hkmiw and Crihl Can Nurring (1992) 8,227-233 Q Longman CroupUK Ltd 1992
Organ donation in intensive care - a look at the ethical issues Jane C. Smith
This paper is based on consideration of the ethical issues surrounding organ donation. This emotive subject has far-reaching implications concerning both donation and transplantation but the purpose in this paper is to deal specifically with issues related to cadaveric organ donation and how they concern nurses in an intensive care unit (ICU). A brief, general description of both ethics and organ donation is followed by a discussion of the issues surrounding the donor himself, including the diagnosis of brainstem death, the donor’s family, and the nursing and medical implications. Legal, social and economic factors are considered with the aim of highlighting ethical areas but not necessarily providing answers to the questions raised.
INTRODUCTION The achievement of successfulorgan donation has meant the possibilityof life and health to many people in recent years. With continuing advancements in medical technology including organ preservation, organ compatibility and immunosuppression, as well as improved methods of ventilation and system support, more and more people who would otherwise die are being given the chance not only of survival, but of longevity and quality of life. However, many of these transplants require cadaveric organs (Whittaker, 1990) and as transplantation becomes more sophisticated and more people are recognised as treatable by
Jane C. Smith RGN ENS 100, Staff Nurse, ITU, Kent and Canterbury UK
Hospital, Canterbury,
(Requests for offprints to JS) Manuscript
accepted
13 June 7992
Kent CT1 3NG.
transplant, donor organs are becoming scarce. This has led to an increase in efforts to obtain more organs. These efforts vary from encouraging the general public to carry organ donor cards, allowing use of their organs in the event of their death, and heightening the awareness of medical and nursing personnel in recognising potential donors and obtaining consent, to more contentious methods, such as the use of live donors for lung and liver transplants (Shaw et al, 1991), and experimentation with the use of the organs of infants born with anencephaly (Fries, 1989). The whole concept of organ donation is surrounded by an increasing variety of ethical issues and considerations often causing heated debate. Although certain facts are accepted and compromises reached, there often appears to be no definitive right or wrong answer to these questions. ‘Ethical situations arise when the moral decision of one person conflicts with the moral decision of another’ (Krekeler, 1987, cited by Fries, 1989), and people come to their own 227
228
lNTENSlVEANDCRITICALCARENURSIN(~
conclusions and decisions according to their personal opinions and feelings, and philosophical views. Fries (1989) describes two extremes of ethical theory, utilitarianism and deontology, which form the basis of ethical conflict. Utilitarianism, according to Fries, seeks the opinion that will benefit the majority and as such, if the outcome is positive, considers most actions justified. Deontology, on the other hand, focuses on the individual and the principles of autonomy, nonmaleficence (doing no harm), beneficence and justice. Human beings are never to be used merely as a means to an end and actions are seen as either right or wrong. These concepts help to give objectivity to ethical dilemmas but as many people identify with concepts from both these extremes, conflict can be caused within individuals and not just between them. Ethical issues may cause continuing debate among health care professionals and the public alike, but in hospitals all over the UK the retrieval of cadaveric organs for the purpose of transplantation is carried out regularly, and nurses are faced with many ethical dilemmas. In order to discuss these issues more thoroughly they can be loosely divided into three groups: those concerning the donor, those concerning the donor’s relatives and those concerning nursing and medical intervention. These three groups will be considered individually.
The donor In the case of cadaveric organ donation the major area of ethical concern surrounds the death of the donor patient. Issues include the identification and diagnosis of brainstem death, the question of responsibility for consent for organ retrieval to go ahead, and the attitudes and beliefs surrounding death itself. One factor that has made the current level of organ donation possible is the recognition of brainstem death and the maintenance of physiological functions until organ retrieval can be arranged. However, with the growing number of patients waiting for transplantation, the problem is how to increase public awareness regard-
ing organ donation, and how to abolish the myths and fears and misconceptions associated with it. But will education necessarily increase the number of available organs? Death is an inevitable fact of life for us all and yet, because of fear, uncertainty or even denial, it is rarely discussed openly unless absolutely necessary, particularly the fact of our own mortality (Whittaker, 1990). Death has traditionally been understood, and even defined as, the cessation of breathing and cardiac function (Conference of Medical Royal Colleges, 1979). Now, with the development of ventilation and other techniques, these functions can be artificially maintained after the brain stem has ceased to function and the patient has actually died. This is a concept that many people find difficult to comprehend and the opponents of practical use of the concept of brainstem death suggest that while the patient may be doomed to die he is not yet actually dead (Neuberger, 1987). The brainstem joins the cerebral cortex to the spinal cord, linking the whole brain to the rest of the body and being responsible for the activation of the higher centres. It also contains vital structures controlling respiration, cardiac function and blood pressure. If the brainstem is damaged so severely that it dies all these functions cease, and as brainstem death is irreversible the patient is legally dead even if the rest of the body is completely uninjured. Eventually, despite mechanical ventilation, the heart will stop beating (Conference of Medical Royal Colleges, 1979). Causes of brainstem death include head trauma, often sustained in a road traffic accident, intracranial haemorrhage such as intra-cerebral or subarachnoid haemorrhage, cerebral neoplasm, or hypoxic brain injury following a cardiac or respiratory arrest.
