After continuous dispute since the 1990s about whether there is in fact a Chinese philosophy, more and more Chinese intellectuals — including and especially philosophers — have begun in the last decade or so to centre on a more concrete problem of philosophical practice, namely: “is philosophy in the Chinese language possible?” and “how should we reason in modern Chinese?” Among many topics raised, “transplanted terms,” initiated by Chen Jiaying (1952–), has attracted widespread attention. Based on Chen's work, this article (...) introduces and explores the problem of transplanted terms as a particular challenge for Chinese philosophical practice. (shrink)

In this comparative analysis of twelve focus groups conducted in Austria, France, and the Netherlands, we investigate how lay people come to terms with two biomedical technologies. Using the term ‘‘technopolitical culture,’’ we aim to show that the ways in which technosciences are interwoven with a specific society frame how citizens build their individual and collective positions toward them. We investigate how the focus group participants conceptualized organ transplantation and genetic testing, their perceptions of individual agency in relation to the (...) two technologies and to more collective forms of acting and governing, and also their understanding of the two technologies’ relationship to broader societal value systems. Against the background of the sustained political effort to build common European values, we suggest that more fine-grained attention toward the culturally embedded differences in coming to terms with biomedical technologies is needed. (shrink)

Transplantation research on samples and organs from deceased donors in England, Wales and Northern Ireland is under threat. The key problems relate to difficulties encountered in gaining consent for research projects, as distinct from consent to donation for clinical transplantation. They are due partly to the terms of the Human Tissue Act 2004 (the 2004 Act), and partly to its interpretation by the Human Tissue Authority (HTA). They include excessive interaction with donor representatives regarding ‘informed consent’ to research projects, uncertainty (...) as to the scope and duration of a donor's ‘authority’ over an organ, and restrictions caused by the apparent need for licensing of transplantation research under the 2004 Act, combined with lack of certainty, or guidance, as to the distinction between ‘research’, which requires a licence, and ‘service development’, which does not. In our view this confusion hinders and deters Specialist Nurses for Organ Donation in approaching donor representatives and discussing possible research projects with them. It has also, as we have reported elsewhere, led to abandonment of research projects for fear of liability, despite both Research Ethics Committee (REC) approval and donor consent. Such problems do not seem to occur under the transplant laws of most other comparable jurisdictions. The Transplantation Ethics Symposium, ‘The ethics of organ retrieval: goals, rights and responsibilities’, hosted by the MRC Centre for Transplantation at King's College London in December 2010, revealed that many senior clinicians and researchers, administrators, and lawyers are both unclear and in disagreement concerning the effects of the 2004 Act and the extent to which it is adhered to or ignored in practice. In this paper we examine the difficulties encountered and suggest solutions based on a less restrictive interpretation of the 2004 Act, or, more probably, a regulatory change under its authority. We propose that, in the long term, a law which includes consent for REC-approved research within the general consent for organ donation and transplantation seems preferable to the present system, both ethically and in practical terms. (shrink)

The current definition of death used for donation after cardiac death relies on a determination of the irreversible cessation of the cardiac function. Although this criterion can be compatible with transplantation of most organs, it is not compatible with heart transplantation since heart transplants by definition involve the resuscitation of the supposedly "irreversibly" stopped heart. Subsequently, the definition of "irreversible" has been altered so as to permit heart transplantation in some circumstances, but this is unsatisfactory. There are three available strategies (...) for solving this "irreversibility problem": altering the definition of death so as to rely on circulatory irreversibility, rather than cardiac; defining death strictly on the basis of brain death (either whole-brain or more pragmatically some higher brain criteria); or redefining death in traditional terms and simultaneously legalizing some limited instances of medical killing to procure viable hearts. The first two strategies are the most ethically justifiable and practical. (shrink)

Here I critique the approach often seen in bioethics, termed "Chicken Little bioethics," which emphasizes only the potential risks of novel therapies, using fecal microbiota transplant (FMT) as a case study. I argue that, instead of cataloging hypothetical risks, bioethicists should focus on establishing an ethical framework for FMT based on justice, beneficence, nonmaleficence, and autonomy. The essay advocates for empirical risk-benefit analysis through initiatives like the FMT registry, which tracks patient outcomes to better assess the actual risks and benefits (...) compared to antibiotic alternatives. Additionally, I address challenges related to informed consent, donor selection, and access to FMT, underscoring the need for balanced policies that consider both patient safety and the equitable availability of this promising therapy. In the end, I call for a regulatory approach that fosters responsible innovation while allowing FMT and similar bacteriotherapies to be integrated safely and effectively into medical practice. (shrink)

Currently, brain tissue transplantations are being developed as a clinical-therapeutic tool in neurodegenerative diseases such as Parkinson's or Alzheimer's disease. From an ethical point of view, distinguishing between the preservation and an alteration of personal identity seems to be central to determining the scope for further application of brain tissue transplantation therapy. The purpose of this article is to review "standard" arguments which are used on the one hand by proponents to prove preservation of personal identity and by opponents on (...) the other hand to prove that brain tissue transplantation results in an altered personal identity. Proponents and opponents are shown to use the same arguments, albeit with different presuppositions. These presuppositions concern the meaning of the term "identity", either numerical or qualitative, the definition of brain identity, either structurally or functionally, and the relationship between mental states, psychological functions and neurophysiological properties as criteria for personal identity. Furthermore the respective neurophysiological, clinical and philosophical evidence for the different presuppositions are discussed. It is concluded that evaluation of personal identity in brain tissue transplantation should not only rely on the "standard" arguments but, additionally, neurophysiological, clinical and philosophical implications should be discussed. (shrink)

Many believe that it is morally wrong to give lower priority for a liver transplant to alcoholics with end-stage liver disease than to patients whose disease is not alcohol-related. Presumably, alcoholism is a disease that results from factors beyond one's control and therefore one cannot be causally or morally responsible for alcoholism or the liver failure that results from it. Moreover, giving lower priority to alcoholics unfairly singles them out for the moral vice of heavy drinking. I argue that the (...) etiology of alcoholism may involve enough control for the alcoholic to be responsible for his condition and accordingly have a weaker claim to receive a new liver than someone who acquires the disease through no fault of his own. In addition, I show why it is more plausible to reframe the question of priority in terms of control and responsibility rather than virtue and vice. Given that medical resources like livers are scarce, some people may justifiably be given lower priority than others in receiving these resources. (shrink)

