reveals that many lay people in Ohio classify legally living persons in irreversible coma or persistent vegetative state (PVS) as dead and that additional respondents, although classifying such patients as living, would be willing to procure organs from them. This paper analyzes possible implications of these findings for public policy. A majority would procure organs from those in irreversible coma or in PVS. Two strategies for legitimizing such procurement are suggested. One strategy would be to make exceptions to the dead donor rule permitting procurement from those in PVS or at least those who are in irreversible coma while continuing to classify them as living. Another strategy would be to further amend the definition of death to classify one or both groups as deceased, thus permitting procurement without violation of the dead donor rule. Permitting exceptions to the dead donor rule would require substantial changes in law—such as authorizing procuring surgeons to end the lives of patients by means of organ procurement—and would weaken societal prohibitions on killing. The paper suggests that it would be easier and less controversial to further amend the definition of death to classify those in irreversible coma and PVS as dead. Incorporation of a conscience clause to permit those whose religious or philosophical convictions support whole-brain or cardiac-based death pronouncement would avoid violating their beliefs while causing no more than minimal social problems. The paper questions whether those who would support an exception to the dead donor rule in these cases and those would support a further amendment to the definition of death could reach agreement to adopt a public policy permitting organ procurement of those in irreversible coma or PVS when proper consent is obtained.

The Irrelevance of Equipoise

It is commonly believed in research ethics that some form of equipoise is a necessary condition for justifying randomized clinical trials, that without it clinicians are violating the moral duty to do what is best for the patient. Recent criticisms have shown how complex the concept of equipoise is, but often retain the commitment to some form of equipoise for randomization to be justified. This article rejects that claim. It first asks for what one should be equally poised (scientific or clinical equipoise), then asks who should be equally poised (scientist, clinician, or subject), and finally asks why any of these players need be equally poised between treatment options. The article argues that only the subjects evaluation of the options is morally relevant and that even the subject need not be equally poised or indifferent between the options in order to volunteer for randomization. All that is needed is adequately informed, free, and unexploited consent. It concludes equipoise is irrelevant.

INDIFFERENCE OF SUBJECTS: AN ALTERNATIVE TO EQUIPOISE IN RANDOMIZED CLINICAL TRIALS

The physician who upholds the Hippocratic oath is supposed to be loyal to his or her patients. This requires choosing only the therapy that the physician believes is best for the patient. However, knowing what is best requires randomized clinical trials. Thus, clinicians must be willing to recruit their patients to be assigned at random to one of two therapies (or perhaps to a therapy or a placebo) in order to determine which is best based on the highest standards of pharmacological science.

Autonomy's Temporary Triumph

The emphasis on patient autonomy in medical decision making which emerged in the 1970s is described as a reaction against the paternalistic viewpoint which reigned unchallenged until then. While strongly agreeing that respect for the patients autonomy takes moral precedence over benefiting the patient against his autonomous will, Veatch maintains that the implications of this principle of autonomy are limited because it does not encompass a social ethic for medicine. He rejects the use of cost-benefit analysis for achieving a social ethic, illustrating the shortcomings of this approach with a case study involving mass screening. He opts instead for an ethic of justice which maximizes benefits within the constraints of the uniqueness of individuals as equals in their claim on social resources.