The dead donor rule: lessons from linguistics?

American society traditionally has assumed a univocal notion of "death," largely because we have only one word for it and, until recently, have not needed a more nuanced notion. The reality of death-processes does not preclude the reality of death events. Linguistically, "death" can be understood only as an event; there are other words for the process. Our death vocabulary should expand to reflect multiple events along the process from sickness to decomposition. Depending on context, some death-related events may constitute a more obvious discontinuity than others and more justifiably may be considered "death" within that context. There is no reason to assume a priori that there must be an overarching, unitary concept of death from which all diagnostic criteria must derive. Regarding organ transplantation, the relevant question is not "Is the patient dead?" but rather "Can organs X, Y, Z ... be removed without causing or hastening death or harming the patient?"     

The dead donor rule: should we stretch it, bend it, or abandon it?

The dead donor rule--that persons must be dead before their organs are taken--is a central part of the moral framework underlying organ procurement. Efforts to increase the pool of transplantable organs have been forced either to redefine death (e.g., anencephaly) or take advantage of ambiguities in the current definition of death (e.g., the Pittsburgh protocol). Society's growing acceptance of circumstances in which health care professionals can hasten a patient's death also may weaken the symbolic importance of the dead donor rule. We consider the implications of these efforts to continually revise the line between life and death and ask whether it would be preferable to abandon the dead donor rule and rely entirely on informed consent as a safeguard against abuse.     

Reconsidering the dead donor rule: is it important that organ donors be dead?

The "dead donor rule" is increasingly under attack for several reasons. First, there has long been disagreement about whether there is a correct or coherent definition of "death." Second, it has long been clear that the concept and ascertainment of "brain death" is medically flawed. Third, the requirement stands in the way of improving organ supply by prohibiting organ removal from patients who have little to lose--e.g., infants with anencephaly--and from patients who ardently want to donate while still alive--e.g., patients in a permanent vegetative state. One argument against abandoning the dead donor rule has been that the rule is important to the general public. There is now data suggesting that this assumption also may be flawed. These findings add additional weight to proposals to abandon the dead donor rule so that organ supply can be expanded in a way that is consistent with traditional notions of ethics, law, public policy, and public opinion.     

Abandon the dead donor rule or change the definition of death?

Research by Siminoff and colleagues reveals that many lay people in Ohio classify legally living persons in irreversible coma or persistent vegetative state (PVS) as dead that additional respondents, although classifying such patients as living, would be willing to procure organs from them. This paper analyzes possible implications of these findings for public policy. A majority would procure organs from those in irreversible coma or in PVS. Two strategies for legitimizing such procurement are suggested. One strategy would be to make exceptions to the dead donor rule permitting procurement from those in PVS or at least those who are in irreversible coma while continuing to classify them as living. Another strategy would be to further amend the definition of death to classify one or both groups as deceased, thus permitting procurement without violation of the dead donor rule. Permitting exceptions to the dead donor rule would require substantial changes in law--such as authorizing procuring surgeons to end the lives of patients by means of organ procurement--and would weaken societal prohibitions on killing. The paper suggests that it would be easier and less controversial to further amend the definition of death to classify those in irreversible coma and PVS as dead. Incorporation of a conscience clause to permit those whose religious or philosophical convictions support whole-brain or cardiac-based death pronouncement would avoid violating their beliefs while causing no more than minimal social problems. The paper questions whether those who would support an exception to the dead donor rule in these cases and those who would support a further amendment to the definition of death could reach agreement to adopt a public policy permitting organ procurement of those in irreversible coma or PVS when proper consent is obtained.     

When are you dead enough to be a donor? Can any feasible protocol for the determination of death on circulatory criteria respect the dead donor rule?

The basic question concerning the compatibility of donation after circulatory death (DCD) protocols with the dead donor rule is whether such protocols can guarantee that the loss of relevant biological functions is truly irreversible. Which functions are the relevant ones? I argue that the answer to this question can be derived neither from a proper understanding of the meaning of the term “death” nor from a proper understanding of the nature of death as a biological phenomenon. The concept of death can be made fully determinate only by stipulation. I propose to focus on the irreversible loss of the capacity for consciousness and the capacity for spontaneous breathing. Having accepted that proposal, the meaning of “irreversibility” need not be twisted in order to claim that DCD protocols can guarantee that the loss of these functions is irreversible. And this guarantee does not mean that reversing that loss is either conceptually impossible or known to be impossible with absolute certainty.

     

Managed care at the bedside: how do we look in the moral mirror?

Managed care per se is a morally neutral concept; however, as practiced today, it raises serious ethical issues at the clinical, managerial, and social levels. This essay focuses on the ethical issues that arise at the bedside, looking first at the ethical conflicts faced by the physician who is charged with responsibility for care of the patient and then turning to the way in which managed care exacts costs that are measured not in dollars but in compromises in the caring dimensions of the patient-physician relationship.     