The study of legal transplants provides a vital critical supplement to mainstream theories about legal change. Legal transplants are not exceptional or isolated occurrences, despite the economic, social, political and cultural barriers that separate the world’s legal systems. This Article goes beyond traditional approaches to the study of transplants by substituting the figurative language of transplants with explicit theory about how legal change is produced. It first provides a brief account of what the literature on legal transplants has achieved so (...) far in terms of "macro" explanations of legal change currently available. It then argues that legal transplants as social acts performed by individuals call for a study of the "micro" level of engagement with legal change by individuals. The key notion that is advanced to explore this dimension is the notion of mediated action, which denotes action that is performed by individuals making use of features of the environment as tools to interact in a specific setting. The notion of mediated action was first introduced in cultural-historical psychological investigations of the social formation of the mind. As social acts, legal transplants represent instances of mediated action. The last part of this Article highlights how legal transplants raise questions of justice and discusses briefly how the new approach to the study of transplants advocated here relates to them. (shrink)

Should Christians support the view that one’s psychological continuity is the main criterion of personal identity? Is the continuity of one’s brain or memory states necessary and sufficient for the identicalness of the person? This paper investigates the plausibility of the psychological continuity theory of personal identity, which holds that the criterion of personal identity is certain psychological continuity between persons existing at different times. I argue that the psychological continuity theory in its various forms suffers from interminable problems. Then, (...) I introduce an alternate account of personal identity, according to which personal identity is not further analyzable in terms of qualitative properties of persons. Rather, persons are individuated by their primitive thisnesses, which are nonqualitative properties of immaterial substances. This alternate conception of personal identity would be of particular relevance to those who believe in the immortality of the soul and are looking for a nonphysicalist account of personal identity. (shrink)

In lieu of an abstract, here is a brief excerpt of the content:The Transformative Journey of TransplantationValen KeeferThe moisture from the ocean floated effortlessly through the air as it glided over the rocky cliff. The steady stream of mist covered my face and frizzy hair with beaded water droplets. I had been sitting on a bench alone for hours admiring the Northern California coast at a magnificent overlook featuring a bird’s-eye view of the endless sea and campground I called home (...) for the past month. The stunning mountain landscape behind me, the soothing colors of the coastal shrubbery, and the smell of eucalyptus made for a trifecta of surreal beauty. The ocean disappeared from my view and I became engulfed in the precipitation and felt like I was suspended in a cloud. I was soaking in every moment as it was the last day of my solo RV trip.The fog slowly separated and exposed bits and pieces of the ocean again and then a breathtaking rainbow came into sight. Each end appeared to be touching either side of the campground like it was giving it a hug. I was eye-level with the center and highest point of the rainbow, arching above our home on wheels. I stood on the bench with my arms wide open, embracing nature and the gift of life in all its glory. This moment would not have possessed such deep meaning if it wasn’t for the journey that came before it—the transformative journey of transplantation.Some may think of transplantation as a singular event when in reality, it’s a lifelong journey that can start with a diagnosis many years prior. My transplant journey began when I was diagnosed with polycystic kidney disease (PKD) at 10-years-old. Being diagnosed with a hereditary disease that has deeply impacted multiple generations of our family and with no known treatment or cure was a lot to carry as a child.My youth was full of love from my parents and filled with illness and the limitations and long-term impacts of growing up with multiple chronic illnesses. My education on PKD was the brutal real-life experiences of enduring it firsthand—with no support groups, resources, or internet to seek answers. I always felt different during a time when you’d do anything to fit in. I couldn’t play sports and had to sit on the sidelines in gym class. I was often in the nurse’s office, hospital, or recovering from a surgery. I hid my scars and unattractive body while changing in gym class. Friendships were really hard. Relationships were even harder.Growing up with chronic illnesses takes away from the fun of dreaming. It’s like that bright future full of endless possibilities is blocked by a huge mountain you know you have to summit first with no supplies, no friends, and no paved path to follow.Complications from PKD followed me from high school right into college, when I spent almost a year in the hospital. Both of my kidneys were removed, I was on dialysis, had pancreatitis, received over 70 blood transfusions, survived an internal bleed, and was in dire need of a lifesaving kidney transplant.At 19-years-old, I was too sick to be placed on the transplant waiting list, but needed a kidney to survive. My parents were living at the Ronald McDonald House, wondering if they would be the next ones to lose their teenage daughter. A close family friend forever changed our lives when she restored my health by selflessly donating her kidney to me. While it was an arduous path to transplantation, in some ways, the journey was just beginning.Fifteen years following my kidney transplant and summiting what I thought was going to be the most challenging mountain of my health journey, I found myself back on death’s doorstep with another battle ahead. I was in need of a second miracle, this time a lifesaving liver transplant. It was PKD again. The bile ducts in my liver were so gnarly that they looked like limbs of an oak tree rather than the desired smooth straw-like appearance. Their malformations led to chronic liver infections and multiple sepsis... (shrink)

Transplant surgeons in the USA have begun performing a novel organ procurement protocol in the setting of circulatory death. Unlike traditional donation after circulatory death (DCD) protocols,in situnormothermic perfusion DCD involves reperfusing organs, including the heart, while still contained in the donor body. Some commentators, including the American College of Physicians, have claimed thatin situreperfusion after circulatory death violates the widely accepted Dead Donor Rule (DDR) and conclude thatin situreperfusion is ethically impermissible. In this paper I argue that, in terms (...) of respecting the DDR,in situreperfusion cardiac transplantation does not differ from traditional DCD cardiac transplantation. I do this by introducing and defending a refined conception of circulatory death, namelyvegetative state function permanentism. I also argue against the controversial brain occlusion feature of thein situreperfusion DCD protocol, on the basis that it is ethically unnecessary and generates the problematic appearance of ethical dubiousness. (shrink)

Fecal microbiota transplantation has demonstrated efficacy and is increasingly being used in the treatment of patients with recurrent Clostridium difficile infection. Despite a lack of high-quality trials to provide more information on the long-term effects of FMT, there has been great enthusiasm about the potential for expanding its applications. However, FMT presents many serious ethical and social challenges that must be addressed as part of a successful regulatory policy response. In this article, we draw on a sample of the scientific (...) and bioethics literatures to examine clusters of ethical and social issues arising in five main areas: informed consent and the vulnerability of patients; determining what a “suitable healthy donor” is; safety and risk; commercialization and potential exploitation of vulnerable patients; and public health implications. We find that these issues are complex and worthy of careful consideration by health care professionals. Desperation of a patient should not be the basis for selecting treatment with FMT, and the patient's interests should always be of paramount concern. Authorities must prioritize development of appropriate and effective regulation of FMT to safeguard patients and donors, promote further research into safety and efficacy, and avoid abuse of the treatment. (shrink)

This article examines the temporality of organ transplantation with a focus on memoirs where the recipient has received an organ from a deceased donor. I argue that death constitutes life. That is, this absent presence – that the organ is materially present but the person is dead and therefore absent – is the foundation for rethinking relationality as constituted through the haunting presence of those who remain central to the continuity of life but who are not alive in any strict (...) definition of the term. This article is therefore attentive to the various meanings of haunting, drawing on queer theory to show how narratives of haunting are derealised experiences and thus a struggle for epistemological authority over specifically transplantation and relationality more broadly. It draws out how these epistemological challenges reimagine ontology as a haunted experience, and thus an intimate tie between the living and the unknown – and somewhat present – dead. (shrink)

