This paper examines questions concerning elective ventilation, contextualised within English law and policy. It presents the general debate with reference both to the Exeter Protocol on elective ventilation, and the considerable developments in legal principle since the time that that protocol was declared to be unlawful. I distinguish different aspects of what might be labelled elective ventilation policies under the following four headings: ‘basic elective ventilation’; ‘epistemically complex elective ventilation’; ‘practically complex elective ventilation’; and ‘epistemically and practically complex elective ventilation’. (...) I give a legal analysis of each. In concluding remarks on their potential practical viability, I emphasise the importance not just of ascertaining the legal and ethical acceptability of these and other forms of elective ventilation, but also of assessing their professional and political acceptability. This importance relates both to the successful implementation of the individual practices, and to guarding against possible harmful effects in the wider efforts to increase the rates of posthumous organ donation. (shrink)

Despite stringent and fine tuned laws most jurisdictions are not able to curb organ trafficking. Nor are they able to provide organs to the needy. There are reports of the kidnapping and murder of children and adults to “harvest” their organs. Millions of people are suffering, not because the organs are not available but because “morality” does not allow them to have access to the organs. Arguments against organ sale are grounded in two broad considerations: sale is contrary (...) to human dignity, and sale violates equity. Both these objections are examined in this article and it is concluded that they reflect a state of moral paternalism rather than pragmatism. It is argued that a live human body constitutes a vital source of supply of organs and tissues and that the possibilities of its optimum utilisation should be explored. Commercialisation should be curbed not by depriving a needy person of his genuine requirements but by making the enforcement agencies efficient. (shrink)

This paper examines questions concerning elective ventilation, contextualised within English law and policy. It presents the general debate with reference both to the Exeter Protocol on elective ventilation, and the considerable developments in legal principle since the time that that protocol was declared to be unlawful. I distinguish different aspects of what might be labelled elective ventilation policies under the following four headings: ‘basic elective ventilation’; ‘epistemically complex elective ventilation’; ‘practically complex elective ventilation’; and ‘epistemically and practically complex elective ventilation’. (...) I give a legal analysis of each. In concluding remarks on their potential practical viability, I emphasise the importance not just of ascertaining the legal and ethical acceptability of these and other forms of elective ventilation, but also of assessing their professional and political acceptability. This importance relates both to the successful implementation of the individual practices, and to guarding against possible harmful effects in the wider efforts to increase the rates of posthumous organ donation. (shrink)

Originally published in 1990, this study of the moral problems bound up with transplant therapy addresses a finely balanced distinction between ethical issues relating to its experimental nature on the one hand and those which arise when transplantation is routine on the other. Among the issues examined are proposals for routine cadaveric harvesting, criteria for organ and tissue procurement from living donors, foetuses, non-human animals and current ethical problems with artificial implants. Written as a contribution to practical (...) philosophy, this book will interest ethicists and health care professionals. (shrink)

Cadaveric donation comprises organ donation—that is, taking organs from brain dead people, as well as tissue donation, meaning taking tissues from brain dead as well as heart dead people. The organ transplant procedure from brain dead patients is beyond the scope of the pathologist, as it is done by surgeons in the operating theatre. In a broader sense, however, pathologists are involved in cadaveric tissue donation as well as taking tissues from cadavers for diagnostic procedures within (...) the framework of the autopsy , and to gather material for research and training students and pathology residents . For cadaveric tissue donation, different ethical and practical issues must be considered, which we will try to review in this paper from the perspective of the pathologist.CADAVERIC TISSUE SAMPLING FOR TRANSPLANTATION PURPOSESSeveral tissues can be taken from “true” cadavers that may still be used for transplantation such as skin, corneas, tendons, bone. This is usually done in collaboration with the pathologist, who is in most countries responsible for the body after the death of the patient in the hospital. All these tissues can be harvested several hours after death, as they undergo only slow degradation. In The Netherlands, as dictated by law, patients must actively have given permission for donation during life by registering with the Transplantation Register. Since this procedure was implemented, the number of organs available for donation has not increased but decreased somewhat, while the number of tissues has increased. A great obstacle to the increase in the number of donations is that only 37% of the population is registered …. (shrink)

The human body is becoming hot property, a resource to be “mined,” “harvested,” patented, and traded commercially for profit as well as scientific and therapeutic advances. Under the new entrepreneurial approach to the body old tensions take on new dimensions—about consent, the fair distribution of tissues and products developed from them, the individual and cultural values represented by the body, and public policy governing the use of organs and tissues.

