Thesis (Selection of subject)Thesis (Selection of subject)(version: 336)
Assignment details
   Login via CAS
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.
 
 
References
A definition of irreversible coma. Report of the Ad Hoc Committee of the Harvard Medical School to Examine the Definition of Brain Death, 1968. . JAMA J. Am. Med. Assoc. 205, 337–340.
Anker, A.E., Feeley, T.H., 2010. Why families decline donation: the perspective of organ procurement coordinators. Prog. Transplant. Aliso Viejo Calif 20, 239–246.
Ariès, P., Navrátilová, D., 2000. Dějiny smrti. II., II.,. Argo, Praha.
Azoulay, E., Timsit, J.-F., Sprung, C.L., Soares, M., Rusinová, K., Lafabrie, A., Abizanda, R., Svantesson, M., Rubulotta, F., Ricou, B., Benoit, D., Heyland, D., Joynt, G., Français, A., Azeivedo-Maia, P., Owczuk, R., Benbenishty, J., de Vita, M., Valentin, A., Ksomos, A., Cohen, S., Kompan, L., Ho, K., Abroug, F., Kaarlola, A., Gerlach, H., Kyprianou, T., Michalsen, A., Chevret, S., Schlemmer, B., Conflicus Study Investigators and for the Ethics Section of the European Society of Intensive Care Medicine, 2009. Prevalence and factors of intensive care unit conflicts: the conflicus study. Am. J. Respir. Crit. Care Med. 180, 853–860. doi:10.1164/ rccm.200810-1614OC
Bartlett, E.T., 1995. Differences between death and dying. J. Med. Ethics 21, 270–276.
Benedikt, Váňa, P., Kozlová, H., 1996. Eschatologie – smrt a věčný život. Barrister & Principal : Centrum pro demokracii a kulturu, Brno.
Bernat, J.L., 1998. A defense of the whole-brain concept of death. Hastings Cent. Rep. 28, 14–23.
Bernat, J.L., 2002. The biophilosophical basis of whole-brain death. Soc. Philos. Policy 19, 324–342.
Bernat, J.L., 2010. Point: are donors after circulatory death really dead, and does it matter? Yes and yes. Chest 138, 13–16. doi:10.1378/chest.10-0649
Bernat, J.L., Culver, C.M., Gert, B., 1981. On the definition and criterion of death. Ann. Intern. Med. 94, 389– 394.
Bernat, J.L., D’Alessandro, A.M., Port, F.K., Bleck, T.P., Heard, S.O., Medina, J., Rosenbaum, S.H., Devita, M.A., Gaston, R.S., Merion, R.M., Barr, M.L., Marks, W.H., Nathan, H., O’connor, K., Rudow, D.L., Leichtman, A.B., Schwab, P., Ascher, N.L., Metzger, R.A., Mc Bride, V., Graham, W., Wagner, D., Warren, J., Delmonico, F.L., 2006. Report of a National Conference on Donation after cardiac death. Am. J. Transplant. Off. J. Am. Soc. Transplant. Am. Soc. Transpl. Surg. 6, 281–291. doi:10.1111/j.1600-6143.2005.01194.x
Birch, S.C.M., 2013. The dead donor rule: a defense. J. Med. Philos. 38, 426–440. doi:10.1093/jmp/jht021
Brabec, L., 1991. Křesťanská thanatologie. GEMMA89, Praha.
Brook, N.R., Waller, J.R., Richardson, A.C., Andrew Bradley, J., Andrews, P.A., Koffman, G., Gok, M., Talbot, D., Nicholson, M.L., 2004. A report on the activity and clinical outcomes of renal non-heart beating donor transplantation in the United Kingdom. Clin. Transplant. 18, 627–633. doi:10.1111/j.1399-0012.2004.00287.x
Capron, A.M., 2001. Brain death--well settled yet still unresolved. N. Engl. J. Med. 344, 1244–1246. doi:10.1056/ NEJM200104193441611
ČernýD, Doležal A, Rusinová K., 2014. Biologické paradigma smrti. Urgentní výzva pro lékařskou etiku 21. století., in: Etické Problémy Medicíny Na Prahu 21. Grada, Praha.
Cole, D.J., 1992. The reversibility of death. J. Med. Ethics 18, 26–30; discussion 31–33.
