Can Anything Good Come of the Navarro Fiasco?

Terry Rosell
December 23, 2008

A transplant surgeon has been acquitted of criminal wrongdoing in the dying of Ruben Navarro http://www.latimes.com/features/health/la-me-transplant19-2008dec19,0,2830878.story. With limited knowledge of what went on in the operating room and the courtroom, I assume this is a good outcome.

But I think the jury is still out on public opinion regarding donation of body parts after cardiac death, and on what should happen next.

Dr. Hootan Roozrokh was accused, and is found not guilty, of dependent adult abuse. He had flown in with a team from San Francisco to procure organs upon the death of Mr. Navarro at the regional medical center in San Luis Obispo.

Organ recovery usually takes place after brain death. This 25 year old comatose patient was not brain dead, and was expected to die the old fashioned way. He had suffered cardiac arrest once already, and his family had consented to organ donation at such time as his heart stopped permanently.

But things didn’t proceed as they should. A prosecuting attorney claimed, unconvincingly, that Dr Roozrokh hastened the prospective donor’s death by ordering relatively large doses of pain and anti-anxiety medications for a patient who was not dying quickly enough. Defense convinced the jury that whatever occurred in that operating room, it wasn’t criminal.

Indeed, it may well have been compassionate care of a patient who was suffering needlessly and in a prolonged manner.

What all can agree on is that, whatever happened in San Luis Obispo, it resulted in little good beyond that of the defense attorney’s claims. Yes, the patient’s suffering was ended. However, the bereaved family experienced a grief complicated by suspicions of medical abuse and a long court battle.

The young surgeon experienced a disruption of vocation from which he may never recover fully. Other well intended clinical caregivers surely were traumatized by testimony or depositions, by the scrutiny of law and media. Organ procurement and hospital institutions have expended scarce resources that might have gone to healing rather than defending.

The American public is left wondering who to trust and whether organ donation is a risky endeavor. And in the Navarro case, no organs ultimately were recovered anyway.

If there is anything good yet to come of this tragedy, it will be seen in the delineation of clearer policies and procedures for recovery of organs and tissue after cardiac death—with sanctions for violation, whether intentional or unintentional. What we hope will not occur is clinical resistance to or additional restrictions on administration of pain and anti-anxiety medications for patients who are actively dying.

That would be tragedy upon tragedy. Clinicians and policy wogs need to focus attention elsewhere.

In reference to recovery of organs after cardiac death, Cleveland transplant surgeon Dr. John Fung accurately noted that the Navarro case “certainly highlighted the potential of extreme problems that could occur without having the proper policies and procedures in place.” (http://www.latimes.com/features/health/la-me-transplant19-2008dec19,0,2830878.story).

The jury concurred with the need for “well defined ethical standards.” Now it is mostly up to the United Network for Organ Sharing (UNOS) and its Department of Health and Human Services contractor to take appropriate actions with sufficient communication such that this fiasco is less apt to be repeated elsewhere or ever again.

I hope they are doing so.

Link: Transplant surgeon acquitted in case involving potential organ donor's death, Los Angeles Times, December 19

What do you think? Please view and share comments.

"The Dignity of a Person"

Rosemary Flanigan

December 19, 2008

Long ago I wrote my dissertation on Robin George Collingwood’s metaphysics of absolute presuppositions, and I was reminded of this far away bit of history when I read the Vatican Congregation for the Doctrine of the Faith’s recently issued “The Dignity of the Person.”

Just as Collingwood taught that certain presuppositions, e.g., that every effect has a cause, help frame our mind’s approach to the analysis of countless events, so, too, do certain moral presuppositions in the Church’s theology frame the analysis of the basis of human dignity.

That human life begins at conception militates against using embryos for stem cell research and cloning; that the unitive and procreative aspects of marital intercourse ought not be separated militates against in vitro fertilization.

None of this is new. Neither is the document’s flexibility on some forms of gene therapy and its open questions surrounding embryo adoption.