This issue of the Journal of Medical Ethics features a special symposium on ‘elective ventilation’ . EV ) was originally described in the 1990s by doctors working in Exeter in the UK.1 At that time there was concern about the large shortfall in organs for transplantation. Patients could become organ donors if they were diagnosed as being brain dead, but this only ever occurred in patients on breathing machines in intensive care who developed signs of brainstem failure. Doctors wondered (...) if there were patients dying outside intensive care who, if they were ventilated, could become brain dead and hence eligible to donate their organs. They embarked on a process of identifying patients who were dying who would not normally be taken to intensive care because their prognosis was judged to be too poor, and then ‘electing’ to insert breathing tubes when they stopped breathing.1 With the consent of family members the patients were supported in intensive care until they were diagnosed as having signs of brain death, or until the family and doctors together judged that this was unlikely to occur.1 The Exeter team saw a 50% increase in their numbers of organs for transplantation.Box 1 Definition of elective ventilation Elective ventilation is the provision to a patient of intensive medical treatment with the sole purpose of facilitating organ donation, in the absence of an expected medical benefit.EV was a controversial practice at the time. There were a number of papers written from points of view defending2 ,3 and criticising it.4 A Department of Health guideline in 1994 concluded that EV was not in the best interests of patients and was therefore unlawful5; subsequently, the practice effectively ceased.2 However, debate about EV has not …. (shrink)

This article draws on a five-year, multi-sited transnational research project on the global traffic in human organs, tissues, and body parts from the living as well as from the dead as a misrecognized form of human sacrifice. Capitalist expansion and the spread of advanced medical and surgical techniques and developments in biotechnology have incited new tastes and traffic in the skin, bones, blood, organs, tissues, marrow and reproductive and genetic marginalized other. Examples drawn from recent ethnographic research in Israel, the (...) Palestinian Authority and Turkey serve to cast light on the dark side of organs harvesting and transplantation. The article focuses on the dangers of the `fetishized kidney' for both sellers and buyers, for whom this new commodity has become an organ of opportunity and an organ of last resort. The bodily sacrifice is disguised as a donation, rendered invisible by its anonymity, and hidden under the medical rhetoric of `life saving' and `gift giving'. It suggests that the ultimate fetish as recognized long ago by Ivan Illich is the idea of `life' as object of manipulation. (shrink)

With so much attention being paid to the development and refinement of appropriate criteria and tests for death, little attention has been given to the broader conceptual issues having to do with its definition or with the relation of a definition to its criterion. The task of selecting the correct criterion is, however, virtually impossible without proper attention to the broader conceptual setting in which the definition operates as the key feature. All of the issues I will discuss arise because (...) of this lack of concern with conceptual matters. Such problems as incorrectly diagnosing a patient as dead prior to the harvesting of his or her organs, defending the idea that death is reversible, and advocating a brainstem criterion of death, are all, I believe, errors that derive from this misplaced emphasis. (shrink)

What makes an act of killing morally wrong is not that the act causes loss of life or consciousness but rather that the act causes loss of all remaining abilities. This account implies that it is not even pro tanto morally wrong to kill patients who are universally and irreversibly disabled, because they have no abilities to lose. Applied to vital organ transplantation, this account undermines the dead donor rule and shows how current practices are compatible with morality.

Organ procurement policy from the recently deceased recasts families into gatekeepers of a scarce medical resource. To the frustration of organ procurement teams, families do not always authorize organ donation. As a result, efforts to increase the number of organs available for transplantation often seek to limit the authority of families to refuse organ retrieval. For example, in some locales if a deceased family member has satisfied the legal conditions for first-person prior assent, a much looser (...) and easier standard to satisfy than informed consent, organ retrieval may proceed despite the family’s objections. Some countries have replaced voluntary consent to organ donation with forms of organ conscription. Often referred to under the misnomer “presumed consent,” such policies legalize the harvesting of organs at death, unless individuals exercise official options to opt out. As this article explores, however, there are good grounds for affirming the authority of the family to consent to or to deny organ donation on behalf of recently deceased family members, as well as to reject first-person assent and “presumed consent” policies of organ procurement. Insofar as individuals have failed clearly and competently to provide informed consent to organ donation, moral authorization for the use of the person and his body ought to be grounded on the foundational authority of the family, rather than the state’s supposed interests in obtaining organs for transplantation. (shrink)

Cloned organisms can be genetically altered so that they do not exhibit higher brain functioning. This form of therapeutic cloning allows for genetically identical organs and tissues to be harvested from the clone for the use of the organism that is cloned. “Spare parts” cloning promises many opportunities for future medical advances. What is the ontological and ethical status of spare parts, headless clones? This paper attempts to answer this question from the perspective of Aristotle’s view of the soul. Aristotle’s (...) metaphysics as applied to his view of biological essences generates an ethic that can contribute to moral reasoning regarding the use of headless spare parts clones. The task of this paper is to show the implications that Aristotle’s view of the soul, if it is true, would have on the ethics of headless, spare parts cloning. (shrink)