Criteriafor brainstemdeath The criteria for the diagnosis of brainstem death in the UK were laid down by the Conference of Medical Royal Colleges and their Faculties (1976) after much discussion and deliberation. It is essential that nurses working in the critical care
INTENSlVEAND
Organ donation in intensive care - a look at the ethical issues Jane C. Smith
This paper is based on consideration of the ethical issues surrounding organ donation. This emotive subject has far-reaching implications concerning both donation and transplantation but the purpose in this paper is to deal specifically with issues related to cadaveric organ donation and how they concern nurses in an intensive care unit (ICU). A brief, general description of both ethics and organ donation is followed by a discussion of the issues surrounding the donor himself, including the diagnosis of brainstem death, the donor’s family, and the nursing and medical implications. Legal, social and economic factors are considered with the aim of highlighting ethical areas but not necessarily providing answers to the questions raised.
INTRODUCTION The achievement of successfulorgan donation has meant the possibilityof life and health to many people in recent years. With continuing advancements in medical technology including organ preservation, organ compatibility and immunosuppression, as well as improved methods of ventilation and system support, more and more people who would otherwise die are being given the chance not only of survival, but of longevity and quality of life. However, many of these transplants require cadaveric organs (Whittaker, 1990) and as transplantation becomes more sophisticated and more people are recognised as treatable by
Jane C. Smith RGN ENS 100, Staff Nurse, ITU, Kent and Canterbury UK
Hospital, Canterbury,
(Requests for offprints to JS) Manuscript
accepted
13 June 7992
Kent CT1 3NG.
transplant, donor organs are becoming scarce. This has led to an increase in efforts to obtain more organs. These efforts vary from encouraging the general public to carry organ donor cards, allowing use of their organs in the event of their death, and heightening the awareness of medical and nursing personnel in recognising potential donors and obtaining consent, to more contentious methods, such as the use of live donors for lung and liver transplants (Shaw et al, 1991), and experimentation with the use of the organs of infants born with anencephaly (Fries, 1989). The whole concept of organ donation is surrounded by an increasing variety of ethical issues and considerations often causing heated debate. Although certain facts are accepted and compromises reached, there often appears to be no definitive right or wrong answer to these questions. ‘Ethical situations arise when the moral decision of one person conflicts with the moral decision of another’ (Krekeler, 1987, cited by Fries, 1989), and people come to their own 227
228
lNTENSlVEANDCRITICALCARENURSIN(~
conclusions and decisions according to their personal opinions and feelings, and philosophical views. Fries (1989) describes two extremes of ethical theory, utilitarianism and deontology, which form the basis of ethical conflict. Utilitarianism, according to Fries, seeks the opinion that will benefit the majority and as such, if the outcome is positive, considers most actions justified. Deontology, on the other hand, focuses on the individual and the principles of autonomy, nonmaleficence (doing no harm), beneficence and justice. Human beings are never to be used merely as a means to an end and actions are seen as either right or wrong. These concepts help to give objectivity to ethical dilemmas but as many people identify with concepts from both these extremes, conflict can be caused within individuals and not just between them. Ethical issues may cause continuing debate among health care professionals and the public alike, but in hospitals all over the UK the retrieval of cadaveric organs for the purpose of transplantation is carried out regularly, and nurses are faced with many ethical dilemmas. In order to discuss these issues more thoroughly they can be loosely divided into three groups: those concerning the donor, those concerning the donor’s relatives and those concerning nursing and medical intervention. These three groups will be considered individually.
The donor In the case of cadaveric organ donation the major area of ethical concern surrounds the death of the donor patient. Issues include the identification and diagnosis of brainstem death, the question of responsibility for consent for organ retrieval to go ahead, and the attitudes and beliefs surrounding death itself. One factor that has made the current level of organ donation possible is the recognition of brainstem death and the maintenance of physiological functions until organ retrieval can be arranged. However, with the growing number of patients waiting for transplantation, the problem is how to increase public awareness regard-
ing organ donation, and how to abolish the myths and fears and misconceptions associated with it. But will education necessarily increase the number of available organs? Death is an inevitable fact of life for us all and yet, because of fear, uncertainty or even denial, it is rarely discussed openly unless absolutely necessary, particularly the fact of our own mortality (Whittaker, 1990). Death has traditionally been understood, and even defined as, the cessation of breathing and cardiac function (Conference of Medical Royal Colleges, 1979). Now, with the development of ventilation and other techniques, these functions can be artificially maintained after the brain stem has ceased to function and the patient has actually died. This is a concept that many people find difficult to comprehend and the opponents of practical use of the concept of brainstem death suggest that while the patient may be doomed to die he is not yet actually dead (Neuberger, 1987). The brainstem joins the cerebral cortex to the spinal cord, linking the whole brain to the rest of the body and being responsible for the activation of the higher centres. It also contains vital structures controlling respiration, cardiac function and blood pressure. If the brainstem is damaged so severely that it dies all these functions cease, and as brainstem death is irreversible the patient is legally dead even if the rest of the body is completely uninjured. Eventually, despite mechanical ventilation, the heart will stop beating (Conference of Medical Royal Colleges, 1979). Causes of brainstem death include head trauma, often sustained in a road traffic accident, intracranial haemorrhage such as intra-cerebral or subarachnoid haemorrhage, cerebral neoplasm, or hypoxic brain injury following a cardiac or respiratory arrest.
Criteriafor brainstemdeath The criteria for the diagnosis of brainstem death in the UK were laid down by the Conference of Medical Royal Colleges and their Faculties (1976) after much discussion and deliberation. It is essential that nurses working in the critical care
INTENSlVEAND
