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People evaluated the organ transplantation success story as “an extraordinary leap in medicine and surgery” and “one of the miracles of modern medicine” (Jonsen, 2012, para. 1). Only after many years of experimental transplants, mostly on animals and occasionally on humans, did surgeons and researchers realize success. As of 2018, more than 120,000 people were waiting on organs for transplants. Every day in the United States, approximately 95 people receive an organ transplant, and an average of 1 person is added to the wait list every 10 minutes (Organ Procurement and Transplantation Network [OPTN], 2018a, 2018b).
In 1954, a surgeon named Joseph Murray, with the help of a physician named John Merrill, performed the first successful kidney transplant from one monozygotic twin to another in Boston at Peter Bent Brigham Hospital, which is now known as Brigham and Women’s Hospital (Jonsen, 2012; President’s Council on Bioethics, 2003). The recipient lived for 8 years because the genetic materials of the twins were identical or similar. In 1990, Murray received a Nobel Prize in Medicine for his contributions. In 1967, a surgeon named Christiaan Barnard, from Cape Town, South Africa, performed the first human heart transplant.
Organ transplantation is more accepted in the 21st century than it was in the 1950s. Then, the ethical questions regarding removing organs from dead or living donors were just as intense and angst provoking as the ethical questions we face today regarding human cloning. Almost instantly, after that first heart transplant, some reasonable ethical issues arose:
1. Should surgeons invade a healthy living donor’s body to retrieve an organ to benefit another person?
2. What method of selection can be used to maintain fairness?
3. Where will kidneys be obtained beyond the living donors?
4. If the donor is dead, what are the criteria for death? (Jonson, 2012)
Murray, the first kidney transplant surgeon, posed the first question as he was trying to decide whether to obtain an organ from a healthy living person, especially in light of his oath to help sick people get well and not to cause harm to others. Question 2 was an issue because, for the first time in history, surgeons were forced to decide on criteria for organ recipients because of a shortage of available organs; in other words, for the first time ever, surgeons were literally choosing who would live and who would die.
Questions 3 and 4 related to unclear information in terms of whether surgeons could retrieve an organ from a dead donor and, if so, at what point they should retrieve an organ. The definition of death in the Uniform Determination of Death Act (UDDA) did not become law until
1981; therefore, clinical evidence to determine the death of a donor was uncertain. Another major issue was that many people were dying from organ rejection because of inadequate and harmful antirejection medications. It was not until 1978 that the effective immunosuppressive medication cyclosporine was available for use.
Sixty years after the first kidney transplant, people are still debating ethical issues regarding organ donation and transplantation, but the issues in the 21st century have shifted to a more diverse set of problems. One current, major issue is societal pressure for organ harvesting, which results from a global demand for organs that far outweighs the supply. Another major issue involves individuals questioning their own moral beliefs about death, organ donation, and the legal definition of death.
Organ procurement is the obtaining, transferring, and processing of organs for transplantation through systems, organizations, or programs. There is evidence that people continue to choose not to donate their organs, which is one of the reasons for the severe imbalance in supply and demand (Kerridge, Saul, Lowe, McPhee, & Williams, 2002; Rock, 2014).
In the United States, 45% of adults are registered organ donors, compared to only 33% of people in the United Kingdom. Even though the number of registered organ donors is low in the United Kingdom, findings in U.K. polls have indicated that the majority of the population (90%) supports organ donation (Rock, 2014).
Some reasons for not having a higher number of registered organ donors stem from misconceptions about the definition of brain death, mistrust of the medical profession, and religious views. Organ donation is a delicate subject, and for many people, organ donation conjures up uncomfortable feelings with death in general. The very thought of donating an organ could lead to individuals having disturbing thoughts about their own death or loss of a body part.
The demand for organs far exceeds the supply. To counterbalance the supply–demand crisis, the U.S. Department of Health and Human Services continues to offer campaigns to increase the organ supply. For the reasons previously outlined, societal ethical conflicts exist between the national organ donor campaigns and the values of potential donors. Utilitarianism is a common ethical framework for planning and implementing goals to increase the organ supply. Conversely, at the core of many people’s beliefs is the value of respect for autonomy and human dignity, which is a deontological ethical framework. Because the public continues to place a high value on self-determination, utilitarian-based programs face challenges to increase the number of organ donors. From a utilitarian perspective, one organ donor can potentially save eight lives with his or her organs; however, people in the United States continue to die while waiting for an organ (OPTN, 2018b). Some countries apply a broader scope of utilitarianism by promoting either presumed consent, meaning that people automatically consent to donating their organs unless they specifically indicate
otherwise, or mandated choice, meaning that competent people are required to indicate yes or no regarding their organ donation choice on license applications, tax returns, and other official state identification records. People are bound by this mandated choice, but an advance directive or a written change of mind can reverse the decision.