The Body as Gift, Resource, and Commodity, edited by Martin Gunnarson and Fredrik Svenaeus, is a volume containing 11 research pieces about organ transplants and organ trade in current times, and is the outcome of a research project at the Centre for Studies in Practical Knowledge, Södertörns University in Stockholm. The main contributors include a philosopher, a historian, and three ethnologists, assisted by medical researchers and physicians and other scholars from the Baltic region. As such, the range of (...) focus is generally limited to the prevailing practices in that region, although their connections with practices in other parts of the world are discussed where directly relevant.The authors’ aim, as mentioned in the introduction of the book, is to add to the growth of knowledge and reflection in the field of reference and thus help to build sound political judgment and policies on organ, tissue, and cell donation, both in view of the need to save lives and their impac .. (shrink)

In lieu of an abstract, here is a brief excerpt of the content:Kennedy Institute of Ethics Journal 14.1 (2004) 97-114 [Access article in PDF] Stem Cell Research in the U.S. after the President's Speech of August 2001 Cynthia B. Cohen On 9 August 2001, in a nationally televised speech, President Bush addressed the contentious question of whether to provide federal funds for human embryonic stem cell research (White House 2001).1 This research involves taking the primordial cells found in embryos and (...) transforming them into certain specialized cells, such as those of the heart, nerves, and muscles, with the ultimate goal of transferring these cells into patients to repair damaged cells and tissues. In his remarks, the President authorized funding for research only on stem cells already harvested from remaining embryos at in vitro fertilization (IVF) centers as of 9 August 2001, the date of the speech. In a "Fact Sheet" about embryonic stem cell research, he added the ethical requirements that (1) the donors of embryos gave informed consent to the derivation of stem cells from their embryos, (2) the embryos were created solely for reproductive purposes, and (3) no financial inducements were given to the embryo donors. The President also prohibited federally funded research on embryonic stem cells derived from embryos after 9 August 2001, as well as the creation of embryos for research purposes and the cloning of human embryos for both reproductive and research purposes. He did not seek to ban the pursuit of embryonic stem cell research with private funds. "This allows us to explore the promise and potential of stem-cell research without crossing a fundamental moral line by providing taxpayer funding that would sanction or encourage further destruction of embryos," the President stated (White House 2001).The President's speech stirred intense controversy. Many applauded the new policy because it allowed some embryonic stem cell research to proceed, thereby raising hope that treatments might be developed for those suffering from such conditions as Parkinson's disease, Alzheimer's disease, and diabetes. Others supported it on grounds that it would discourage the future destruction of embryos in stem cell research. They maintained that although it was wrong to have derived stem cells from embryos, this wrong was no longer remediable and it therefore was justifiable to allow research using such embryos to proceed. Some, however, objected to the new policy because they held that it unduly limited the [End Page 97] number of embryonic stem cells available for federally funded research. Still others opposed it on grounds that it made the federal government complicit in what they took to be the wrongful destruction of human embryos that had taken place prior to 9 August 2001. The President established the President's Council on Bioethics by executive order in November 2001 and charged it, among other tasks, with monitoring stem cell research and recommending guidelines and regulations for biomedical innovations.Questions about the moral status of human embryos have so captured public attention since the President issued his remarks that other significant ethical and policy issues raised about stem cell research inside the Beltway have remained in the shadows. A number of individuals and organizations—legislators, scientists, patient groups, the President's Council on Bioethics, ethicists, religious task forces, and social commentators—have attempted to bring these other issues to legislative and public attention. They also have revisited the more publicly prominent question of what sorts of protections we owe to human embryos. In response, Congress has attempted to address several of these newly emerging issues at hearings and in legislation. I review these efforts, consider developing issues and arguments, and conclude by exploring possible future directions for federal and private sector stem cell policy. The Availability of Embryonic Stem Cell Lines to Federally Funded Researchers President Bush, in developing his stem cell research policy, accepted a distinction between the "derivation" and the "use" of embryos enunciated by the General Counsel of the Department of Health and Human Services toward the end of the Clinton administration. This distinction was adopted to avoid contravening the Dickey-Wicker Amendment (added... (shrink)