DOPORUČENÍ PŘEDSTAVENSTVAČLKč. 1/2010
DuBois, J.M., Anderson, E.E., 2006. Attitudes toward death criteria and organ donation among healthcare personnel and the general public. Prog. Transplant. Aliso Viejo Calif 16, 65–73.
Ecker, J.L., 2014. Death in Pregnancy – An American Tragedy. N. Engl. J. Med. doi:10.1056/NEJMp1400969
Esmaeilzadeh, M., Dictus, C., Kayvanpour, E., Sedaghat-Hamedani, F., Eichbaum, M., Hofer, S., Engelmann, G., Fonouni, H., Golriz, M., Schmidt, J., Unterberg, A., Mehrabi, A., Ahmadi, R., 2010. One life ends, another begins: Management of a brain-dead pregnant mother-A systematic review-. BMC Med. 8, 74. doi:10.1186/1741-7015-8-74
Farragher, R.A., Laffey, J.G., 2005. Maternal brain death and somatic support. Neurocrit. Care 3, 99–106. doi:10.1385/NCC:3:2:099
Franz, H.G., DeJong, W., Wolfe, S.M., Nathan, H., Payne, D., Reitsma, W., Beasley, C., 1997. Explaining brain death: a critical feature of the donation process. J. Transpl. Coord. Off. Publ. North Am. Transpl. Coord. Organ. NATCO 7, 14–21.
French, C.C., 2005. Near-death experiences in cardiac arrest survivors. Prog. Brain Res. 150, 351–367. doi:10.1016/S0079-6123(05)50025-6
Gaylin, W., 1988. Doctors Must Not Kill’. JAMA J. Am. Med. Assoc. 259, 2139. doi:10.1001/ jama.1988.03720140059034
Gross, T., Martinoli, S., Spagnoli, G., Badia, F., Malacrida, R., 2001. Attitudes and behavior of young European adults towards the donation of organs--a call for better information. Am. J. Transplant. Off. J. Am. Soc. Transplant. Am. Soc. Transpl. Surg. 1, 74–81.
Hirsh, H.L., 1975. Brain death: medico-legal fact, or fiction? North. Ky. State Law Forum 3, 16–41.
Hoffenberg, R., 2001. Christiaan Barnard: his first transplants and their impact on concepts of death. BMJ 323, 1478–1480.
Hornby, K., Hornby, L., Shemie, S.D., 2010. A systematic review of autoresuscitation after cardiac arrest. Crit. Care Med. 38, 1246–1253. doi:10.1097/CCM.0b013e3181d8caaa
Howlett, T.A., Keogh, A.M., Perry, L., Touzel, R., Rees, L.H., 1989. Anterior and posterior pituitary function in brain-stem-dead donors. A possible role for hormonal replacement therapy. Transplantation 47, 828–834.
Ibrahim, A.W., Wu, V., Zafari, A.M., 2013. Neurologically intact survival after prolonged cardiopulmonary resuscitation for pulseless ventricular tachycardia. Am. J. Med. 126, e7–9. doi:10.1016/j.amjmed.2012.11.008
It’s over, Debbie, 1988. . JAMA J. Am. Med. Assoc. 259, 2094–2098.
Joffe, A.R., Carcillo, J., Anton, N., deCaen, A., Han, Y.Y., Bell, M.J., Maffei, F.A., Sullivan, J., Thomas, J., Garcia-Guerra, G., 2011. Donation after cardiocirculatory death: a call for a moratorium pending full public disclosure and fully informed consent. Philos. Ethics Humanit. Med. PEHM 6, 17. doi:10.1186/1747-5341-6-17
Jox, R.J., 2014. Sketching the Alternative to Brain Death: Dying Through Organ Donation. Am. J. Bioeth. 14, 37–39. doi:10.1080/15265161.2014.925163
Kass, L.R., 1971. Death as an event: a commentary on Robert Morison. Science 173, 698–702.
Kennedy, I.M., 1976. The Karen Quinlan case: problems and proposals. J. Med. Ethics 2, 3–7.
Kompanje, E.J., de Groot, Y.J., 2012. Autoresuscitation is not a determinant to lower the observation time in declaring death for organ donation. Crit. Care Med. 40, 708; author reply 708–709. doi:10.1097/ CCM.0b013e31823b8b1e
Kootstra, G., Daemen, J.H., Oomen, A.P., 1995. Categories of non-heart-beating donors. Transplant. Proc. 27, 2893–2894.