During their settlement in Vienna and New York City, Bosnian refugees experienced class and ethnic conflicts. While the integration mechanisms of the two host societies differed substantially, Bosnian men and women have developed quite different networks. Bosnian women in the Vienna sample developed often lasting relationships with natives or other non-refugees that eventually led to permanent jobs and rather substantial networks. They integrated particularly into wider majority societal circles. However, even though women in Vienna developed substantial networks, clashes based on (...) different social classes often resulted in conflicts in the women's work environment. Bosnian women and men in New York City only rarely established similar networks with US residents and other long-term residents. Their integration occurred more along ethnic boundaries. Bosnian men in Vienna and the Bosnian refugee population in general in New York City integrated predominantly into the newly formed Bosnian communities in those locales. (shrink)

Not that long ago, any thought of transferring body parts, or fluids like blood, among individuals was expressed in terms of a nightmare. Consider the problem of involuntary blood transfusions to Count Dracula! Or recall the infamous brain transplant to the brutish body under Dr. Frankenstein's ministrations. The very thought of bodily transference stimulated writers to create monsters. The stuff of evil seemed to surround any attempt. Hubris was considered the evil that exceeded the normal limits of scientific research and (...) development. Transplantation seemed to make humans into gods who defied death but who, like Icarus and his wax wings, flew too close to the sun. (shrink)

Patient autonomy and distributive justice are fundamental ethical principles that may be at risk in liver transplant units where decisions are dictated by the need to maximise the utility of scarce donor organs. The processes of patient selection, organ allocation and prioritisation on the wait list have evolved in a constrained environment, leading to high levels of complexity and low transparency. Regarding paternalism, opaque listing and allocation criteria, patient factors such as passivity, guilt, chronic illness and sub-clinical encephalopathy are cited (...) as factors that may inhibit patient engagement. Regarding justice, established regional, gender and race based inequities are described. The paradox whereby hepatologists both advocate for individual patients and discharge their duty of stewardship to apportion organs according to larger utilitarian principles is explored. Competing subjective factors such as physicians’ perception of moral responsibility, the qualitative nature of expert medical assessment and institutional or personal loyalty to re-transplantation candidates are described. Realistic limits of self-determination and justice are discussed, and possible future directions in terms of patient involvement proposed. (shrink)

Organ transplantation has been central to debates on medical technologies and their complex biopolitical consequences, new forms of medical governance and new opportunities for capital. Attending to transplantation has also opened up new ways of thinking about, acting on and living ‘in’ the body, raising important questions about what it means to be embodied under particular cultural conditions. The specific ways in which a technology like transplantation puts the body parts of some at the disposal of the bodies of others (...) has served to (re)write bodily boundaries, commoditise body parts and reorganise the social relations of exchange, care and responsibility. The controversies that this family of technologies has given rise to are both readable and read as embedded in and expressive of wider forms of conflict and contestation. Putting these controversies and their entanglements centre-stage, this article focuses on the manner in which transplant technologies construct their publics in gendered and socially stratified terms, as they reconstruct the transplanted organ as a new site for the extraction of surplus value. Drawing on data from fieldwork in Mexico, I will examine the catastrophic consequences of transplant medicine for Mexico’s poor, particularly women who bear the burden of care for the country’s predominantly living transplant programme. In carrying the costs (moral, social and economic) their accounts of these processes offer us an important critical vantage point from which to assess the interplay between state, market and the ‘worn’ body in the context of transplantation. (shrink)

This paper deals with a problem which has received a great deal of attention in the ethical literature, but about which very little is known empirically: the selection of recipients for organs in transplant medicine. Based on a larger study, it is shown how this problem is practically resolved in one European country, Germany. It is demonstrated that most of the criteria used to determine recipients are non-medical in nature, even though they generally tend to be rationalized in medical terms. (...) Moreover, the choice of criteria depends as much on prognostic considerations as on personal indiosyncrasies and values held by individual physicians who are in charge at the various programs. Several examples of the extremely diverse policies in which this results are presented. (shrink)

Transplantation is now the best therapy for eligible patients with end-stage organ disease. For patients with failed kidneys, successful renal transplantation improves the quality and increases the quantity of their lives. For people with other types of organ failure, transplantation offers the only hope for long-term survival. a.

This article probes the voucher program from an ethical perspective. It focuses mainly on an issue of inequity. A disparity exists in US kidney transplantation. Although African-Americans suffer far higher rates of ESRD than whites, African-Americans are much less likely than whites to get a transplant. The article explores the voucher program in light of this disparity. It motivates the view that, at least in the short term, more whites than African-Americans are likely to take advantage of the voucher program. (...) The program is, thus, likely to increase the gap in transplantation rates between the two groups. If this is correct, what impact does it have on the moral acceptability of the program? (shrink)

This paper explores Jean‐Luc Nancy's philosophical reflection on surviving his own heart transplant. In ‘The Intruder’, he raises central questions concerning the relations between what he refers to as a ‘proper’ life, that is, a life that is thought to be one's own singular ‘lived experience’, and medical techniques, shaped at this particular historical juncture by cyclosporine or immuno‐suppresssion. He describes the temporal nature of an ever‐increasing sense of strangeness and fragmentation which accompanies his heart transplant. In doing so, Nancy (...) opens up the concealed of transplantation in terms of the problematic ‘gift’ of a ‘foreign’ organ, the unremitting suffering intrusiveness of the treatment regimen, and the living of life as ‘bare life’. He uncovers and exposes the relentless uncanniness that pervades the post‐transplant experience, which for him is an example of our humanistic, never‐ending impulse, to alter ourselves. Nevertheless, Nancy offers no answer to this dilemma, but instead calls us to think about the meaning or ‘sense’ of the prolonging of life and deferring of death, which currently drives our medical interventions. (shrink)

ABSTRACT An American surgical team has announced its intention to perform the first human facial transplantation. The team has, however, invited further analysis of the ethical issues before it proceeds and in this paper we take up that challenge in seeking to frame the debate with a particular focus on the recipients of the transplant. We address seven related areas of concern and identify numerous questions that require answers or, perhaps, better answers. We start by examining the nature of the (...) procedure and its intended benefits, why the procedure is being developed, and whether or not this should be viewed as experimental. Having concluded that this is experimental in nature, we then consider the broad question, who is the patient? Here we perceive difficulties in terms of the autonomy of the recipient, the unpredictable effects of receiving the transplant, and the role and influence of society. We conclude by asking whether the question should be ‘whether or not?’ rather than ‘when?’, particularly while the risks of losing face appear to far outweigh the likelihood of gaining face. (shrink)