: The chronic shortage of transplantable organs has reached critical proportions. In the wake of this crisis, some bioethicists have argued there is sufficient public support to expand organ recovery through use of neocortical criteria of death or even pre-mortem organ retrieval. I present a typology of ways in which data gathered from the public can be misread or selectively used by bioethicists in service of an ideological or policy agenda, resulting in bad policy and bad ethics. Such (...) risks should lead us to look at alternatives for increasing organ supplies short of expanding or abandoning the dead donor rule. The chronic problem of organ scarcity should prompt bioethicists to engage in constructive dialogue about the relation of the social sciences and bioethics, to examine the social malleability of the definition of death, and to revisit the question of the priority of organ transplants in the overall package of healthcare benefits provided to most, but not all, citizens. (shrink)

Elements compose organic bodies, including tissues and organs, and in so doing are for the sake of the whole organism of which they are the transformed parts. But the starting point for the explanation of living things is the identification of its functions: nutrition and reproduction for plants, perception and locomotion for animals, and virtue and intelligence for humans. Since the functions of plants are fundamental to all other living things, the vegetative functions are the primary ones in biological explanation. (...) Thus, the survival and reproduction of each species is the basis for its explanation, and these are represented as goods for it. But although goods come first in the order of explanation, they come last in the order of development of the organism. Thus, intelligence is the last thing developed by a human, even though everything else has come to be for the sake of this. The reversal of explanatory and genetic order does not, however, imply some kind of mysterious “backwards causation”. (shrink)

In an attempt to increase the number of organs available for transplantation, section 43 of the Human Tissue Act 2004 provides, for the first time, a statutory basis for the non-consensual preservation of organs. However, several issues arise out of the terminology of the section relating to where the preservation steps can be carried out and, indeed, what preservation steps can be performed which may affect the success of this attempt to increase the organ donor pool.

Aristotle normally begins a teleological explanation of a living thing with an identification of its goods. The existence of these goods implies certain requirements or “hypothetical necessity”. For example, if a fish is to survive and reproduce, it must be able to acquire food, which requires that it move, and so it must have fins, which in turn require tissues, and these must be composed of a certain combination of the elements. Some features of living things are not necessary for (...) its survival, but only as a concomitant to some other necessity, or because it is better for the creature that way. The case of animal behavior shows that Aristotle does not indulge in anthropomorphism: apparently purposeful behavior is not caused by deliberation. In fact, far from assimilating animal to human behavior, Aristotle goes the other direction and shows how many purposeful human activities happen without deliberation. (shrink)

The current position on the deceased’s consent and the family’s consent to organ and tissue donation from the dead is a double veto—each has the power to withhold and override the other’s desire to donate. This paper raises, and to some extent answers, questions about the coherence of the double veto. It can be coherently defended in two ways: if it has the best effects and if the deceased has only negative rights of veto. Whether the double veto (...) has better effects than other policies requires empirical investigation, which is not undertaken here. As for rights, the paper shows that it is entirely possible that individuals have a negative right of veto but no positive right to compel acceptance of their offers. Thus if intensivists and transplant teams turn down the deceased’s offer, they do not thereby violate the deceased’s right. This leaves it open whether non-rights based reasons—such as avoiding bad publicity or distress —require intensivists and transplant teams to turn down or accept the deceased’s offer. This, however, is beyond the scope of this paper. The current position may or may not be wrong, but it is at least coherent. (shrink)

Because organic certification standards institutionalized a product-based rather than process-based definition, certified organic produce can be grown on large-scale industrial monocrop farms. Besides toxicity of inputs, these farms operate in much the same way as conventional production. Scholars emphasize the fact that labor rights have been left out of certification criteria, and because of that, organic farms reproduce the same labor relations as conventional. Empirical studies of organic farm labor, however, rely primarily on the perspective of farmers. In this study, (...) I ask the farmworkers themselves how harvesting on organic farms compares to conventional, and found that working in organic negatively impacts farmworker livelihoods. Qualitative interviews with 36 strawberry harvesters in Oxnard, California reveal that farmworkers make more money in conventional strawberry production because of the interaction between wage structure and size of the berry. Conventional strawberries are larger and therefore fewer of them fill up a box. Farmworkers routinely pick more boxes in conventional than in organic, thus earning more, since under the piece rate system, farmworkers are paid per box. With short-term economic survival rather than long-term occupational health concerns in mind, strawberry harvesters would rather work on conventional farms because “la fresa orgánica es más chiquita”. (shrink)