Krakauer, E.L., Penson, R.T., Truog, R.D., King, L.A., Chabner, B.A., Lynch, T.J., Jr, 2000. Sedation for intractable distress of a dying patient: acute palliative care and the principle of double effect. The oncologist 5, 53–62.
Levvey, B.J., Westall, G.P., Kotsimbos, T., Williams, T.J., Snell, G.I., 2008. Definitions of warm ischemic time when using controlled donation after cardiac death lung donors. Transplantation 86, 1702–1706. doi:10.1097/ TP.0b013e3181901f24
Lizza, J., 2005. Potentiality, Irreversibility, and Death. J. Med. Philos. 30, 45–64. doi:10.1080/03605310590907057
Lizza, J.P., 1993. Persons and death: what’s metaphysically wrong with our current statutory definition of death? J. Med. Philos. 18, 351–374.
Machado, C., 2005. The first organ transplant from a brain-dead donor. Neurology 64, 1938–1942. doi:10.1212/01.WNL .0 0 0 0163515.09793.CB
Meier-Kriesche, H.U., Ojo, A.O., Port, F.K., Arndorfer, J.A., Cibrik, D.M., Kaplan, B., 2001. Survival improvement among patients with end-stage renal disease: trends over time for transplant recipients and wait-listed patients. J. Am. Soc. Nephrol. JASN 12, 1293–1296.
Miller, F.G., 2012. Death, dying, and organ transplantation: reconstructing medical ethics at the end of life. Oxford University Press, Oxford.
Miller, F.G., Truog, R.D., 2008. Rethinking the ethics of vital organ donations. Hastings Cent. Rep. 38, 38–46.
Miller, F.G., Truog, R.D., 2009. The incoherence of determining death by neurological criteria: a commentary on „Controversies in the determination of death“, a White Paper by the President’s Council on Bioethics. Kennedy Inst. Ethics J. 19, 185–193.
Miller, F.G., Truog, R.D., Brock, D.W., 2010. The dead donor rule: can it withstand critical scrutiny? J. Med. Philos. 35, 299–312. doi:10.1093/jmp/jhq019
MOLLARET, P., GOULON, M., 1959. [The depassed coma (preliminary memoir)]. Rev. Neurol. (Paris) 101, 3–15.
Montaigne, M. de, Conche, M., Saulnier, V.-L., Villey, P., 2004a. Les essais. Presses universitaires de France, Paris.
Montaigne, M. de, Conche, M., Saulnier, V.-L., Villey, P., 2004b. Les essais. Presses universitaires de France, Paris.
Morison, R.S., 1971. Death: process or event? Science 173, 694–698.
Nair-Collins, M., 2010. Death, brain death, and the limits of science: why the whole-brain concept of death is a flawed public policy. J. Law Med. Ethics J. Am. Soc. Law Med. Ethics 38, 667–683. doi:10.1111/j.1748- 720X.2010.00520.x
Nietzsche, F., Koubová, V., 2001. Radostná věda. Aurora, Praha.
Parnia, S., Spearpoint, K., Fenwick, P.B., 2007. Near death experiences, cognitive function and psychological outcomes of surviving cardiac arrest. Resuscitation 74, 215–221. doi:10.1016/j.resuscitation.2007.01.020
Peigne, V., Chaize, M., Falissard, B., Kentish-Barnes, N., Rusinova, K., Megarbane, B., Bele, N., Cariou,
A., Fieux, F., Garrouste-Orgeas, M., Georges, H., Jourdain, M., Kouatchet, A., Lautrette, A., Legriel, S., Regnier, B., Renault, A., Thirion, M., Timsit, J.-F., Toledano, D., Chevret, S., Pochard, F., Schlemmer, B., Azoulay, E., 2011. Important questions asked by family members of intensive care unit patients. Crit. Care Med. 39, 1365–1371. doi:10.1097/CCM.0b013e3182120b68
Port, F.K., Wolfe, R.A., Mauger, E.A., Berling, D.P., Jiang, K., 1993. Comparison of survival probabilities for dialysis patients vs cadaveric renal transplant recipients. JAMA 270, 1339–1343.