What does the public think of placebo use? The Canadian experience

Part of the National Placebo Initiative in Canada included public consultations, based on the belief that the views of the public should inform Canadian policy development on what constitutes appropriate placebo use. Public consultations took place nationally in 2003. A deliberative dialogue approach was used, or a structured discussion format designed to facilitate the consideration of complex issues and build consensus. The placebo debate was characterized as having 3 distinct approaches and each were explored. The first approach “Maximize Patient Protection” identified the need for experts to determine appropriate placebo use and that placebos should only be allowed under very restricted conditions. The second approach “Maximize Medical Knowledge” identified that placebos give essential information about the safety and efficacy of new drugs, and are appropriate when the rights, safety and well-being of research participants are ensured. The third approach “Maximize Patient Autonomy” identified that the current system of regulating placebo use is paternalistic and that patients should be able to define what is in their best interests and have more leeway to determine for themselves if they wish to participate in a placebo-controlled trial. Advantages and disadvantages of each approach were considered and feedback on what constitutes appropriate placebo use was sought. The major findings were that: PCTs were considered a valuable and acceptable part of advancing medical knowledge; research using placebos must be valid and justifiable; a patient-centred approach needs to be fostered; patient autonomy (choice) should be a first consideration and take clear precedence in trials of low to medium risk; patient protection (or health) may need to “trump” patient autonomy at higher levels of risk and/or patient vulnerability; placebos are not a violation of the duty of care as duty of care is best met by identifying a choice for patients, whenever a choice is available. These consultations clearly were not designed to produce conclusive evidence, but rather to provide some useful insights into what the public may think about placebo use; additional studies are indicated. Funding for the public consultations was provided by Health Canada and the Canadian Institutes of Health Research. An earlier version of this paper was presented at an international conference, “Placebo: Its Action and Place in Health Research Today,” held in Warsaw, Poland on 12–13 April, 2003.     

Collaboration and psychological ownership: how does the tension between the two influence perceived learning?

Collaborative writing may evoke conflict between individuals’ feeling of contribution and their sense of ownership toward the collective outcomes. The present study tested the relations between perceived psychological ownership, perceived quality of the product, and perceived learning in five experimental conditions: two collaborative, two sharing, and a control. Analysis of the changes made between versions revealed differences in quantity and in types of changes between collaboration, sharing, and control conditions. Results showed that collaboration may improve the perceived quality of the written product more than sharing or control. In addition, less intrusive collaboration seems to enhance the sense of perceived learning. The relation between perceived ownership and perceived learning was mediated by perceived quality of the written product. We conclude that students may avoid collaboration partly because they do not want to lose a sense of personal ownership or to lessen peer ownership.     

Multimedia mug books: how multi should the media be?

The impact of allowing witnesses to choose the type of cues presented in multimedia mug books was explored in two experiments. In Experiment 1, participants viewed a videotaped crime and attempted to identify the perpetrator from one of three types of mug books: (a) dynamic‐combined—participants could choose to follow static mug shots with a computerized video clip combining three types of dynamic cues: the person walking, talking, and rotating; (b) dynamic‐separable—participants could limit the types of dynamic cues presented; and (c) static—just the static mug shot was presented. The dynamic‐separable condition produced significantly fewer false positive foil identifications than the static condition. Within the dynamic‐separable condition, voice was the most preferred cue. Experiment 2 explored the contribution of the individual cues. Participants attempted identifications from single dynamic cue mug books where only one type of cue was presented if a participant chose additional information. It was found that providing individual cues did not improve performance over the static mug book control. Based on the potential danger of witnesses choosing to rely on single dynamic cues, it was suggested that multimedia mug books should present dynamic cues in combination. Copyright © 2000 John Wiley & Sons, Ltd.     

Who should manage care? The case for patients

After establishing that it is essential that health care be rationed in some fashion, the paper examines the arguments for and against clinicians as gatekeepers. It first argues that bedside clinicians do not have the information needed to make allocation decisions. Then it claims that physicians at the bedside can be expected to make the wrong choice for two reasons: their commitment to the Hippocratic ethic forces them to pursue the patient's best interest (even when resources will produce only very marginal benefit and could do much more good elsewhere) and their values will lead them to calculate the net value of treatments incorrectly. Alternative decision makers are considered. It is argued that both groups of physicians and administrators will also make allocations incorrectly and that leaving the allocation decisions to patients themselves is the best approach. Mechanisms for fair and efficient rationing by patients at the societal and individual level are examined.     

Who should manage care? The case for providers

Health care professionals should be the ones to make allocation decisions in the managed care setting because they are in the best position to assess outcomes, cost effectiveness, and quality of care.