This article examines an Australian campaign to increase organ and tissue donation for transplantation. It analyses the use of the gift rhetoric to promote community awareness and resources, target migrant groups, and recruit cultural and religious leaders to endorse organ and tissue donation as an altruistic act. In unpacking this ‘gift of life’ approach to organ donation, it explores the convergence of medical and religious bodies and pushes beyond uniform determinations of death to reveal how (...) multiple deaths transpire in organ donation. Drawing on recent advances in the anthropology of becoming as a critical lens to examine death and organ donation, it examines how the ‘unfinishedness’ of donor bodies produces new possibilities for understanding donation. This article thus attends to the situated, layered and contradictory sensibilities that open up multiple and malleable understandings of the donation of body parts. (shrink)

Although the term commodification is sometimes criticised as imprecise or overused, in fact it has a complex philosophical ancestry and can never be used too much, because the phenomena that it describes are still gaining ground. The issues that commodification raises in relation to reproductive technologies include whether it is wrong to commodify human tissues generally and gametes particularly, and whether the person as subject and the person as object can be distinguished in modern biomedicine. This chapter examines three areas (...) in which commodification is a serious concern for important reproductive technologies: the sale of eggs for IVF and research, the banking of umbilical cord blood, and the use of gestational surrogates both domestically and internationally. Sales of human eggs for IVF or research are frequently disguised as “gifts”, which conceals the very real bodily risks and harms associated with ovarian hyperstimulation and egg harvesting undergone by egg “donors.” Umbilical cord banking is a fast-growing industry, with donated cord blood trading globally at very high prices; women who consent to banking of cord blood ostensibly for the potential future benefit of their child may not be informed of the likelihood that it will be traded in commercial markets or that the method used for harvesting may increase risks of jaundice in their babies. Commercial surrogacy also exploits altruism but in addition involves wrongful sale of babies, particularly in the international context. In each example, the commodification of women’s reproductive labour is masked by the manner in which ‘the lady vanishes’ under a gift model, ignoring the true economic value of their labour. (shrink)

Organ donation after a circulatory determination of death is possible in selected patients where consent is given to support donation and the patient has been legally declared dead by two doctors. The National Health Act (61 of 2003) and regulations provide strict controls for the certification of death and the donation of organs and tissues after death. Although the National Health Act expressly recognises that brain death is death, it does not prescribe the medical standards of testing for the (...) determination of brain death (neurological determination of death), circulatory death (circulatory determination of death) or for determination of death based on somatic criteria. However, in all cases of organ donation, including after circulatory death, the National Health Act mandates that two doctors certify the death, with one doctor possessing more than 5 years of experience. Additionally, both doctors must be independent from the transplant team. The standard for such determination, as for brain death, aligns with accepted medical standards. The Critical Care Society of Southern Africa has published South African (SA) Guidelines on Death Determination that outline rigorous standards for death determination in hospital settings by either a neurological or circulatory method. Legislation and the Health Professions Council of SA’s (HPCSA) professional guidance direct clinicians on obtaining informed consent for donation either from the patient or in cases of incapacity from their surrogate decision maker. Collectively, the legislation, regulations and professional guidelines in SA provide a robust ethical framework that supports organ donation after circulatory death. (shrink)

One must technologize bodies to conceive of organ transplantation. Organs must be envisioned as replaceable parts, serving mechanical functions for the workings of the body. In this way, it becomes possible to imagine exchanging someone’s organs without changing anything essential about the selfhood of the person. But to envision organs as mechanical parts is phenomenologically uncomfortable; thus, the terminology used to describe the practice of organ retrieval seems to attempt other, less technological ways of viewing the human body. (...) In this paper, I analyze three common metaphors that currently contextualize the process of organ retrieval in English-speaking communities: harvesting the agrarian body, procuring the commodified body, and receiving the gifted body. These powerful images constrain the gaze toward the body in important ways. Every gaze both obscures and reveals. While each of these three metaphors makes sense of some aspects of organ retrieval, each of them is ultimately subject to being overtaken by what Jeffrey Bishop calls the technological imaginary. This imaginary deploys a gaze that obscures important elements of what it means to be human and does violence to parts of the phenomenological experience of transplantation and bodily existence. I argue that no matter how hard one tries to avoid the technological aspect of transplantation practices by embracing nonviolent metaphors—even the metaphor of gifting, which seems the most promising—it will never be possible to fully resist organ transplantation’s violence toward our phenomenological sense of embodiment. (shrink)

A man of twenty‐two is admitted to an intensive care unit (ICU)after intentionally overdosing on Tylenol. The nurse asks the intensivist on call if someone from the local organ procurement organization should be called in to speak to the family, given a worsening clinical picture and the likelihood that the patient will progress to brain death. The patient's condition is such that multiple organs, including his heart and lungs, could be donated. The intensivist instructs the nurse not to call, (...) as he wishes to have an end‐of‐life discussion with the parents. He believes that the parents should know that death is imminent and that further interventions will not save their son. He argues that introducing the OPO at this point will cause the family more distress. He wants the parents to be able to give their son a peaceful death without additional stressors. What are the broader implications of not calling the OPO at this juncture? Does the nurse involved have an ethical obligation to override the intensivist's instructions by calling the OPO? Should the fact that multiple healthy organs could be harvested from this patient's body have any bearing on the decision to call the OPO? (shrink)