Abstract:This symposium includes thirteen personal narratives from people who have received at least one organ transplant from a living or deceased donor. These narratives foster better understanding of the experiences of life-saving organ recipients and their families, including post-transplant difficulties experienced—sometimes requiring multiple transplants. This issue also includes three commentaries by Macey L. Levan, Heather Lannon, and Vidya Fleetwood, Roslyn B. Mannon & Krista L. Lentine. Dr. Levan is a living kidney donor and associate professor of surgery and population health. (...) She writes and teaches on organ transplant and has expertise and experience in governance at the federal level as a member of the board of directors for the U.S. Organ Procurement and Transplantation Network. Dr. Lannon is a social worker and transplant advocate. Her work and interest in the topic were inspired by her husband who needed a heart transplant. Dr. Fleetwood is a surgeon specializing in liver transplantation, pancreas transplantation, kidney transplantation, as well as living donor nephrectomy. Dr. Mannon is a nephrologist and professor of medicine, pathology and microbiology. Her work focuses on understanding and improving long-term kidney transplant outcomes for patients, donors, and caregivers. Dr. Lentine is a nephrologist specializing in treatment of adult patients with kidney disease. She is a researcher and co-chaired the international work group that developed guidelines for living donor kidney transplantation. (shrink)

In lieu of an abstract, here is a brief excerpt of the content:Kennedy Institute of Ethics Journal 10.1 (2000) 75-80 [Access article in PDF] Bioethics Inside the Beltway: A New Basis for Allocating Livers for Transplant Robert M. Veatch The Department of Health and Human Services (DHHS) and the United Network for Organ Sharing (UNOS), the private organization with the government contract to manage the national organ transplant program, are in the midst of a protracted dispute over how livers for (...) transplant should be allocated. UNOS, which is based in Richmond, Virginia, has for many years set the national policy for allocating cadaver organs. UNOS had a policy that, in effect, gave healthy local recipients priority over much sicker, more urgent cases beyond the local level. In April of 1998, Donna Shalala, the Secretary of Health and Human Services, issued a regulation requiring that organs must be allocated according to uniform medical criteria and that organ sharing must take place over broad enough areas to ensure that organs can reach the patients who need them most. In effect, she sought to overturn the strict local priority in favor of a more uniform national list based on medical need or at least an approach that extended allocation beyond the strict locals-first approach.UNOS has put up great resistance, expressing a strong preference for retaining local priority even though doing so means some desperately sick people at more distant centers almost certainly will die for lack of organs. What sounds at first like a rather esoteric dispute over government regulation turns out to raise some fascinating issues involving questions of ethics and moral epistemology. The Background For several years, UNOS followed a policy of dividing all potential liver transplant recipients into four categories based on how urgently the person needed a transplant. Status 1 patients were the sickest, essentially those in intensive care. Status 2 patients were the next most ill-in the hospital, but not the ICU. Status 3 patients were ill enough to be at home, while Status 4 patients were still up and about. UNOS coordinates 62 local organ procurement organizations (OPOs), each serving a metropolitan area. These are grouped into 11 regions.The long-term allocation rule gave first priority to local Status 1 patients. If no Status 1 patient was available locally, rather than sending the organ to another OPO, it would be assigned to a Status 2 patient in the same OPO where the [End Page 75] organ was procured, then to a local Status 3 patient, and then to one at Status 4. Only if no patients could use the organ locally would it be "exported" to another OPO. It would then be offered to another OPO in the same region, starting once again with patients at the most urgent status. Only if no patients in the region could use the organ would it be offered outside the region. The effect of this policy was that in some cases quite well-off local patients could get priority over more distant patients who only had hours or days to live if they did not get transplanted. (It was because of this policy that Mickey Mantle-who was Status 2-got an organ so quickly. There were no other suitable Status 1 or 2 patients in the Dallas area. He did not have to compete with any of the thousands of liver transplant patients on the waiting lists beyond his local area.)The realization that critically ill patients beyond the local area were dying while healthy local patients got organs even though they still could wait for perhaps months or years led DHHS to issue its mandate. The goal was to get more organs to people who were in desperate need.The response at UNOS has been hostile. UNOS is made up primarily of representatives from the OPOs, which, in turn are often dominated by transplant surgeons. They did not like the idea that locally-procured organs were being shipped to other communities when they had their own patients who needed them.Spokespersons for this position offered two primary arguments. First, they believed that people would be more... (shrink)

This longitudinal, qualitative study investigated the genesis and transformation of the social representations of organ transplants. A search of the West Australian newspaper, from 1954 to 1995 found 672 articles pertaining to organ transplants. Two distinct, but conflicting, representations emerged in the analyses. In the first representation, found from 1967/68, the surgeon was paramount and organ transplants were iconised as ‘spare part surgery’. In the second representation, found from 1984/85, the role of the donor was emphasised and transplants iconised as (...) a ‘gift of life’. Both representations were discernible in 1994/95. We consider the question whether there are now two conflicting representations or one representation with two conflicting sets of beliefs at its core. The results are discussed in terms of anchoring, objectification, transformation, and structure, as well as Moscovici’s notion of canonic themata. (shrink)

This issue of The Journal of Medicine and Philosophy brings together an international group of scholars from Hong Kong, Mainland China, and North America, critically to explore whole-body/head transplantation. The proposed procedure raises significant philosophical, ethical, and social/political questions. For example, assuming transplant is successful, who survives the surgery? Does personal identity necessarily follow the head? The contributors to this special thematic issue explore the nature and ground of personal identity, what it would mean to preserve personal identity, given such (...) a significant set of physical changes, as well as the morality of such a procedure. As the authors make clear, careful conceptual philosophical analysis is essential for understanding whether whole-body/head transplantation is a life-saving/life-enhancing technological innovation, or a bioethical morass that should not be attempted. How we come to terms with such conceptual and moral concerns will have a significant impact on the future of medicine and medical technological innovation. (shrink)

This book supports the emerging field of vascularized composite allotransplantation for face and upper-limb transplants by providing a revised, ethically appropriate consent model which takes into account what is actually required of facial and upper extremity transplant recipients. In place of consent as permission-giving, waiver, or autonomous authorization, this book imagines consent as an ongoing mutual commitment, i.e. as covenant consent. The covenant consent model highlights the need for a durable personal relationship between the patient/subject and the care provider/researcher. Such (...) a relationship is crucial given the recovery period of 5 years or more for VCA recipients. The case for covenant consent is made by first examining the field of vascularized composite allotransplantation, the history and present understandings of consent in health care, and the history and use of the covenant concept from its origins through its applications to health care ethics today. This book explains how standard approaches to consent are inadequate in light of the particular features of facial and upper limb transplantation. In contrast, use of the covenant concept creates a consent model that is more appropriate ethically for these very complex surgeries and long-term recoveries. (shrink)

