Practical Ethics

When the heart stops: harvesting organs from the newly (nearly) dead

In the New England Journal of Medicine yesterday, doctors from Denver reported on three controversial cases of heart transplantation from newborn infants. These cases are striking for several reasons. They were examples of so-called ‘donation after cardiac death’ (DCD), an increasingly frequent source of organs for transplantation, but done very rarely in newborns. They are controversial because the transplanted organs were hearts that were ‘restarted’ in recipients after they had stopped in the donor. Transplant surgeons waited only a relatively short period after the donor’s heart had stopped (75 seconds) before starting the organ retrieval process. These transplants raise serious questions about the diagnosis and definition of death.

Would you rather be invisible or be able to fly? (Or: are you a sneaky superhero?)

If, like me, you were one of the kids whose preferred superpower was invisibility, you may soon be in luck. The BBC reports today that US scientists have created a material that could one day be used to make people and objects invisible. The material, which has so far been created only on a microscopic scale, neither absorbs nor reflects light, meaning that anyone looking at an object covered in it would see what lies behind the object rather than the object itself. It’s likely that such technology will be snapped up first by the military, but perhaps, in years to come, invisibility cloaks will be available to all.

For some, the idea of being invisible is distasteful. Being invisible means being able to get away with anything - and why bother to act morally when you can be sure that you’ll never be caught out? In this case, would a world full of people who can turn invisible at the drop of a hat be a world full of thieves, cheats, and sneaks?

The point of death

The Guardian yesterday reported the death of the man who had been so tragically shot in Antigua, with his wife, three weeks after their wedding. It began like this:

"Ben Mullany, the newlywed who was shot on honeymoon in Antigua in an attack that killed his wife, Catherine, died in hospital in Wales yesterday after his life support machine was switched off.  The 31-year-old trainee physiotherapist, who had suffered a fractured skull and had a bullet lodged in the back of his head, was flown back to Britain while in a coma on Saturday. Tests carried out when his condition stabilised after the 24-hour journey established he was brain dead." 

This is a familiar way of describing such happenings, even among clinical professionals.   Brain death is pronounced, so the life support machine is switched off, and the patient dies.   The clear implication is that brain death is not death.  The machine is still keeping the patient alive, and it is switching off the machine that causes real death. 

Slaves to consent?

Nature reports that in response to analysis done by bioethicist Robert Streiffer (and published in the Hastings Center Report), Stanford University may withdraw the use for research of several of its publicly funded stem cell lines because of concerns about consent. In 2001 President Bush decreed that only lines already in existence would be eligible for federal funding – 21 lines were subsequently approved by the NIH.

Saving the planet by reducing birth rates

Climate change will impact the well-being of future generations, directly by, for example, increased intensity and frequency of extreme weather events such as heavy storms. It will have also indirect impacts on human heath – via cardiovascular diseases or by a rise in epidemics as emerging disease leave the tropic and go North.

 
The beginning of this year, the British Medical Journal declared that since climate change impacts public health, doctors have to deal with it. And in tackling the problem, John Guillebaud, emeritus professor of family planning and reproductive health at University College London , and GP Pip Hayes from Exeter suggest that doctors should talk to their patients about climate change and encourage them to think about the environmental impacts of having a big family: see for example the Editorial or an article in the Daily Telegraph, or the Guardian. After all, “each UK birth will be responsible for 160 times more greenhouse ags emissions […] than a new birth in Ethiopia.”

 
Fair enough, the world is interconnected: environmental changes involve impacts on the population, and changes in the population impact the environment. But is it sensible to treat environmental problems not primarily as such, but making them problems of family planning?

Care for the Dying and Cost-effectiveness

Yesterday’s news reports the launch of the Government’s End of Life Care Strategy for England. This strategy will dedicate in excess of £250 million allowing patients who are dying to decide, as the Times puts it, “where and how to die.” This is part of a programme to provide better care for the dying. According to the BBC, only one in five deaths takes place at home despite a comfortable majority expressing a preference for such familiar surroundings. This prioritisation raises some interesting ethical issues particularly in the light of cost-effectiveness considerations.

Activists and acts of mercy

In Germany this week, and in Australia recently, there has been public concern and significant media attention about the actions of euthanasia activists. A former government official and lawyer, Roger Kusch, went public in Germany with a video of an elderly woman who he had helped to die. In Australia, Phillip Nitschke has been criticised for his involvement and subsequent comments about the death of Graeme Wylie a man suffering from Alzheimer’s disease whose partner and close friend have been found guilty of manslaughter.

Opponents of euthanasia have used these cases to argue against liberalisation of laws on assisted suicide or euthanasia.

Education and the Fairness of Capital Punishment

Regardless of their views on capital punishment most people desire it to be centred on due process and fairness. But a software experiment, by showing that the likelihood of execution of people on death row can be predicted to high accuracy, paradoxically suggests a great degree of arbitrariness in how the death penalty is applied in the US. A death sentence is essentially a lottery ticket: the condemned will be executed with a certain probability and otherwise suffer a long and uncertain imprisonment. But different convicts get different probability tickets, even when the legal system and all criminal circumstances are the same.

Duck and cover: how expensive does impact safety have to be?

This week is Tunguska week: on June 30 1908 a large meteoroid or comet exploded with the force of 5-30 megatons above the Tunguska River in Russia. The journal Nature celebrates it with several articles about impacts, ranging from a discussion of a controversial meteorite artwork to the confirmation that most of the northern hemisphere of Mars is a gargantuan crater.

From an ethics perspective the most interesting issue is how we should protect ourselves from rare but very destructive events. Had the Tunguska impactor hit an inhabited area it could easily have killed
millions, and larger impacts could imperil our species. But big impacts are rare: how much should we pay to detect and avoid them?

When autonomy trumps sense: the costs of refusal to allow withdrawal of life support.

In Canada this week, an 84 year old man died after 9 months of treatment in an intensive care unit. He had severe brain damage and multi-organ failure, but his family sought a legal injunction to prevent doctors in the intensive care unit from withdrawing life-support. Over the course of his long intensive care stay, intensive care beds at a major trauma centre were closed so that nurses could used instead to support his care, and three doctors resigned from the hospital in protest at being required to provide what they felt was ‘unethical’ treatment.