The article is a critical commentary on Peter Singer’s thesis that the brain death definition should be replaced by a rule outlining the conditions permitting organ harvesting from patients who are biologically alive but are no longer persons. Largely agreeing with the position, I believe it can be justified not only on the basis of utilitarian arguments, but also those based on Kantian ethics and Christianity. However, due to the lack of reliable methods diagnosing complete and irreversible loss (...) of consciousness, we should refrain from implementing upper brain death into medical practice. Organs also should not be harvested from people in a persistent vegetative state or from anencephalic children, for similar reasons. At the same time, patients who suffered from whole-brain death should not be artificially sustained; in light of current knowledge they can be declared dead and become organ donors. (shrink)

There are not enough solid organs available to meet the needs of patients with organ failure. Thousands of patients every year die on the waiting lists for transplantation. Yet there is one currently available, underutilized, potential source of organs. Many patients die in intensive care following withdrawal of life-sustaining treatment whose organs could be used to save the lives of others. At present the majority of these organs go to waste.In this paper we consider and evaluate a range of (...) ways to improve the number and quality of organs available from this group of patients. Changes to consent arrangements (for example conscription of organs after death) or changes to organ donation practice could dramatically increase the numbers of organs available, though they would conflict with currently accepted norms governing transplantation.We argue that one alternative, Organ Donation Euthanasia, would be a rational improvement over current practice regarding withdrawal of life support. It would give individuals the greatest chance of being able to help others with their organs after death. It would increase patient autonomy. It would reduce the chance of suffering during the dying process. We argue that patients should be given the choice of whether and how they would like to donate their organs in the event of withdrawal of life support in intensive care.Continuing current transplantation practice comes at the cost of death and prolonged organ failure. We should seriously consider all of the alternatives. (shrink)

Often the only treatment available for patients suffering from diseased and injured organs is whole organ transplant. However, there is a severe shortage of donor organs for transplantation. The goal of organ engineering is to construct biological substitutes that will restore and maintain normal function in diseased and injured tissues. Recent progress in stem cell biology, biomaterials, and processes such as organ decellularization and electrospinning has resulted in the generation of bioengineered blood vessels, heart valves, livers, kidneys, (...) bladders, and airways. Future advances that may have a significant impact for the field include safe methods to reprogram a patient's own cells to directly differentiate into functional replacement cell types. The subsequent combination of these cells with natural, synthetic and/or decellularized organ materials to generate functional tissue substitutes is a real possibility. This essay reviews the current progress, developments, and challenges facing researchers in their goal to create replacement tissues and organs for patients. (shrink)

Background: The family interview context is permeated by numerous ethical issues which may generate conflicts and impact on organ donation process. Objective: This study aims to analyze the family interview process with a focus on principlist bioethics. Method: This exploratory, descriptive study uses a qualitative approach. The speeches were collected using the following prompt: “Talk about the family interview for the donation of organs and tissues for transplantation, from the preparation for the interview to the decision of the family (...) to donate or not.” For the treatment of qualitative data, we chose the method of content analysis and categorical thematic analysis. Participants: The study involved 18 nurses who worked in three municipal organ procurement organizations in São Paulo, Brazil, and who conducted family interviews for organ donation. Ethical considerations: The data were collected after approval of the study by the Research Ethics Committee of the School of Nursing of the University of São Paulo. Results: The results were classified into four categories and three subcategories. The categories are the principles adopted by principlist bioethics. Discussion: The principles of autonomy, beneficence, non-maleficence, and justice permeate the family interview and reveal their importance in the organs and tissues donation process for transplantation. Conclusion: The analysis of family interviews for the donation of organs and tissues for transplantation with a focus on principlist bioethics indicates that the process involves many ethical considerations. The elucidation of these aspects contributes to the discussion, training, and improvement of professionals, whether nurses or not, who work in organ procurement organizations and can improve the curriculum of existing training programs for transplant coordinators who pursue ethics in donation and transplantation as their foundation. (shrink)

