Robyn S. Shapiro

Financial incentives for cadaver organ donation: An ethical reappraisal

A panel of ethicists, organ procurement organization executives, physicians, and surgeons was convened by the sponsorship of the American Society of Transplant Surgeons to determine whether an ethically acceptable pilot trial could be proposed to provide a financial incentive for a family to consent to the donation of organs from a deceased relative. An ethical methodology was developed that could be applied to any proposal for monetary compensation to elucidate its ethical acceptability. An inverse relationship between financial incentives for increasing the families’ consent for cadaver donation that clearly would be ethically acceptable (e.g., a contribution to a charity chosen by the family or a reimbursement for funeral expenses) and those approaches that would more likely increase the rate of donation (e.g., direct payment or tax incentive) was evident. The panel was unanimously opposed to the exchange of money for cadaver donor organs because either a direct payment or tax incentive would violate the ideal standard of altruism in organ donation and unacceptably commercialize the value of human life by commodifying donated organs. However, a majority of the panel members supported reimbursement for funeral expenses or a charitable contribution as an ethically permissible approach. The panel concluded that the concept of the organ as a gift could be sustained by a funeral reimbursement or charitable contribution that conveyed the appreciation of society to the family for their donation. Depending on the amount of reimbursement provided for funeral expenses, this approach could be ethically distinguished from a direct payment, by their intrusion into the realm of altruism and voluntariness. We suggest that a pilot project be conducted to determine whether this kind of a financial incentive would be acceptable to the public and successful in increasing organ donation.

The effect of legislative requirements on the use of breast-conserving surgery

BACKGROUND We studied the effect of state legislation requiring the disclosure of options for the treatment of breast cancer on the use of breast-conserving surgery in clinical practice. METHODS The National Cancer Institutes Surveillance, Epidemiology, and End Results registry provided data on women from 30 through 79 years of age who underwent breast-conserving surgery or mastectomy for local or regional breast cancer from 1983 through 1990. We examined the trend over time in use of breast-conserving surgery among patients in four sites (Connecticut, Iowa, Seattle, and Utah) where there were no state laws specifically requiring the disclosure of options for the treatment of breast cancer by physicians. For four additional sites (Detroit, Atlanta, New Mexico, and Hawaii) that had such legislation, we determined whether the rate of breast-conserving surgery after the legislation was different from the expected rate. RESULTS An attorney rated the legislation as giving most direction to physicians in Michigan, followed by Hawaii, Georgia, and New Mexico. The rate of breast-conserving surgery was up to 8.7 percent higher than expected in Detroit for six months after the passage of the Michigan law (P<0.01). The rate was up to 13.2 percent higher than expected in Hawaii for 12 months after that states law was passed (P<0.05) and up to 6.0 percent higher than expected in Atlanta for 3 months after the passage of the Georgia law (P<0.01). After these transient increases, the surgery rates reverted to the expected levels. No significant effect was detected in New Mexico, where only a resolution without legal force was passed. CONCLUSION Legislation requiring physicians to disclose options for the treatment of breast cancer appeared to have only a slight and transient effect on the rate of use of breast-conserving surgery.

Health Care Providers’Liability Exposure for Inappropriate Pain Management

R ecent studies have exposed the startling inadequacy of health care providers’ knowledge about and practice of effective pain management. For example, in one study, it was reported that 79 percent of a random sample of 454 medical-surgical inpatients experienced pain during hospitalization, and that 58 percent of patients with pain considered the pain horrible or excruciating.’ In another study, 67 percent of 2,415 randomly selected hospitalized patients had pain during the twenty-four hours prior to being interviewed, and 50 percent reported pain at the time of the interview? In a study of seriously ill hospitalized patients reported in 1996, half of the patients complained of pain, and one-sixth reported that they experienced extremely severe pain at least half the time? According to one literature review, 75 percent of cancer patients have reported suffering pain: and one study estimates that 25 percent of cancer patients die with severe unrelieved pain? Chronic nonmalignant pain has been described as “an extremely prevalent problem,”‘ and over two-thirds of nursing home residents experience serious pain.’ Yet, despite the clinical data, experts contend that pain can be controlled for a great percentage of patients.x For example, a study evaluating the World Health Organization’s guidelines for the relief of cancer pain reported that only 3 percent of the 401 dying patients in the study experienced severe pain at the time of death: and recent articles in the clinical literature contend that in up to 90 percent of cancer patients, pain can be controlled by relatively simple means.*O Decisions in two recent lawsuits suggest that proper pain management is beginning to evolve as an element of the standard of care required of health care providers. A

The Role of an Ethics Committee in Resolving Conflict in the Neonatal Intensive Care Unit