This article proposes the term “safety logics” to understand attempts within the European Union to harmonize member state legislation to ensure a safe and stable supply of human biological material for transplants and transfusions. With safety logics, I refer to assemblages of discourses, legal documents, technological devices, organizational structures, and work practices aimed at minimizing risk. I use this term to reorient the analytical attention with respect to safety regulation. Instead of evaluating whether safety is achieved, the point is to (...) explore the types of “safety” produced through these logics as well as to consider the sometimes unintended consequences of such safety work. In fact, the EU rules have been giving rise to complaints from practitioners finding the directives problematic and inadequate. In this article, I explore the problems practitioners face and why they arise. In short, I expose the regulatory anatomy of the policy landscape. (shrink)

Recent commentaries by Verheijde et al, Evans and Potts suggesting that donation after cardiac death practices routinely violate the dead donor rule are based on flawed presumptions. Cell biology, cardiopulmonary resuscitation, critical care life support technologies, donation and transplantation continue to inform concepts of life and death. The impact of oxygen deprivation to cells, organs and the brain is discussed in relation to death as a biological transition. In the face of advancing organ support and replacement technologies, the reversibility of (...) cardiac arrest is now purely related to the context in which it occurs, in association to the availability and application of support systems to maintain oxygenated circulation. The 'complete and irreversible' lexicon commonly used in death discussions and legal statutes are ambiguous, indefinable and should be replaced by accurate terms. Criticism of controlled DCD on the basis of violating the dead donor rule, where autoresuscitation has not been described beyond 2 minutes, in which life support is withdrawn and CPR is not provided, is not valid. However, any post mortem intervention that re-establishes brain blood flow should be prohibited. In comparison to traditional practice, organ donation has forced the clarification of the diagnostic criteria for death and improved the rigour of the determinations. (shrink)

Marion Lee Sanders,1 Anthony James Langone2 1Department of Medicine, Division of Nephrology and Hypertension, University of Iowa, Iowa City, IA, 2Department of Medicine, Division of Nephrology and Hypertension, Vanderbilt University Medical Center, Nashville, TN, USA: Transplantation is the preferred treatment option for individuals with end-stage renal disease. Individuals who undergo transplantation must chronically be maintained on an immunosuppression regimen for rejection prophylaxis to help ensure graft survival. Current rejection prophylaxis consists of using a combination of calcineurin inhibitors, mTOR inhibitors, antimetabolite (...) agents, and/or corticosteroids. These agents have collectively improved the short-term outcomes of renal transplantation, but improvements in late/chronic graft loss and recipient survival have lagged significantly behind challenging the field of transplantation to develop novel prophylactic agents. There have been several clinical trials conducted within the last 5 years in an attempt to bring such novel agents to the commercial market. These trials have resulted in the US Food and Drug Administration approval of extended-release tacrolimus, as well as belatacept, which has the potential to replace calcineurin inhibitors for rejection prophylaxis. Other trials have focused on the development of novel calcineurin inhibitors, costimulation blockade, kinase inhibitors, and inhibitors of leukocyte migration. While these later agents have not been FDA-approved for use in transplantation, they remain noteworthy, as these agents explore pathways not previously targeted for allograft-rejection prophylaxis. The purpose of this review was to consolidate available clinical trial data with regard to the recent developments in rejection prophylaxis in kidney transplantation. Keywords: rejection, prophylaxis, immunosuppression, transplantation. (shrink)

The distinction between stakeholders and shareholders frequently employed in business ethics can illuminate challenges faced by a bioethics advisory panel. I use the distinction to reflect back on the work of an advisory panel on which I served, a panel on US transplant policy. The panel hearings were akin to a shareholders’ meeting, with many stakeholders absent. In addition to ‘hearing out’ the shareholders who were present, the panel had duties to absent stakeholders to insure their interests were included in (...) public discussion. While panel efforts to include stakeholder perspectives rightfully framed its report, such duties should have framed its operating procedures more robustly. The stakeholder/shareholder distinction also offers a critical prism on the actual evolution of organ allocation policy, which the panel failed to influence. Current policy embodies a compromise among shareholders that obscures major stakeholder interests. This results in under‐attention to likely medical benefit of transplant, compared to other allocation criteria. Recognition of duties to stakeholders amidst pressures of shareholders complicates the notion of ‘consensus’ for an advisory panel. Consensus framed on terms defined only by shareholders, not stakeholders, may be an inadequate measure of public interest. (shrink)

The 11 original regions for organ allocation in the United States were determined by proximity between hospitals that provided deceased donors and transplant programs. As liver transplants became more successful and demand rose, livers became a scarce resource. A national system has been implemented to prioritize liver allocation according to disease severity, but the system still operates within the original procurement regions, some of which have significantly more deceased donor livers. Although each region prioritizes its sickest patients to be liver (...) transplant recipients, the sickest in less liver-scarce regions get transplants much sooner and are at far lower risk of death than the sickest in more liver-scarce regions. This has resulted in drastic and inequitable regional variation in preventable liver disease related death rate.A new region districting proposal – an eight district model – has been carefully designed to reduce geographic inequities, but is being fought by many transplant centers that face less scarcity under the current model. The arguments put forth against the new proposal, couched in terms of fairness and safety, will be examined to show that the new system is technologically feasible, will save more lives, and will not worsen socioeconomic disparity. While the new model is likely not perfect, it is a necessary step toward fair allocation. (shrink)

The field of human organ transplantation, and most particularly that of heart transplantation where the donor is always deceased, is one in which the rhetoric of hope leaves little room for any exploration or understanding of the more negative emotions and affects that recipients may experience. Where a donated heart is commonly referred to as the ‘gift of life’, both in lay discourse and by those engaged in transplantation procedures, how does this imbricate with the alternative clinical term of a (...) ‘graft’? For recipients of donor organs, the experience of living on in the face of otherwise certain death is fraught with complex emotions, not only about the self and the now dead other, but the persistence of the other within the self. In contrast to our expectations of the feel-good narrative of the gift of life, recipients are often significantly troubled by the aftermath of the procedure, which may fundamentally challenge notions of personal identity, as well as having deep implications for our understanding of the relation between death and ‘staying alive’. Drawing on recent research into heart transplantation, I shall theorise the field through a reflection – drawing on both Mauss and Derrida – on the meaning of the gift, before moving on to consider whether a Deleuzian approach to both the assemblage and the ‘event’ of death might offer a more productive framework. (shrink)