In the United States, donor cards are legal documents that are used along with other documentation in the organ donation process.
A donor card gives permission for the use of a person’s bodily organs in the event of death. Advance directives are also legal documents that are used to express one’s desires about organ donation. Adults in the United States express their wishes regarding organ donation through a required response. People can decline or willingly agree to donate their organs, and they can allow a relative to be their designated surrogate.
Fair Allocation of Organs
The National Organ Transplant Act of 1984 led the way for the creation of a national list of candidates; it is currently maintained by the United Network for Organ Sharing (UNOS; https://unos.org). This organization assures the allocation of organs to the best-matched candidates. This act also designated the establishment of the OPTN, a national sharing organization that primarily safeguards fairness across the United States for all organ allocation. The scarcity of available organs prompted the OPTN to apply two factors to assure a balanced decision: justice and medical utility. Justice is the “fair consideration of candidates and medical needs,” and medical utility is an effort to “increase the number of transplants performed and the length of time patients and organs survive” (2018b, para. 1). All the names of people in the United States who need an organ go on a national list only after a physician from one of the transplant centers evaluates each person for documented need. Although the criteria for organ donation varies by organ, the general guidelines include medical emergency, blood/tissue type and size match with the donor, time on the waiting list, and proximity between the donor and the recipient (Gift of Life Donor Program, 2018a). The Gift of Life Donor Program began in
1974 as a small organization in Delaware for the purpose of managing a few kidney transplants. Today, it is a large national organization with an impeccable reputation that manages a variety of organs. The primary goal of the program is to “improve the quality of life of patients awaiting transplantation by maximizing the availability of donor organs and tissues while upholding the highest medical, legal, ethical, and fiscal standards” (Gift of Life Donor Program, 2018b). Additionally, the organization coordinates training for transplantation and donation professionals.
Ethical Issues of Death and the Dead Donor Rule::
The 1981 Uniform Determination of Death Act (UDDA) defined death as an irreversible cessation of circulatory and respiratory functions or irreversible cessation of all functions of the brain (President’s Commission for the Study of Ethical Problems in Medicine and Biomedical and Behavioral Research, 1981). Rubenstein, Cohen, and Jackson (2006) posed the following questions regarding this legal definition of death:
1. Why does having a sound definition of death matter at all?
2. What are the human goods at stake in getting this question right?
3. What are the moral hazards in getting it wrong?
The medical community adopted two guiding moral principles, known collectively as the dead donor rule. This rule functions as the norm for managing potential organ donations.The principles of the dead donor rule are that the donor must first be dead before the retrieval of organs and a person’s life and care “must never be compromised in favor of potential organ recipients” (DeGrazia & Mappes, 2001, p. 325).
There are three unresolved ethical issues regarding the retrieval of a person’s organs in accordance with the legal definition of death:
(1) properly caring for the dying person until death is pronounced, (2) the well-being of family members who must say goodbye to their dying loved one, and (3) the perceived good of the organ donation itself (Rubenstein et al., 2006).
The primary ethical concern is assuring competent and uncompromised treatment up until the person’s death . The care of a dying patient must come first, and nurses and other healthcare professionals may need to offer intensive therapy or present evidence that the patient’s treatment is ineffective.
The second ethical issue is the well-being of families and healthcare professionals. Specifically, this ethical issue involves the risk of causing harm to the families when there has not been sufficient time for them to grieve and process the information versus the risk of not having viable organs if the families wait too long to come to terms with the death. A point made by Rubenstein and colleagues (2006) is that “these final moments of life and first moments of death belong to the grieving at least as much as to the departed person”. yet this same window of time also belongs to the procurement team and surgeons. Quick actions to remove the organs and deliver them to the unknown beneficiary are necessary. Following the pronouncement of death, providers of care maintain the physical body by way of ventilation and circulatory support until the organ procurement team can harvest the organs. The procurement teams, who are well trained, tread on morally shaky ground with the deceased’s family. Approaching the grieving family is difficult, even when the team just needs to confirm the patient’s or family’s wish of wanting to donate organs. Sometimes, the person’s death will have occurred suddenly, such as in a car accident or another injury, and families must have some time to come to terms with the death of their loved one. When the potential donor is pronounced dead, the person continues to remain on a mechanical ventilator as if still living, with warm skin and up-and-down chest movements, and the person continues to receive intravenous fluids. The family sees their loved one’s chest moving up and down, and even though the person has been pronounced dead, the family sees their loved one as still living. This leaves healthcare professionals and families with feelings of ambiguity. Nurses experience moral distress when a person is declared dead and will not be an organ donor, and the provider suspends medical treatment and ventilation support.
