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Pravidlo mrtvého dárce a jeho význam v současné etice transplantací
Thesis title in Czech: Pravidlo mrtvého dárce a jeho význam v současné etice transplantací
Thesis title in English: The meaning of the dead donor rule in current transplantion ethics
Key words: pravidlo mrtvého dárce, transplantace, non-maleficence, autonomie
English key words: dead donor rule, transplantation, ethics, death, non-maleficence, autonomy
Academic year of topic announcement: 2014/2015
Type of assignment: dissertation
Thesis language: čeština
Department: nezařazení_neaktivní (11-00000)
Supervisor: doc. MUDr. Jiří Šimek, CSc.
Author: hidden - assigned and confirmed by the Study Dept.
Date of registration: 02.03.2015
Date of assignment: 02.03.2015
Confirmed by Study dept. on: 02.03.2015
Date and time of defence: 07.04.2015 00:00
Date of electronic submission:11.03.2015
Date of proceeded defence: 07.04.2015
Course: Defence of the dissertation (B90002)
Reviewers: doc. MUDr. Eva Kieslichová, Ph.D.
  Tomáš Hříbek, Ph.D.
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Preliminary scope of work
Současný transplantační program je mimořádně úspěšný a zachraňuje velké množství životů. Pokud jsou orgány od dárců získávány eticky a právně akceptovatelným způsobem, je zvyšování počtu dárců přijatelným medicínským i společenským cílem. Současný model získávání orgánů od dárců je založen na tzv. pravidlu mrtvého dárce (dead donor rule, DDR). Toto pravidlo vychází z dlouhé medicínské tradice, která zakazuje lékaři způsobit aktivně smrt pacienta. Jeho cílem je ochránit pacienty před usmrcením z důvodu získání orgánu k transplantaci a zajišťuje tím společenskou důvěryhodnost transplantačního programu. Podle tohoto pravidla platí, že orgány k transplantaci lze odebrat až po smrti pacienta. Samotný princip transplantací založený na získání životaschopného, VIABILNÍHO orgánu, který je voperován a funguje v těle příjemce, však dává základ paradoxní situaci: jak zajistit, aby byl dárce zároveň mrtvý a zároveň aby byly z jeho těla odebrány viabilní orgány?
K řešení tohoto paradoxu přispěly práce zkoumající situaci tzv. ireverzibilního komatu v 50. a 60. letech 20. století. Na jejich základě bylo konsenzuálně formulováno, že ireverzibilní závažné poškození mozku (klinicky přesně definované) je rovnocenné smrti pacienta. V 90. letech přibylo k neurologickému kritériu stanovení smrti i kritérium smrti vymezené na základě tzv. nevratné zástavy oběhu. Na základě naplnění těchto dvou kritérií v současnosti probíhá stanovování smrti tak, že formálně vyhovuje pravidlu mrtvého dárce. Orgány k transplantaci jsou odebírány až po vypsání úmrtního listu.
Hlavní náplň práce je představit současný koncept smrti, jeho kritiku a kritéria pro stanovení smrti v kontextu transplantačního programu a dokázat teze:.
1) Pravidlo mrtvého dárce (dead donor rule) nemá být nezbytnou podmínkou odběru životně důležitých orgánů (např. srdce, plíce, játra, obě ledviny atd.).
2) Životně důležité orgány k transplantaci má být přípustné odebírat i od pacientů bezprostředně umírajících, při respektování principu autonomie a non-maleficence.
Dále je kriticky hodnocen význam pravidla mrtvého dárce ve smyslu, že
1. dárci orgánů nesplňují kritéria pro stanovení smrti a pravidlo mrtvého dárce je v běžné praxi dodržováno pouze formálně (tj. jsou naplněna kritéria právní, nikoliv strictu senso biologická). Pro eticky přípustný odběr orgánů není nezbytně nutné definovat smrt organismu.
2. požadavek implicitně obsažený v pravidlu mrtvého dárce - odběr orgánů nesmí způsobit smrt pacienta - je v kontextu současné intenzivní medicíny překonaný, protože hranice mezi „umožněním zemřít” a „kauzálním způsobením smrti” není ostrá a absolutní.
3. opuštění pravidla mrtvého dárce neznamená ztrátu ochrany nejlepšího zájmu pacienta, protože ta může být zajištěna (i bez tohoto pravidla) na základě dvou fundamentálních etických principů: principu non-maleficence a principu respektu k autonomii pacienta.
Preliminary scope of work in English
Current outcomes of transplantation medicine are outstanding and organ transplantation is considered as a life-saving procedure. If the organs for transplantation are retrieved in an ethically and legally transparent manner, then increasing the number of organ donors is an acceptable medical and societal goal. Current practice is based on the “dead donor rule” (DDR). This rule translates a deep theme of medical ethics, stating, “doctors must not kill”. The purpose of the dead donor rule is to protect patients from being killed through organ retrieval and thus to ensure the important societal trust in organ donation programs. According to this rule, organs can only be retrieved after the patient has died. The principle of organ transplantation is based on the paradoxical claim of retrieving a viable organ from a dead body. The real question is: in what moment do we have a dead body with viable organs? Important contributions to solve this paradoxical claim were made in 1950s and 1960s, when a clinical condition of patients with irreversible coma was explored. The definition of irreversible coma resulting from irreversible severe brain damage prompted the consensual statement in 1968 that the irreversible coma is the best surrogate for the death of an organism. Later in 1990s, the so-called circulatory criterion of death was added to the neurological criterion. Currently, death is considered to be an unique phenomenon that can be determined two ways: based on either neurological or circulatory criteria. Formally, in both clinical situations, the dead donor rule is followed.
The main purpose of this thesis is to review the current concept of death used in transplantation medicine, present main controversies in this subject and to summarize a critical appraisal of the criteria for determining death.
I will argue that:
1) the dead donor rule should not be necessary in retrieving organs for transplantation (heart, lungs, liver, both kidneys etc.)
2) it should be allowed to retrieve these organs pre-mortem, from imminently dying patients, respecting the principles of non-maleficence and autonomy
I will further argue that
1. organ donors currently do not fulfill the criteria for determination of death and that the dead donor rule is followed only formally. (i.e. the legal conditions are fulfilled, while the biological conditions are not). It is not necessary to declare patients dead for ethically justified policy in transplantation
2. the claim implicitly formulated in the dead donor rule (that the organ retrieval must not cause the patient’s death) is outdated and unnecessary, because the line between allowing patients to die and causing death is no more “sharp” and absolute in current practice of intensive care medicine
3. abandoning the dead donor rule does not mean we lose the only safeguard of patient’s best interests. The sound ethical arguments for allowing pre-mortem retrieval of organs for transplantation should include careful consideration of the patient’s prognosis (the principle of non-maleficence) and respect for his/her wishes and preferences.
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