Bradford C Bemiss, Chad A WittDepartment of Internal Medicine, Division of Pulmonary and Critical Care Medicine, Washington University School of Medicine, St Louis, MO, USA: Chronic rejection is a major cause of death after the first year following lung transplantation. Bronchiolitis obliterans is the most common pathologic finding on biopsy, characterized by fibrous granulation tissue, which obliterates the lumen of the bronchiole. Clinically, in the absence of tissue for pathology, BO syndrome refers to a progressive irreversible drop in the forced (...) expiratory volume in 1 second. Recently, a broader definition of chronic rejection, termed "chronic lung allograft dysfunction", has been used to encompass a more inclusive definition of posttransplant dysfunction. Recently, the lung transplant community has come to realize that chronic rejection may be the final common result after repetitive epithelial insults. Acute rejection, infection, and alloreactivity to mismatched HLA antigens are a few of these insults that damage the surface of the bronchioles. Recent evidence of autoimmunity to the normally hidden structural proteins collagen V and K-α1 tubulin have been correlated with a BO phenotype as well, perhaps correlating the epithelial damage with a mechanism for developing BO lesions. Many immunomodulatory medications and treatments have been studied for effectiveness for the treatment of chronic lung allograft dysfunction. New drugs, which more precisely target the immune system, are being developed and tested. Further study is required, but recent advances have improved our understanding of the pathogenesis and potential intervention for this common and deadly complication of lung transplantation.Keywords: lung transplant, bronchiolitis obliterans syndrome, rejection. (shrink)

Bulang He,1,2 Jeffrey M Hamdorf2 1Liver and Kidney Transplant Unit, Sir Charles Gairdner Hospital, Perth, WA, Australia; 2School of Surgery, The University of Western Australia, Perth, WA, Australia Aims: The aim of this paper was to review the current status of laparoscopic/robotic kidney transplant and evaluate its feasibility and safety in comparison with conventional standard "open" kidney transplant. Methods: An electronic search of PubMed, Embase, and the Cochrane library database was performed to identify the papers between January 1980 and June (...) 2013 that reported on laparoscopic/robotic kidney transplantation. The terms "laparoscopic kidney/renal transplant" and "robotic kidney/renal transplant " were used. Cross-referencing was also used to find the further publications. Only English language reports were selected and accepted for descriptive analysis. Results: A total of 17 papers and abstracts were retrieved. There were two case-control studies of small volume. High-level evidence comparing the safety and efficacy of laparoscopic/robotic kidney transplant with conventional open kidney transplant was not available at the time of this review. Conclusion: The limited published data have suggested that laparoscopic/robotic kidney transplant may offer the advantages of less pain, better cosmesis, possible shorter hospital stay, and fewer wound complications, without compromising graft function. Accordingly, some immunosuppressive agents, such as sirolimus, might be able to be commenced earlier, after laparoscopic/robotic kidney transplant. The techniques are various at this early stage. A uniformed operative technique may be established in the near future. With refinement of laparoscopic devices, this technique may be widely employed. Further studies will be needed to demonstrate the advantages of laparoscopic/robotic kidney transplant over the conventional open kidney transplant. Keywords: laparoscopic surgery, robotic surgery. (shrink)

Science fiction is often used as a tool with which to think about actual science. While often this is depicted in terms of imaginary future potential, science fiction has also shown itself to be a poignant critique of existing science and a means of exploring our collective anxieties regarding the continued logic of current scientific development. This article explores the science fiction of organ transplantation, as mapped against scientific and medicolegal developments in actual organ transplantation. Explored through the lens of (...) Adorno’s work on cultural criticism, it is argued that science fiction serves as a tool with which we address (and critique) the ethical boundaries (and fears, often colonial in nature) of actual organ transplantation. Science fiction works such as Larry Niven’s Known Space Universe and Repo! The Genetic Opera are examined, demonstrating that in critiquing the science of organ transplantation, fictionists ultimately come to examine changing cultural understandings of selfhood and embodiment. (shrink)

In response to Koplin and Wilkinson, I argue, first, that the uncertain clinical prospects of human-pig chimera based transplantation makes the reason to spend resources for clarifying whether such practice might imply serious ethical breach due to enhanced cognitive capacities of the chimeras rather weak. T he benefits of further pursuing this avenue of research is so uncertain, so that taking even very unclear risks of serious ethical breach (thus in need of clarification for justification of the research) is not (...) worth the price in terms of spent resources, and therefore only limited resources should be spent to clarify such risk before the project is abandoned due to unacceptable risks. Second, I argue that as there are some reason to pursue this avenue further (and thus investigate the risk in question), the analogy to the notion of halting all farming of larger animals for food does not hold up. The reason is that we do not need to probe any further any comparable risk to know that such farming practices should be halted. A fundamental underlying issue to the question discussed by Koplin and Wilkinson1 in this paper is formulated when they write: > We should therefore be confident that human-pig chimeras would lack morally relevant cognitive capacities before setting out to use them as a source of transplantable human organs. This leaves open the question of how confident …. (shrink)

Background Intestinal transplant in infants with severe short bowel syndrome (SBS) is an emerging therapy, yet without sufficient long-term data or established guidelines, resulting in possible variation in practice. Objectives To assess current attitudes and counselling practices among physicians regarding intestinal transplant in infants with SBS, and to determine whether counselling and management vary between subspecialists or centres. Methods A national sample of practicing paediatric surgeons and neonatologists was surveyed via the American Academy of Paediatrics listserves. Results were analysed by (...) physician subspecialty and again by presence or absence of intestinal transplant at respondent's centre. Results The survey was completed by 433 respondents, consisting of 363 neonatologists and 70 paediatric surgeons. Fifty-seven respondents (13.2%) practiced at a centre that performed intestinal transplants in children. The vast majority of respondents (91% for preterm, 95% for term neonates) felt that maintaining a neonate with SBS on total parenteral nutrition for intestinal transplant was ethically optional (neither impermissible nor obligatory), and that parents should be given an informed choice whether to pursue that option. However, only 33% indicated they often/always offer intestinal transplant as a treatment option to families in this situation. Conclusions There is a marked disparity between individual physicians’ beliefs regarding the acceptability of intestinal transplant for severe SBS and their reported practice. Wide variability exists among physicians with respect to their knowledge, beliefs and practice regarding severe SBS, raising concerns about transparency and justice. Survival data prior to transplant, currently unavailable, are essential to rational decision making and informed parental permission. (shrink)

Despite having paved the way for face, womb and penis transplants, hand transplantation today remains a small hybrid of reconstructive microsurgery and transplant immunology. An exceptionally limited patient population internationally complicates medical researchers’ efforts to parse outcomes “objectively.” Presumed functional and psychosocial benefits of gaining a transplant hand must be weighed in both patient decisions and bioethical discussions against the difficulty of adhering to post-transplant medications, the physical demands of hand transplant recovery on the patient, and the serious long-term health (...) risks of immunosuppressant drugs. This paper relates five narratives of hand transplantation drawn from an oral history project to show how narrative methods can and should inform ethical evaluations and the clinical process of hand transplantation. The interviews with patients and their partners analyzed here lead us to suggest that qualitative accounts of patient experiences should be used to complement clinical case studies reported in medical journals and to help develop instruments to assess outcomes more systematically. (shrink)