Potts, M., Evans, D.W., 2005. Does it matter that organ donors are not dead? Ethical and policy implications. J. Med. Ethics 31, 406–409. doi:10.1136/jme.2004.010298
Poulton, B., Garfield, M., 2000. The implications of anaesthetising the brainstem dead. Anaesthesia 55, 695; author reply 695–696.
Powner, D.J., Bernstein, I.M., 2003. Extended somatic support for pregnant women after brain death. Crit. Care Med. 31, 1241–1249. doi:10.1097/01.CCM.0000059643.45027.96
přílohač. 3 k vyhlášceč. 114/2013 Sb., n.d.
Puybasset, 2010. Enjeux éthique en réanimation. Springer-Verlag, Paris.
Robertson, J., 2014. Should we scrap the dead donor rule? Am. J. Bioeth. AJOB 14, 52–53. doi:10.1080/15265161. 2014.929755
Robertson, J.A., 1999. The dead donor rule. Hastings Cent. Rep. 29, 6–14.
Salen, P., Melniker, L., Chooljian, C., Rose, J.S., Alteveer, J., Reed, J., Heller, M., 2005. Does the presence or absence of sonographically identified cardiac activity predict resuscitation outcomes of cardiac arrest patients? Am. J. Emerg. Med. 23, 459–462.
Sanghavi D, 2009. When does death start. N. Y. Times Mag.
Shah, S.K., Truog, R.D., Miller, F.G., 2011. Death and legal fictions. J. Med. Ethics 37, 719–722. doi:10.1136/ jme.2011.045385
Shemie, S.D., Baker, A.J., Knoll, G., Wall, W., Rocker, G., Howes, D., Davidson, J., Pagliarello, J., Chambers- Evans, J., Cockfield, S., Farrell, C., Glannon, W., Gourlay, W., Grant, D., Langevin, S., Wheelock, B., Young, K., Dossetor, J., 2006. National recommendations for donation after cardiocirculatory death in Canada: Donation after cardiocirculatory death in Canada. CMAJ Can. Med. Assoc. J. J. Assoc. Medicale Can. 175, S1.
Shemie, S.D., Hornby, L., Baker, A., Teitelbaum, J., Torrance, S., Young, K., Capron, A.M., Bernat, J.L., Noel, L., and The International Guidelines for Determination of Death phase 1 participants, in collaboration with the World Health Organization, 2014. International guideline development for the determination of death. Intensive Care Med. doi:10.1007/s00134-014-3242-7
Shewmon, D.A., 1998. Chronic „brain death“: meta-analysis and conceptual consequences. Neurology 51, 1538– 1545.
Shewmon, D.A., 2010. Constructing the death elephant: a synthetic paradigm shift for the definition, criteria, and tests for death. J. Med. Philos. 35, 256–298. doi:10.1093/jmp/jhq022
Siminoff, L.A., Gordon, N., Hewlett, J., Arnold, R.M., 2001. Factors influencing families’ consent for donation of solid organs for transplantation. JAMA J. Am. Med. Assoc. 286, 71–77.
Siminoff, L.A., Mercer, M.B., Arnold, R., 2003. Families’ understanding of brain death. Prog. Transplant. Aliso Viejo Calif 13, 218–224.
Sprung, C.L., Truog, R.D., Curtis, J.R., Joynt, G.M., Baras, M., Michalsen, A., Briegel, J., Kesecioglu, J., Efferen, L., De Robertis, E., Bulpa, P., Metnitz, P., Patil, N., Hawryluck, L., Manthous, C., Moreno, R., Leonard, S., Hill, N.S., Wennberg, E., McDermid, R.C., Mikstacki, A., Mularski, R.A., Hartog, C.S., Avidan, A., 2014. Seeking Worldwide Professional Consensus on the Principles of End-of-life Care for the Critically Ill: The Welpicus Study. Am. J. Respir. Crit. Care Med. doi:10.1164/rccm.201403-0593CC
Truog, R.D., 1997. Is it time to abandon brain death? Hastings Cent. Rep. 27, 29–37.
Truog, R.D., 2005. Organ donation without brain death? Hastings Cent. Rep. 35, 3.
