History of organ donation by patients with cardiac death

When successful solid organ transplantation was initiated almost 40 years ago, its current success rate was not anticipated. But continuous efforts were undertaken to overcome the two major obstacles to success: injury caused by interrupting nutrient supply to the organ and rejection of the implanted organ by normal host defense mechanisms. Solutions have resulted from technologic medical advances, but also from using organs from different sources. Each potential solution has raised ethical concerns and has variably resulted in societal acclaim, censure, and apathy. Transplant surgery is now well accepted, and the list of transplant candidates has grown far quicker than the availability of organs. More than 30,000 patients were awaiting organs for transplantation at the end of March 1993. While most organs came from donors declared dead by brain criteria, the increasing shortage of donated organs has prompted a reexamination of prior restrictions of donor groups. Recently, organ procurement from donors with cardiac death has been reintroduced in the United States. This practice has been mostly abandoned by the U.S. and some, though not all, other countries. Transplantation has been more successful using organs procured from heart-beating, "brain dead" cadavers than organs from non-heart-beating cadavers. However, recent advances have led to success rates with organs from non-heart-beating donors that may portend large increases in organ donation and procurement from this source.     

Dying but not killing: donation after cardiac death donors and the recovery of vital organs

Michael Potts, Paul A. Byrne, and David W. Evans are critical of donation after cardiac death (DCD). Contrary to the authors' assertion that the removal of vital organs is the proximate cause of death, the eventual fulfillment of the neurological criteria of death is solely dependant on the rate of brain cell death in the absence of circulation. Consistent with the "dead donor rule," DCD is not the cause of death.There are also procedural mechanisms to address the potential conflicts of interest that concern the authors. Rather than being prohibited, DCD may be an ethically justifiable exception to the rule that organ donors must be dead prior to organ recovery.     

The sad truth about depressive realism

In one form of a contingency judgement task individuals must judge the relationship between an action and an outcome. There are reports that depressed individuals are more accurate than are nondepressed individuals in this task. In particular, nondepressed individuals are influenced by manipulations that affect the salience of the outcome, especially outcome probability. They overestimate a contingency if the probability of an outcome is high—the “outcome-density effect”. In contrast, depressed individuals display little or no outcome-density effect. This apparent knack for depressives not to be misled by outcome density in their contingency judgements has been termed “depressive realism”, and the absence of an outcome-density effect has led to the characterization of depressives as “sadder but wiser”. We present a critical summary of the depressive realism literature and provide a novel interpretation of the phenomenon. We suggest that depressive realism may be understood from a psychophysical analysis of contingency judgements.*     

Recovery of transplantable organs after cardiac or circulatory death: Transforming the paradigm for the ethics of organ donation

Organ donation after cardiac or circulatory death (DCD) has been introduced to increase the supply of transplantable organs. In this paper, we argue that the recovery of viable organs useful for transplantation in DCD is not compatible with the dead donor rule and we explain the consequential ethical and legal ramifications. We also outline serious deficiencies in the current consent process for DCD with respect to disclosure of necessary elements for voluntary informed decision making and respect for the donor's autonomy. We compare two alternative proposals for increasing organ donation consent in society: presumed consent and mandated choice. We conclude that proceeding with the recovery of transplantable organs from decedents requires a paradigm change in the ethics of organ donation. The paradigm change to ensure the legitimacy of DCD practice must include: (1) societal agreement on abandonment of the dead donor rule, (2) legislative revisions reflecting abandonment of the dead donor rule, and (3) requirement of mandated choice to facilitate individual participation in organ donation and to ensure that decisions to participate are made in compliance with the societal values of respect for autonomy and self-determination.     

The uncomfortable truth about wrongful life cases

Our ambivalent attitudes toward the notion of ‘a life worth living’ present a philosophical puzzle: Why are we of two minds about the birth of a severely disabled child? Is the child’s life worth living or not worth living? Between these two apparently incompatible evaluative judgments, which is true? If one judgment is true and the other false, what makes us continue to find both evaluations appealing? Indeed, how can we manage to hold these inconsistent judgments simultaneously at all? I critically examine two solutions to this puzzle: the hidden-indexical account and Velleman’s anti-realist account. I propose an alternative explanation which appeals to (a) state-given, as opposed to object-given, reasons for belief and (b) the distinction between belief and acceptance. I argue that (1) the fact that a severely disabled life is not worth living provides object-given reason to believe that that life is not worth living, but (2) after the birth of a severely disabled child, the psychological utility of positive evaluation gives us a state-given reason to believe that that child’s life is worth living, and a reason to accept that, in our relation with the child, her life is worth living. I conclude by drawing a practical lesson about wrongful life suits.     

Presumed consent for organ preservation in uncontrolled donation after cardiac death in the United States: a public policy with serious consequences

Organ donation after cessation of circulation and respiration, both controlled and uncontrolled, has been proposed by the Institute of Medicine as a way to increase opportunities for organ procurement. Despite claims to the contrary, both forms of controlled and uncontrolled donation after cardiac death raise significant ethical and legal issues. Identified causes for concern include absence of agreement on criteria for the declaration of death, nonexistence of universal guidelines for duration before stopping resuscitation efforts and techniques, and assumption of presumed intent to donate for the purpose of initiating temporary organ-preservation interventions when no expressed consent to donate is present. From a legal point of view, not having scientifically valid criteria of cessation of circulation and respiration for declaring death could lead to a conclusion that organ procurement itself is the proximate cause of death. Although the revised Uniform Anatomical Gift Act of 2006 provides broad immunity to those involved in organ-procurement activities, courts have yet to provide an opinion on whether persons can be held liable for injuries arising from the determination of death itself. Preserving organs in uncontrolled donation after cardiac death requires the administration of life-support systems such as extracorporeal membrane oxygenation. These life-support systems can lead to return of signs of life that, in turn, have to be deliberately suppressed by the administration of pharmacological agents. Finally, allowing temporary organ-preservation interventions without expressed consent is inherently a violation of the principle of respect for a person's autonomy. Proponents of organ donation from uncontrolled donation after cardiac death, on the other hand, claim that these nonconsensual interventions enhance respect for autonomy by allowing people, through surrogate decision making, to execute their right to donate organs. However, the lack of transparency and the absence of protection of individual autonomy, for the sake of maximizing procurement opportunities, have placed the current organ-donation system of opting-in in great jeopardy. Equally as important, current policies enabling and enhancing organ procurement practices, pose challenges to the constitutional rights of individuals in a pluralistic society as these policies are founded on flawed medical standards for declaring death.     

Infant heart transplantation after cardiac death: ethical and legal problems

The donation of organs after cardiac death in infants is not morally justified and should not be continued.     

Frege's puzzle about the cognitive function of truth

The aim of this paper is to give a detailed reconstruction of Frege's solution to his puzzle about the cognitive function of truth, which is this: On the one hand, the concept of truth seems to play an essential role in acquiring knowledge because the transition from the mere hypothetical assumption that p to the acknowledgement of its truth is a crucial step in acquiring the knowledge that p, while, on the other hand, this concept seems to be completely redundant because the sense of the word ‘true’ does not make any essential contribution to the senses of the sentences in which it occurs.