Background: Black, Asian and minority ethnic groups have a high need for organ transplantation but deceased donation is low. This restricts the availability of well-matched organs and results in relatively long waiting times for transplantation, with increased mortality risks. Objective: To identify barriers to organ donor registration and family consent among the BAME population, and to develop and evaluate a training intervention to enhance communication with ethnic minority families and identify impacts on family consent. Methods: Three-phase programme comprising community-based research (...) involving two systematic reviews examining attitudes and barriers to organ donation and effective interventions followed by 22 focus groups with minority ethnic groups; hospital-based research examining staff practices and influences on family consent through ethics discussion groups with staff, a study on intensive care units and interviews with bereaved ethnic minority families; and development and evaluation of a training package to enhance cultural competence among ICU staff. Setting: Community focus group study in eight London boroughs with high prevalence of ethnic minority populations. Hospital studies at five NHS hospital trusts. Participants: Community studies: 228 focus group participants; hospital studies: 35 nurses, 28 clinicians, 19 hospital chaplains, 25 members of local Organ Donation Committees, 17 bereaved family members; and evaluation: 66 health professionals. Data sources: Focus groups with community residents, systematic reviews, qualitative interviews and observation in ICUs, EDGs with ICU staff, bereaved family interviews and questionnaires for trial evaluation. Review methods: Systematic review and narrative synthesis. Results: Community studies: Organ Donor Register – different ethnic/faith and age groups were at varying points on the ‘pathway’ to organ donor registration, with large numbers lacking knowledge and remaining at a pre-contemplation stage. Key attitudinal barriers were uncertainties regarding religious permissibility, bodily concerns, lack of trust in health professionals and little priority given to registration, with the varying significance of these factors varying by ethnicity/faith and age. National campaigns focusing on ethnic minorities have had limited impact, whereas characteristics of effective educational interventions are being conducted in a familiar environment; addressing the groups’ particular concerns; delivery by trained members of the lay community; and providing immediate access to registration. Interventions are also required to target those at specific stages of the donation pathway. Hospital studies: family consent to donation – many ICU staff, especially junior nurses, described a lack of confidence in communication and supporting ethnic minority families, often reflecting differences in emotional expression, faith and cultural beliefs, and language difficulties. The continuing high proportion of family donation discussions that take place without the collaboration of a specialist nurse for organ donation reflected consultants’ views of their own role in family consent to donation, a lack of trust in SNODs and uncertainties surrounding controlled donations after circulatory death. Hospital chaplains differed in their involvement in ICUs, reflecting their availability/employment status, personal interests and the practices of ICU staff. Evaluation: professional development package – a digital versatile disk-based training package was developed to promote confidence and skills in cross-cultural communication. Initial evaluation produced positive feedback and significant affirmative attitudinal change but no significant difference in consent rate over the short follow-up period with requirements for longer-term evaluation. Limitations: Participants in the focus group study were mainly first-generation migrants of manual socioeconomic groups. It was not permitted to identify non-consenting families for interview with data regarding the consent process were therefore limited to consenting families. Conclusions: The research presents guidance for the effective targeting of donation campaigns focusing on minority ethnic groups and provides the first training package in cultural competence in the NHS. Future work: Greater evaluation is required of community interventions in the UK to enhance knowledge of effective practice and analysis of the experiences of non-consenting ethnic minority families. Funding: The National Institute for Health Research Programme Grants for Applied Research programme. (shrink)

Acceptance of elderly or marginal health individuals as kidney donors is debated, with practices varying between centres. Transplant recipients, live kidney donors and health-care professionals caring for patients with renal failure were surveyed regarding their views on live donor kidney transplantation (LDKT) of marginal health (diabetes, hypertension, atherosclerosis, obesity, etc.) and elderly donors. Participants were recruited within a tertiary renal and transplant centre and invited to participate in focus groups and structured interviews. They also completed an anonymous questionnaire. Of 464 (...) participants who completed the questionnaire (36% health-care professionals and 64% patients), 49% and 64%, respectively, stated that marginal and elderly donors should be accepted for LDKT. In the structured interviews, emphasis was given to presenting to donor, recipient and their respective families a calculated risk regarding the effect that either a nephrectomy or transplant has on long-term quality of life. Participants stated that an independent third party in addition to the transplant team should discuss involved risks. Issues of ‘how desperate’ the recipient's situation is should also be considered. Health-care professionals stated that regardless of the strength of will of an individual to donate a kidney (despite age, health problems or personal risk), they should always have the right to say ‘no’ if performing a specific LDKT was against their professional and ethical values. About half of those surveyed considered that marginal health and elderly donors were acceptable for LDKT. Emphasis was given to the explanation to donors and recipients of the risks involved in such transplantation. (shrink)

Recent years have seen a rise in the number of sociological, anthropological, and ethnological works on the gift metaphor in organ donation contexts, as well as in the number of philosophical and theological analyses of giving and generosity, which has been mirrored in the ethical debate on organ donation. In order to capture the breadth of this field, four frameworks for thinking about bodily exchanges in medicine have been distinguished: property rights, heroic gift-giving, sacrifice, and gift-giving as aporia. Unfortunately, they (...) all run into difficulties in terms of both making sense of the relational dimensions of postmortem and live organ donations and being normatively adequate in the sense of shedding light and providing guidance on ethical concerns when body parts are donated. For this reason, this article presents a phenomenological framework of giving-through-sharing, based on Maurice Merleau-Ponty’s philosophy. This framework makes sense of relational dimensions of postmortem and live organ donation. It also sheds light on three highly debated concerns in organ donation ethics: indebtedness on the part of recipients, the fact that some live donors do not experience donation as a matter of choice, and the potentially painful experience of donors’ relatives, who need to make decisions about postmortem organ donation at a time of bereavement. It can indirectly support what may be called a normalization of bodily exchanges in medicine. (shrink)