There is an interesting discussion in the conclusion of the document concerning the perception that moral teaching in the church “contains too many prohibitions.” To refute this charge, the authors contrast the problems of earlier times.

Working classes were oppressed and denied their fundamental rights; the church came to their defense by proclaiming the sacrosanct rights of the worker as a person. Today’s problems deal with defending the right to life of the unborn. “The Church feels duty bound to speak out with the same courage on behalf of those who have no voice.”

The document praises human progress in the understanding and recognition of the value and dignity of persons by legal and political prohibitions of racism, slavery, unjust discrimination of the marginalized together with today’s developments in information technologies, research in genetics, medicine and biotechnologies for human benefit.

But the authors still call the attention of the faithful to those at the very beginning of life whose very life is threatened.

“Behind every ‘no’ in the difficult task of discerning between good and evil there shines a great ‘yes’ to the recognition of the dignity and inalienable value of every single unique human being called into existence.”

What do you think? View and leave comments by clicking here.

Links:

Vatican hardens opposition to stem cell research, Associated Press, December 12
Instruction Dignitas Personae on Certain Bioethical Questions, December 12
Will a New Vatican Document Affect Science and Reproductive Health?, Scientific American, December 12
Scientist reacts to Vatican bioethics paper, William B. Neaves, National Catholic Reporter, December 12

Is Face Transplant an Identity Transplant?

The face is visible in a way that internal organs are not. Further, it is visible in a way that is highly associated with one’s individual identity. If we have someone else’s face, are we really and truly our self?

John Lantos, MD
December 18, 2008

A few weeks ago, surgeons at The Cleveland Clinic performed “a face transplant.” News reports of this remarkable technological achievement almost always include comments from bioethicists who, as bioethicists tend to do, urge caution, worry about consequences, and wonder about the patient’s autonomy.

Perhaps it might be more appropriate to urge awe and wonder about our interconnectedness.

Certain ethical issues accompany all medical innovations. Nobody really knows the long term risks or benefits. Great hopes might be dashed by unforeseen complications. Progress has inherent perils. The first patients can be harmed rather than helped. All this has been true for prior pioneering transplantations of heart, liver, kidney, and intestine.

It has also been true for cancer chemotherapy, immunizations, and other medications. What, then, is really new and different about face transplantation?

The face is visible in a way that internal organs are not. Further, it is visible in a way that is highly associated with one’s individual identity. If we have someone else’s face, are we really and truly our self? Do we become, in some weird way, the donor? Is a face transplant really an identity transplant?

The relationship between transplanted body parts and transplanted identities has always been a concern. Fiction writers have explored this territory more than have scientists.

John Irving’s novel, The Fourth Hand, imagines a hand transplant in which the recipient gets not only the physical hand but much of the life of the donor. Robert Heinlein’s I Will Fear No Evil imagines a brain transplant, and one in which the brain of an old man is transplanted into the body of a young woman.

Both novels deal with the scintillating concerns that a transplant can never be simply of tissue, that when we put bodies together, we also put souls and psyches together. Tabloid newspapers get it. (The Daily Mail, in the UK, had a recent headline, “I was given a young man’s heart – and started craving beer and Kentucky Fried Chicken.”)

Even transplant surgeons themselves worry. Anthropologist Margaret Lock quotes a surgeon who was a little queasy about the possibility of obtaining organs from death row prisoners, “I wouldn’t like to have a murderer’s heart put into my body. I might find myself starting to change.”

The fact is that transplantation of body parts creates a strange and unique bond between donor and recipient. A gift has been given that is like no other – a gift of self that crosses the boundary between life and death. The families of donors often cling to a belief that their loved on “lives on” because a body part is still alive. Recipients often talk of being reborn, or of not being the same person that they were before.

Face transplants differ from other transplants in degree, not kind. All transplants, all use of the body parts of other people, reflect the subtle ways in which we are interconnected and almost interchangeable with one another.

