Giving Thanks on Labor Day

Bill Colby, JD
Senior Fellow, Law and Patient Rights
bcolby@PracticalBioethics.org

On September 5, 1882, our country celebrated the first Labor Day. On September 1, 2008 we will pause once again to honor “the contributions workers have made to the strength, prosperity and well-being of our country.”

This week’s E.Alert reports the stories of bioethics – families fighting over life-support, improving healthcare access for the poor, and others – all important stories, all with questions we’ve wrestled before and will again.

To celebrate Labor Day, though, scroll down. There you’ll find a delightful 82nd birthday “card” for our Center colleague, Dr. Rosemary Flanigan, written by Rev. Norman Rotert.

Rosemary is a philosopher. In the famous black-and-white television footage she is one of the nuns in habit marching at front of the protest in Selma after Bloody Sunday. Since the Sixties she has devoted her life to teaching the world about ethics. She’s not the person you want to be in line behind as St. Peter is weighing your good works on earth. (I’d also avoid standing near Father Rotert.)

The spirit of Labor Day, to me, is in the old adage of trying to leave each place we visit a little better for us having been there. That’s what Rosemary does. But she’s not alone.

So on September 1, I’m going to stop and give thanks for the labor of all of the Rosemary Flanigans out there.

Happy Labor Day.

To comment, click on "Comments" at the end of this post.

Link: Sister Rosemary teaches us how to be good people, Kansas City Star, August 23

The Dead Donor Rule and its Detractors

Tarris Rosell, PhD, DMin
Program Associate
August 22, 2008

A recent New England Journal of Medicine article has created an ethics stir regarding death criteria for organ donation. Two heart transplants in Denver occurred in infants upon declaration of death by cardiac, not brain death, criteria—and just 75 seconds after a “flat-line” reading. The heart recipients are doing fine; but were their donors really “dead”? And does it matter?

Cadaveric donation for transplantation is premised on the “dead donor rule.” Up until recently, that has meant that only brain dead bodies could yield organs for transplant, since cardiac death declaration wasted precious minutes during which cell death ruined the heart, liver, lungs and kidneys.

Since there aren’t enough brain dead donors to meet the demand for organs, we have looked elsewhere. Living donors have increased the kidney supply, but don’t impact the shortage of hearts. So we adjusted federal guidelines for declaring death after a potential donor heart stops. The Institute of Medicine chose 5 minutes as the national standard.

Denver doctors chose 75 seconds because there is no data to show that a heart once stopped will restart of its own accord after 60 seconds. “Irreversible” cardiac function counts for what it means to be “dead”. Except that in the case of heart transplantation, those same hearts do indeed start beating again in other bodies, with help, and presumably would have done so in the bodies of the babies who “died”.

In a NEJM “roundtable” response, Dr. Bob Truog opines that we should dispense with the dead donor rule and focus on “valid informed consent” to donate in conjunction with a terminal prognosis due to “devastating neurologic injury.” His arguments are logical, his moral claims are well grounded, and he is almost convincing.

Indeed, much good is to be gained by his proposed approach. For those of us rather skeptical of current death criteria standards, the Truog solution simply makes them moot.

Yet there also is something morally unsettling about Dr. Truog’s proposal. It may only be “slippery slope” worries or attachment to tradition or distrust of the medical establishment or of our insatiable Western appetite for life extension at any cost.

I’m not certain that I can construct a persuasive ethics argument against Truog, nor that I even want to do so. But neither can I and the general public, I’m betting, quite go there with him—yet.

What do you think? Share and view your comments by clicking on "Comments" below this post.

Links:

Doctors debate when to declare organ donors dead, Associated Press, August 14

Infant Transplant Procedure Ignites Debate, Washington Post, August 14

New England Journal of Medicine, August 14, 2008

The Boundaries of Organ Donation after Circulatory Death, James L. Bernat, M.D.

Donating Hearts after Cardiac Death — Reversing the Irreversible, Robert M. Veatch, Ph.D.

The Dead Donor Rule and Organ Transplantation, Robert D. Truog, M.D., and Franklin G. Miller, Ph.D.

Expertise in "Doing" Ethics

John Lantos, MD
John B. Francis Chair in Bioethics
August 15, 2008

There is a big debate in the world of bioethics about the nature of expertise in ethics. That debate spawns two sub-debates.

One focuses on the lack of any certification or accreditation of bioethicists. Anybody who considers themselves ethical enough can hang out their shingle and start practicing.

Membership on ethics committees is extremely democratic - anybody can serve. Some folks take a course, others read the Hastings Center Report, still others just claim to have a virtuous moral character. Whether or not this seems scandalous depends, in part, on whether or not one thinks that specific training actually helps.

That is the second debate. If we are going to train ethicists, we need to decide on the content of that training. We, at the Center for Practical Bioethics, have ongoing discussions and debates about the nature of that training.

We work with our ethics committee consortium partners to refine our orientation and training programs for ethics committees. But we still haven't gotten it right, or even come to consensus.

The technique of role playing with professional actors is an interesting approach. It seems to start with the assumption that ethics consultation is less about what you know and more about what you say and do.

Ethics consultation, by this view, is a practical skill or craft than it is an intellectual discipline. It is one that people master by doing, rather than by studying. It implicitly claims that everything we need to know to do ethics consults we learned in kindergarten.

This approach can help ethics consultants refine the mediation skills that are important to many ethics consultations. It does not address the need for ethics consultants to be familiar with a growing body of knowledge and learned opinion in law, philosophy, and theology that inform judgments about whether any particular outcome of a mediation is right or wrong, better or worse.

What do you think? Share or view comments by clicking on "comments" after this post.

Links:

Ethics consultants get doses of realism through simulations, American Medical News, August 11

The minefield of medical morals, BBC News, August 1, 2008

Healthcare reform needed but comes hard

Flanigan Lecture
August 8, 2008

Health care reform comes hard because we didn't get to where we are by accident. That's according to Steven Schroeder, MD, Distinguished Professor of Health and Health Care at the University of California - San Francisco and former president and CEO of the Robert Wood Johnson Foundation.

Dr. Schroeder spoke before more than 200 people at the 14th Annual Flanigan Lecture on July 31 in Kansas City, MO.

While there's a long time consensus to reform health care, Dr. Schroeder noted a number of barriers keep us from doing so, including a tendency to look for painless, quick fixes, and a reluctance to take on the involved sectors in healthcare.

There's also an economic Catch 22 to health insurance reform. Dr. Schroeder said when the economy is prosperous and unemployment low, the middle class feels secure about health insurance. When the economy goes bad and people lose jobs and healthcare, there is not enough money to pay for expanded coverage.

Dr. Schroeder noted a number of factors keeping us from reforming healthcare, while also pointing to four pathways that could lead us toward that goal:

1. Economic depression mobilizes the middle class
2. Charismatic president pushes legislation
3. Business asks for help
4. The medical profession mobilizes

What do you think? Share and view your comments by clicking on “Comments” at the end of this post.

Links:

Lecture summary
Video: Dr. Steven Schroeder regarding why healthcare reform comes so hard
Dr. Schroeder Lecture PowerPoint