In lieu of an abstract, here is a brief excerpt of the content:Ethics and the Allocation of Organs for TransplantationJames F. Childress (bio)A quarter of a century ago, in my second year of teaching at the University of Virginia, I began to explore the emerging field of biomedical ethics through a seminar on “Artificial and Transplanted Organs,” which included both faculty and students from law, medicine, and the humanities. My paper for the seminar was entitled “Who Shall Live When Not (...) All Can Live?” This experience drew me into biomedical ethics, because of the complex mix of ethical, legal, and medical issues and the fruitfulness of interdisciplinary and interprofessional dialogue.Several of the major problems confronting that seminar have persisted, often in altered form. In the area of organ transplantation, two significant issues continue to require society’s attention: (1) how can the organ supply be increased, and (2) how should the available organs be allocated? I want to make a few points about ethical criteria in the allocation of donated organs, as a way to indicate some directions for organ allocation policies in the twenty-first century. I will focus on the second question because I believe that a tremendous and ever-widening gap will persist between the need for transplantable organs and the supply of human cadaveric organs.Community Ownership of Donated Organs and Public ParticipationSince the mid-1980s, the operative conception of the ownership of donated organs has shifted, with major implications for the procedures used to formulate policies for organ allocation. As vice-chair of the federal Task Force on Organ Transplantation in the mid-1980s, I did not immediately realize that debates about allocation policies often reflected different conceptions of the ownership of donated organs. More specifically, organ allocation policies largely presupposed that donated organs belonged to, or were under the dispositional authority of, transplant surgeons, with only limited public accountability. However, the Task Force (1986) held that donated organs belong to the community, and that transplant professionals are only trustees and stewards of those organs for the [End Page 397] community’s welfare. This conception of ownership implies that the public should participate in setting the criteria for organ allocation.According to Jeffrey Prottas (1994), another member of the Task Force, these shifts represent the “socialization” of organ transplantation. Although professional dominance, through knowledge and power, continues in the United Network for Organ Sharing (UNOS)—the national organ procurement and transplantation network that was established in the late 1980s—that dominance is now more circumscribed and accountable, particularly because UNOS, in developing any allocation policy, has to respond “to public criticisms with public answers.” Not only is organ allocation policy now in the public domain—and thus a matter of public ethics rather than medical ethics—the terms of the debate have changed, as Prottas further notes, so that equity must be considered along with efficiency.Balancing Several Ethical Principles or ValuesThe main ethical criteria for organ allocation express principles that are prominent in the major competing theories of justice, particularly libertarian, egalitarian, utilitarian, and communitarian theories. The principles of liberty, equality, utility, and community all play important roles, and organ allocation policies often seek to balance these competing principles, which frequently are specified or circumscribed—for instance, utility is specified as medical utility. Just or equitable policies are found in the process of balancing.UNOS (1994) attempts to develop an equitable organ allocation system in light of a “set of basic principles” and “specific measurable objectives” that have been derived from these principles. It uses the metaphor of “balance” for its efforts to relate these different principles and objectives. For instance, it holds that balancing requires that “equal consideration” be given to both medical utility and to justice, so that neither can be ranked a priori over the other. However, it may not be possible to “give equal weight to [both] medical utility and justice” (UNOS 1994, p. 123) because trade-offs appear to be unavoidable in many policies and are consistent with the metaphor of balancing.Medical Utility and EqualityMedical utility—maximizing the welfare of patients suffering from end-stage organ failure—includes, at a minimum, attention to the factors that influence both graft and patient survival, as well... (shrink)

It is now possible for someone with HIV disease to receive a kidney transplant from a living donor, although there is evidence only about the short-term outcomes of such a procedure. A person with HIV disease may not wish to disclose their diagnosis to a potential kidney donor. This paper argues that disclosure of the diagnosis of HIV to the donor is not necessary for informed consent. Concerns about the relationship of trust between the clinical team and the donor hold (...) weight in deciding whether disclosure is essential, though openness about the limited nature of informed consent may facilitate a trusting relationship in the absence of disclosure. In general, the recipient's medical information should be treated as confidential, thereby avoiding any need to distinguish between HIV and other medical conditions. (shrink)

Recently, several articles in the scholarly literature on medical ethics proclaim the need for “responsible scholarship” in the debate over the proper criteria for death, in which “responsible scholarship” is defined in terms of support for current neurological criteria for death. In a recent article, James M. DuBois is concerned that academic critiques of current death criteria create unnecessary doubt about the moral acceptability of organ donation, which may affect the public’s willingness to donate. Thus he calls for a closing (...) of the debate on current death criteria and for journal editors to publish only critiques that “substantially engage and advance the debate.” We argue that such positions as DuBois’ are a threat to responsible scholarship in medical ethics, especially scholarship that opposes popular stances, because it erodes academic freedom and the necessity of debate on an issue that is literally a matter of life and death, no matter what side a person defends. (shrink)

This paper will present and discuss our conclusions about the ethics of living donation for liver transplant (LDLT) after 8 year of collaboration between our clinical ethics consultation service and liver transplant teams, in the course of which we met with all donor-candidates. We will focus on the results of a follow-up study that was conducted in order to evaluate the long-term consequences for potential donors and to interview them on the ethical aspects of the screening process. This study was (...) conducted from April 2007 to November 2009 and consisted of interviews with donor-candidates, regardless of whether they underwent harvest surgery, at least 1 year after the recipient’s transplant. We explored their views about their own and the recipients’ physical and psychological condition, changes in family and career dynamics, their experience as potential or real donors, and their views about LDLT process in general. Results shed new light on the ethical grounds of LDLT and allow us to envisage new ways of improving the ethical soundness of current procedures and practices. In particular, we argue that the purpose of an ethics committee should be to provide follow-up support for the donors rather than merely to check the freedom of donors’ consent. We also suggest that the recipient’s consent deserves more attention than it currently receives. (shrink)

Despite a growing awareness within American biomedicine and bioethics that the social category “race” is of limited use in describing patients, some fields of medicine continue to use it interchangeably with, or instead of, the term “ethnicity.” Doing so reflects the assumption that social categories have a basis in physiology.

Leah Andress,1 Anjali Gupta,2 Nida Siddiqi,3 Kwaku Marfo2,3 1University at Buffalo School of Pharmacy and Pharmaceutical Sciences, Department of Pharmacy Practice, Buffalo, 2Montefiore Medical Center, The University Hospital for Albert Einstein College of Medicine Department of Abdominal Organ Transplant Program, Bronx, 3Montefiore Medical Center, Department of Pharmacy, Bronx, NY, USA: Rabbit anti-thymocyte globulin has proven benefit as induction therapy in renal transplant recipients, achieving reduced acute rejection rates and better short-term allograft function, with slightly higher rates of complications such as (...) infections and malignancy. Compared with other agents, the most benefit from rATG induction has been observed in renal transplant recipients at high immunologic risk for rejection. However, in special populations, such as pediatrics, the elderly, and hepatitis C-positive and human immunodeficiency virus-positive renal transplant recipients, additional information is needed to delineate the absolute benefit of rATG induction compared with other induction agents. Selection of rATG as the choice of induction therapy in renal transplant recipients should be guided by a cost-effective approach in balancing efficacy, safety, and cost. This review summarizes the published literature on efficacy, safety, and cost of rATG induction in renal transplantation. Keywords: anti-thymocyte globulin, renal transplantation, induction therapy. (shrink)