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.

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. 

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.

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.

Legal Abortion Time-Limits: Arbitrary Limits Harm Women

By Dr. Lachlan de Crespigny, Department of Obstetrics and Gynaecology, University of Melbourne

The vote by the British parliament to keep the upper legal limit on abortion at 24 weeks was headline news around the world. An article in The Economist (1) considers that the British were spared America's abortion wars partly because Britain is less religious than America, but also because abortion laws are made in Parliament, where shades of grey can be debated, not in the courts, where black or white usually prevails.

Interestingly much of the debate was about ‘viability’ - the minimum gestational age at which a newborn is said to be capable of surviving with modern intensive care facilities. This is a simple across-the-board week count. But the survival rate of newborns also depends on many other factors, including where they are born (2, 3), fetal health including the presence or absence of an abnormality (which remains lawful where the child will be ‘seriously handicapped’), plus the condition of the newborn. While around half or so of 24 week newborns in Britain may survive, many or most of the abortions at around that gestation are of problem, or unhealthy, pregnancies.