There is beauty in that, as well as fear and trembling. We shouldn’t shrink from the new responsibilities that our new powers foist upon us. But we shouldn’t minimize or simplify those responsibilities, either. We should never do things simply because we can, but neither should we avoid doing things simply because they raise frightening new ways to think about who we are or who we might become.

We are blessed by scientific breakthroughs that enable us to take care of each other in new, spooky, and miraculous ways. Our interconnectedness should generate in us a sense of awe, wonder, and, ultimately, responsibility.

We can harm each other. We can take care of each other. We can choose. The surgeons, the bioethicists, the patient and the families of the donor and recipient all chose to improve life in a way that was only possible through extraordinary human interconnectedness. They have taken risks for us.

They have done a brave and good thing.

What do you think? Click here to view and leave your comments.

Links:

First U.S. face transplant completed at Cleveland Clinic, USA Today, December 16

Transplanting a Face: The Ethical Issues, New York Times, December 17

Is face transplant worth risking patient's life?, Arthur Caplan, Ph.D., December 17

Practicing on the newly dead

Rosemary Flanigan
December 11, 2008

When we “argue” (discuss?) at an ethics consult, we find ourselves sometimes arguing about erroneous conscience decisions, I think.

FOR EXAMPLE, let’s say as an intern, a physician may have practiced intubation on a newly dead patient without family consent. Years later, in retrospect, the physician may have arrived at the judgment that this was wrong to do and that he/she will teach medical students not to do it.

AH HA!!! So medicine needs to be practiced, and this particular procedure probably needs a lot of practice. What would lead the physician to see that such “practicing” was not a good thing?

What about the physician who doesn’t need to practice anymore—but still sees that practicing on the newly dead is better than not practicing at all so he/she does not teach medical students to avoid doing so?

Would you argue with this physician?

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Calling Rationing what it Is

John Lantos, MD
John B. Francis Chair in Bioethics
December 5, 2008

One of the best articles ever written on health policy and rationing is by Princeton health economist Uwe Reinhardt. His 1981 paper, “Table manners at the health-care feast: 'regulation' vs. 'market',” suggests that we will never understand health policy until we call things by their proper names.

Reinhardt proposes that, instead of speaking about “national health care expenditures,” we should instead discuss, “national health care incomes.” “Increased efficiency” becomes “reduced employment.” “Cost containment” becomes “income containment.”

By this tongue-half-in-cheek shift in terms, Reinhardt highlights the ways in which the health care industry is different from other industries.

In the rest of the economic world, growth is good. Companies try to maximize revenue (that is, maximize expenditures on their product) in order to maximize income. Only in health care is growth seen as bad, and that is only because all industrialized countries view health care as a special sort of good, one to which we all have some entitlement.

This leads to the two central questions of health policy everywhere: 1) how equal the entitlement will be? And, 2) to what, exactly, are we entitled?

Equality can be limited on the basis of age, disability, prognosis, gender, location (i.e. rural vs. urban or suburban) or ability to pay. Scope of coverage can be limited by an almost infinite array of considerations. The most common, and most ethically defensible, is cost-effectiveness.

Rationing treatments based on cost-effectiveness can either be done systematically, as they do in England, or on an ad hoc basis, as we do here. Peter Ubel described – and defended - the American approach in his 1995 paper in the Annals of Internal Medicine called, “The unbearable rightness of bedside rationing: physician duties in a climate of cost-containment.”

Most bioethicists reject Ubel’s approach and argue for something like the British approach, with its admirable honesty, transparency, and accountability. The United States health system has resisted such approaches, however, and never heeded Reinhardt’s call for better “table manners.”

Instead, everyone grabs whatever he or she can get. Perhaps with the strains on our economic system and the reformist mood in Washington, the stars are aligned to allow a new approach. If so, Britain’s National Institute for Health and Clinical Excellence (NICE) might show us the way.

What do you think? Share your comments by clicking here.

Links:

British Balance Gain Against the Cost of the Latest Drugs, New York Times
December 2

Physicians' Role in Cost Containment, Virtual Mentor, American Medical Association, November 2003.