Truog, R.D., 2007. Brain death – too flawed to endure, too ingrained to abandon. J. Law Med. Ethics J. Am. Soc. Law Med. Ethics 35, 273–281. doi:10.1111/j.1748-720X.2007.00136.x
Truog, R.D., 2008. Consent for organ donation--balancing conflicting ethical obligations. N. Engl. J. Med. 358, 1209–1211. doi:10.1056/NEJMp0708194
Truog, R.D., Arnold, J.H., Rockoff, M.A., 1991. Sedation before ventilator withdrawal: medical and ethical considerations. J. Clin. Ethics 2, 127–129.
Truog, R.D., Brock, D.W., White, D.B., 2012. Should patients receive general anesthesia prior to extubation at the end of life? Crit. Care Med. 40, 631–633. doi:10.1097/CCM.0b013e3182413b8a
Truog, R.D., Campbell, M.L., Curtis, J.R., Haas, C.E., Luce, J.M., Rubenfeld, G.D., Rushton, C.H., Kaufman, D.C., American Academy of Critical Care Medicine, 2008. Recommendations for end-of-life care in the intensive care unit: a consensus statement by the American College [corrected] of Critical Care Medicine. Crit. Care Med. 36, 953–963. doi:10.1097/CCM.0B013E3181659096
Truog, R.D., Cochrane, T.I., 2006. The truth about „donation after cardiac death“. J. Clin. Ethics 17, 133–136.
Truog, R.D., Miller, F.G., 2008. The dead donor rule and organ transplantation. N. Engl. J. Med. 359, 674–675. doi:10.1056/NEJMp0804474
Truog, R.D., Miller, F.G., 2010. Counterpoint: are donors after circulatory death really dead, and does it matter? No and not really. Chest 138, 16–18; discussion 18–19. doi:10.1378/chest.10-0657
Truog, R.D., Miller, F.G., 2012. „Brain death“ is a useful fiction. Crit. Care Med. 40, 1393–1394; author reply 1394. doi:10.1097/CCM.0b013e3182451a08
Truog, R.D., Miller, F.G., 2014a. Changing the conversation about brain death. Am. J. Bioeth. AJOB 14, 9–14. do i:10.1080/15265161.2014.925154
Truog, R.D., Miller, F.G., 2014b. Defining death: the importance of scientific candor and transparency. Intensive Care Med. 40, 885–887. doi:10.1007/s00134-014-3301-0
Truog, R.D., Miller, F.G., 2014c. The meaning of brain death: a different view. JAMA Intern. Med. 174, 1215– 1216. doi:10.1001/jamainternmed.2014.2272
Truog, R.D., Miller, F.G., Halpern, S.D., 2013. The dead-donor rule and the future of organ donation. N. Engl. J. Med. 369, 1287–1289. doi:10.1056/NEJMp1307220
Veatch, R.M., 1993. The impending collapse of the whole-brain definition of death. Hastings Cent. Rep. 23, 18–24.
Wetzel, R.C., Setzer, N., Stiff, J.L., Rogers, M.C., 1985. Hemodynamic responses in brain dead organ donor patients. Anesth. Analg. 64, 125–128.
Whetstine, L.M., 2007. Bench-to-bedside review: when is dead really dead--on the legitimacy of using neurologic criteria to determine death. Crit. Care Lond. Engl. 11, 208. doi:10.1186/cc5690
Williams, M.A., Lipsett, P.A., Rushton, C.H., Grochowski, E.C., Berkowitz, I.D., Mann, S.L., Shatzer,
J.H., Short, M.P., Genel, M., Council on Scientific Affairs, American Medical Association, 2003. The physician’s role in discussing organ donation with families. Crit. Care Med. 31, 1568–1573. doi:10.1097/01. CCM.0000063090.21056.A6
Wind, J., Faut, M., van Smaalen, T.C., van Heurn, E.L., 2013. Variability in protocols on donation after circulatory death in Europe. Crit. Care Lond. Engl. 17, R217. doi:10.1186/cc13034
Young, P.J., Matta, B.F., 2000. Anaesthesia for organ donation in the brainstem dead--why bother? Anaesthesia 55, 105–106.
Zamperetti, N., Bellomo, R., Ronco, C., 2003. Defining death in non-heart beating organ donors. J. Med. Ethics 29, 182–185.
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.
 
Charles University | Information system of Charles University | http://www.cuni.cz/UKEN-329.html