BackgroundThe COVID-19 pandemic has had a significant impact on the health system worldwide. The organ and tissue donation and transplantation (OTDT) system is no exception and has had to face ethical challenges related to the pandemic, such as risks of infection and resource allocation. In this setting, many Canadian transplant programs halted their activities during the first wave of the pandemic.MethodTo inform future ethical guidelines related to the COVID-19 pandemic or other public health emergencies of international concern, we (...) conducted a literature review to summarize the ethical issues.ResultsThis literature review identified three categories of ethical challenges. The first one describes the general ethical issues and challenges reported by OTDT organizations and transplantation programs, such as risks of COVID-19 transmission and infection to transplant recipients and healthcare professionals during the transplant process, risk of patient waitlist mortality or further resource strain where transplant procedures have been delayed or halted, and resource allocation. The second category describes ethical challenges related to informed consent in the context of uncertainty and virtual consent. Finally, the third category describes ethical issues related to organ allocation, such as social considerations in selecting transplant candidates.ConclusionThis literature review highlights the salient ethical issues related to OTDT during the current COVID-19 pandemic. As medical and scientific knowledge about COVID-19 increases, the uncertainties related to this disease will decrease and the associated ethical issues will continue to evolve. (shrink)

At the end of 1999 the Danish Council of Ethics published a report on organ and tissue donation from living donors. The report focused on kidney and bone marrow transplantations, as these are presently the most common transplantations from live donors. During the work on the report, it became clear to the Council that, apart from problems concerning coercion and commercialization that affected both adult and child donors, by far the largest ethical problems occurred in donations from children.

Most tissues contain cells capable of the self‐renewal and differentiation necessary to maintain tissue and organ integrity. These somatic stem cells are generally thought to have limited developmental potential. The mechanisms that restrict cell fate decisions in somatic stem cells are only now being understood. This understanding will be important in the clinical exploitation of adult stem cells in tissue repair and replacement. Experiments performed over fifty years ago in Drosophila showed that developmental restriction could be relaxed (...) in the proliferating larval cells that are destined to form the adult fly integument. This phenomenon, called transdetermination, can serve as a model for mechanisms of stem‐cell commitment. A recent publication1 sheds new light on the mechanism of transdetermination by demonstrating that loss of homeotic gene silencing leads to increased frequency of transdetermination. In addition, the authors link a specific signaling pathway induced by tissue regeneration to the relaxation of homeotic gene silencing. The data identify key mechanisms that control developmental homeostasis and cell fate restriction that could be manipulated to make somatic stem‐cell engineering possible. BioEssays 28: 574–577, 2006. © 2006 Wiley Periodicals, Inc. (shrink)

Age‐related and cancer‐related epigenomic modifications have been associated with enhanced cell‐to‐cell gene expression variability that characterizes increased cellular stochasticity. Since gene expression variability appears to be highly reduced by—and epigenetic and phenotypic stability acquired through—direct or long‐range cellular interactions during cell differentiation, we propose a common origin for aging and cancer in the failure to control cellular stochasticity by cell–cell interactions. Tissue‐disruption‐induced cellular stochasticity associated with epigenetic drift would be at the origin of organ dysfunction because of an (...) increase in phenotypic variation among cells, ultimately leading to cell death and organ failure through a loss of coordination in cellular functions, and eventually to cancerization. We propose mechanistic research perspectives to corroborate this hypothesis and explore its evolutionary consequences, highlighting a positive correlation between the median age of mass loss onset (a proxy for the onset of organ aging) and the median age at cancer diagnosis. (shrink)

More and more areas of medicine involve subjects donating tissues to another — blood, organs, bone marrow, sperm, ova and embryos can all be transferred from one person to another. Within the technical frameworks of biomedicine, such fragments are generally treated as detachable things, severed from social identity once they are removed from a particular body. However an abundant anthropological and sociological literature has found that, for donors and patients, human tissues are not impersonal. They retain some of the values (...) of personhood and identity, and their incorporation often has complex effects on embodied identity. This article draws on feminist philosophy of the body to think through the implications of some of these practices. Specifically, it draws on the idea of intercorporeality, wherein the body image is always the effect of embodied social relations. While this approach is highly productive for considering the stakes involved in tissue transfer, it is argued that the concept of body image has been too preoccupied with the register of the visual at the expense of introceptive data and health/illness events. Empirical data around organ transplant and sperm donation are used to demonstrate that the transfer of biological fragments involves a profound kind of intercorporeality, producing identifications and disidentifications between donors and recipients that play out simultaneously at the immunological, psychic and social levels. (shrink)