The third ethical issue involves the perceived good of organ donation itself. From one perspective, organ donation can give death a certain degree of meaning, allowing a last act of benevolence and selflessness. For example, when no hope exists for continuance of life, parents might donate their child’s organs as an imagined way to carry on that child’s life. From another perspective, patients are guaranteed some autonomy and self-determination when they preregister to donate their organs. The procurement team often views itself as an advocate for carrying out the patient’s wish after death. This act of advocacy goes beyond the principle of autonomy in health care, but carrying out the recipient’s wishes or releasing a dead person’s organs for the good of another is a widely accepted utilitarianism paradigm in society. An intensely debated ethical question involves the dead donor rule and its legitimacy.
Is the dead donor rule outdated? Alan Shewmon (2004) clarified his thoughts on death as an unreal and unknowing ontological (study of being or existence) event without significant meaning, especially when society defines a person as dead by the legal standard created by people in the past 26 years.
As a consequence of questioning the soundness of the dead donor rule, a few bioethicists have attempted to define death as an event, instead of a process, as they grapple with the idea of expanding the scope of utilitarianism to overturn the dead donor rule; ultimately, organs could be retrieved from patients without higher brain function (Miller & Truog, 2008). Patients without higher brain function have no cognitive functioning, but they have an intact brain stem and usually breathe without the assistance of mechanical ventilation. An example is patients who have only lower brain function (and no higher brain), such as those in a persistent vegetative state, like Terri Schiavo. This notion raises the question of whether this practice would be ethical or legally acceptable. Pronouncing patients’ dead who have a functioning brain stem but no higher brain functioning would be a complete ontological shift in how society views death. Overturning the dead donor rule and retrieving organs from patients who are still alive by the UDDA definition of death would be a utilitarian ethical framework when viewed from the perspective of longer-term quality of life and the number of people who could be saved; for example, one person’s organs may save eight lives. Society must answer these questions:
1. If the dead donor rule changes so organ teams can harvest organs from patients with only lower brain function, how will the definition of death change to include these patients?
2. Do patients without higher brain function, but who are not dead by the current legal definition of death, have full moral standing?
Society needs to search for what death really means in terms of the moral imperative of doing good for others versus acting within moral limits and respecting primum non nocere (first do no harm).
Nurses and Organ Donors
In intensive care units and on transplant teams, nurses manage care for potential organ donors, recipients, and their families on a daily basis. Organ procurement teams consist of nurses, surgeons, and other trained healthcare professionals. The psychosocial impact and outcome of the organ transplantation process for donors, donor families, and recipients are unique. According to the ANA Code of Ethics for Nurses with Interpretative Statements (2015), nurses work within a moral framework of good personal character to promote the principles of autonomy, beneficence, nonmaleficence, and justice. To review how those principles are evident in the essential aspects of the code, refer to the box Research Note: Attitudes of Caring for Brain Dead Organ Donors. Most nurses want to have a sense of
satisfaction based on their belief that they are promoting human good, preserving their patients’ dignity as much as possible, and maintaining a caring environment.
The ANA Code of Ethics for Nurses with Interpretive Statements (2015) includes some essential aspects for the care of adult patients in Provisions 1.2, 1.3, 1.4, 2.1, 5.1, 6.1, 6.2, and 8.3. These provisions consist of the importance of consideration of the following items:
■ Culture, values systems, belief systems, social support, gender orientation, and primary language
■ Interventions that optimize health and well-being of patients in nurses’ care
■ Patient autonomy in terms of decision making, cultural beliefs, and understanding of health, autonomy concerns, and relationships
■ A commitment of nurses to respect the uniqueness, worth, and dignity of patients
■ Respect for moral worth and dignity of all persons
■ Practice the “good nurse” virtues of knowledge, skill, wisdom, patience, compassion, honesty, altruism, and courage
■ Practice the promotion of human virtues and values of dignity, well-being, respect, health, and independence, among others
■ Create and maintain excellence in practice environments that support nurses tofulfill their ethical obligations