W hat should be the role of an institutional ethics committee (IEC) in resolving conflict concerning patient care decisions in the neonatal intensive care unit (NICU)? This question takes on added importance in light of recent court decisions which suggest that IEC deliberations may serve as persuasive evidence in court,’ of proposed state regulations that would establish an IEC as an alternative to judicial review: and of recent Joint Commission on Accreditation of Healthcare Organizations (JCAHO) guidelines that require an institutional policy on limitation or withdrawal of treatment to include a specified mechanism for resolving conflict.) Unfortunately, despite these developments, prospective case consultation remains one of the most controversial and poorly understood aspects of IEC functions: Questions and concerns persist about the relation the IEC has and should have to actual decisions in specific cases. We briefly examine the clinical, organizational, and regulatory complexity of the NICU environment and suggest five potential sources of uncertainty, disagreement, and conflict among parent(s) and NICU staf& We then discuss how these potential conflicts are usually dealt with, in our experience, in the NICU, thus setting the context in which to consider the ways an IEC may be involved through policy formation, continuing education, and prospective case consultation. We conclude that the primary role of an IEC case consultation should be to provide a forum for open discussion. Consensus may be the result, but should not be the goal of such discussion. Finally, while the fact of IEC consultation should be admissible in subsequent judicial proceedings, its advisory opinion should not.

Future issues in transplantation ethics: ethical and legal controversies in xenotransplantation, stem cell, and cloning research

With little prospect of developing a sufficient supply of human transplantable organs to meet the large and growing demand, attention has turned to xenotransplantation, as well as stem cell and cloning research, as possible approaches for alleviating this allograft shortage. This article explores ethical and legal issues that surround developments in these fields.

Managed Care: Effects on the Physician-Patient Relationship

Over the past several years, healthcare has been profoundly altered by the growth of managed care. Because managed care integrates the financing and delivery of healthcare services, it dramatically alters the roles and relationships among providers, payers, and patients. While analysis of this change has focused on whether and how managed care can control costs, an increasingly important concern among healthcare providers and recipients is the impact of managed care on the physician–patient relationship. The literature includes a number of theoretical articles and anecdotal accounts of managed cares impact on the doctor–patient relationship, but little data have been collected and analyzed. We designed a survey for distribution to Wisconsin physicians to analyze the prevalence and types of managed care arrangements in the state, and the impact of these arrangements on physicians and their relationships with patients.

Integrating bioethics into clinical and translational science research: a roadmap.

Recent initiatives to improve human health emphasize the need to effectively and appropriately translate new knowledge gleaned from basic biomedical and behavioral research to clinical and community application. To maximize the beneficial impact of scientific advances in clinical practice and community health, and to guard against potential deleterious medical and societal consequences of such advances, incorporation of bioethics at each stage of clinical and translational science research is essential. At the earliest stage, bioethics input is critical to address issues such as whether to limit certain areas of scientific inquiry. Subsequently, bioethics input is important to assure not only that human subjects trials are conducted and reported responsibly, but also that results are incorporated into clinical and community practices in a way that promotes and protects bioethical principles. At the final stage of clinical and translational science research, bioethics helps to identify the need and approach for refining clinical practices when safety or other concerns arise. The framework we present depicts how bioethics interfaces with each stage of clinical and translational science research, and suggests an important research agenda for systematically and comprehensively assuring bioethics input into clinical and translational science initiatives.

Legislative research bans on human cloning.

Recently, the U.S. House of Representatives voted, for the second time in two years, to ban all human-cloning research, whether the research involves reproduction or creating cells that might be used to understand and treat disease. As I explain in this article, the proposed legislation has important implications not only for human cloning research but also for research in general.

Everything You Always Wanted to Ask a Lawyer about Ethics Committees

It should come as no surprise that we will get three different answers to the same question since we have three lawyers on the panel. The law is a matter of policy , and there is usually no single “right” answer to these questions. Each lawyer will come to a question from a very different perspective and bring a different approach to the answer.

Wisconsin healthcare ethics committees.

Over the past two decades ethics committees have proliferated in healthcare institutions across the country. Catalysts for this growth include the endorsement of ethics committees by the New Jersey Supreme Court in the Quinlan case, by the Presidents Commission for the Study of Ethical Problems in Medicine and Biomedical Research (“Presidents Commission”) in its report entitled Deciding to Forgo Life Sustaining Medical Treatment , by the U.S. Department of Health and Human Services in its 1985 “Baby Doe” regulations, by numerous other courts in treatment decisionmaking opinions issued after Quinlan , and more recently by the Joint Commission on Accreditation of Healthcare Organizations (JCAHO).