The use of human tissue raises ethical issues of great concern to health care professionals, biomedical researchers, ethics committees, tissue banks and policy makers because of the heightened importance given to informed consent and patient autonomy. The debate has been intensified by high profile scandals such as the “baby hearts” debacle and revelations about the retention of human brains in neuropathology laboratories worldwide. Respect for patient’s rights seems, however, to impede research and development of clinical knowledge in contemporary (...) health care. The Common clinical endeavour argument and a Presumption for beneficial use argument suggest that the use of tissues for research and teaching in contemporary health care can respect patients and their values in multicultural communities where there are provisions for oversight and for opting not to contribute, both of which should respect the diverse views of different ethnic or cultural groups. (shrink)

Two competing intuitions have dominated the debate over facial tissue transplantation. On one side are those who argue that relieving the suffering of those with severe facial disfigurement justifies the medical risks and possible loss of life associated with this experimental procedure. On the other are those who say that there is little evidence to show that such transplants would have longterm psychological benefits that couldn’t be achieved by other means and that without clear benefits, the risk is simply (...) too great. Ethicists on both sides have called for more analysis of the link between the face and personal identity in order to get a better grasp on potential gains and losses. This paper responds to that call by looking at contemporary philosophical analyses of the relation between organ transplants and personal identity and between the human face, human dignity, and human vulnerability. It is argued that the face matters not because it is the unique marker of our identity, but because of its role in the intersubjective constitution of moral identity and human dignity. (shrink)

Gametes, tissue, and organs can be taken from the dying or dead for reproduction, transplantation, and research. Whole bodies as well as parts can be used for teaching anatomy. While these uses are diverse, they have an ethical consideration in common: the claims of the people whose bodies are used. Is some use permissible only when people have consented to the use, actually wanted the use, would have wanted the use, not opposed the use, or what? The aim of (...) this article is to make progress in answering these questions. Initially I assume knowledge of people’s desires in order to test whether consent is directly required by their rights without worrying about mistaken uses against their wishes. I claim consent is not directly required by people’s rights. If we know people wanted or would want a use, their rights permit the use, but if we know they wanted or would want not to be used, their rights do not permit the use. The knowledge assumption is then dropped and the question becomes how to decide what to do when the wishes of rightholders are not known. I suggest working out what to do when wishes are known and then adjusting, on the basis of whatever evidence there is, for probability and strength of desire. There are other considerations too, for instance about default rules. The key general comment here is that, in setting rules, the costs to rightholders in not getting what they want needs to be taken into account. The final section tries to show that, in setting these rules, mistaken uses are not to be taken as worse than mistaken failure to use. (shrink)

The controversies in Bristol, Alder Hey and elsewhere in the UK surrounding the removal and retention of human tissue and organs have led to extensive law reform in all three UK legal systems. This paper reports a short study of the reactions of a range of health professionals to these changes. Three main areas of ethical concern were noted: the balancing of individual rights and social benefit; the efficacy of the new procedures for consent; and the helpfulness for professional (...) practice of the new legislation and regulation. Recognition of these concerns may help in forging a new partnership between professionals and patients and their families. (shrink)

In the United States, people may donate organs and tissues to a family member, friend, or anyone whose specific need becomes known to them. For example, in late 2003 dozens of people came forward to donate a kidney to a professional basketball player known to them only through his sports performances. People may also donate a kidney to no one in particular through a process known as nondirected donation. In nondirected donation, people donate a kidney to the organ allocation (...) system rather than to anyone known to them personally. There are limits, though, to generosity. People are usually not allowed to donate to groups of people, no matter the contours of the group, whether white, black, Catholic or Presbyterian, third-time liver recipient, and so on. As the agency that oversees national transplantation policy, the United Network for Organs Sharing does not allow this sort of restricted donation, though it appears that some regional Organ Procurement Organizations occasionally bend the rules when donors insist that their organs go to children or to first-time recipients. Those ad hoc arrangements are, however, the exception to the rule. (shrink)

Over 115 000 people are waiting for life-saving organ transplants, of whom a small fraction will receive transplants and many others will die while waiting. Existing efforts to expand the number of available organs, including increasing the number of registered donors and procuring organs in uncontrolled environments, are crucial but unlikely to address the shortage in the near future and will not improve donor/recipient compatibility or organ quality. If successful, organ bioengineering can solve the shortage and improve (...) functional outcomes. Studying manufactured organs in animal models has produced valuable data, but is not sufficient to understand viability in humans. Before risking manufactured organ experimentation in living humans, study of bioengineered organs in recently deceased humans would facilitate evaluation of the function of engineered tissues and the complex interactions between the host and the transplanted tissue. Although such studies do not pose risk to human subjects, they pose unique ethical challenges concerning the previous wishes of the deceased, rights of surviving family members, effective operation and fair distribution of medical services, and public transparency. This article investigates the ethical, legal and social considerations in performing engineered organ research on the recently deceased. (shrink)