Ethicalissues in

JChung March19,2013

At the end of this session, students will be able to:

Describe the current situation of organ donation in Hong Kong. Discuss the general misconception in organ donation. Discuss the ethical issues in organ donation.

Whatisorgantransplant?
An organ transplant is a surgical operation where a failing or damaged organ in the human body is removed and replaced a new one.

Whatisthedifferencebetween agraftandatransplant?
A graft is similar to a transplant. It does not remove or replace an entire organ, rather only a portion.
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Organtransplant
Typically refers to transplant of the solid organ Two sources for donor organs:
Cadaveric organ donation: a person indicates that he/she would like to be an organ donor when he/she died Living organ donation: donor organs is a living person. Living donors are often related to the patient

HongKongOrganTransplantation
Milestones
Year 1961 1969 1991 1992 1995 Organ/Tissue Cornea Kidney Liver Bone Heart Skin Lung CombinedHeart&Lung

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http://www.organdonation.gov.hk/eng/statistics.html

Number of organ/tissue donations & patient waiting for transplantation under Hospital Authority (20012012) Waiting Organ/ Tissue (asat 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 31.12.20 Donated (cases) 12) Kidney Cadaveric Living Liver Cadaveric Living Heart Lung Cornea (piece) Skin Bone 23 37 10 1 239 37 6 30 45 12 4 19 36 5 0 20 56 7 0 24 38 8 2 23 48 7 1 244 8 3 26 41 5 1 26 42 6 1 43 41 10 2 42 53 13 2 30 44 9 1 45 33 17 3 17 15 500
uncertain

49 14

74 9

42 7

44 6

50 8

53 13

58 8

65 12

87 8

74 7

59 8

84 15

1808

121

295 198 230 214 22 5 5 0 30 4 13 3

198 211 203 250 238 259 13 1 19 1 17 0 23 6 21 0 6 3

uncertain 6

http://www.organdonation.gov.hk/eng/statistics.html

Centralised OrganDonationRegister(CODR)
Set up by the Department of Health (DH) in 2008 More convenient for prospective donors to voluntarily register their wish to donate organs after death The Register will enable medical personnel responsible for organ donation to know upon the patients' death about their wish to donate organs The bereaved family to acknowledge the deceased's wish to rekindle lives of other people
http://www.organdonation.gov.hk/eng/knowmore.html http://www.organdonation.gov.hk/eng/lightuplives.html

Ethicalissues
Organshortage noteveryonewhoneedsanorgantransplantgetsone!

How to fairly divide resources? Distributive justice theory states that there is not one right way to distribute organs, but rather many ways a person could justify giving an organ to one particular individual over someone else.

Ethicalissues
Distributivejusticecriteria
Equal access: Organs allocated according to Equal access criteria based on objective factors aims to limit biases and unfair distribution Age(youngesttooldest);Lengthoftimewaiting Criteria: __________________________________ Free of biases based on race, sex, social status Equal access supporters who believe organ distribution process free of medical worthiness and social worthiness.

Ethicalissues
Distributivejusticecriteria
Maximum benefit: To maximize the number of successful transplants. Criteria include: Medical need (i.e. the sickest people are given the first opportunity for a Transplantable organ) Probable success of a transplant (i.e. giving organs to the person who will be most likely to live the longest)
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Ethicalissues
Howdowedecidewhowillreceivethetransplants?
The central registry prioritizes allocation of cadaveric livers to patients in accordance with objective clinical parameters Ensure fairness and consistency in distribution facilitate efficient management enable doctors to make judgment based on consensus and to ensure the benefits of patients Scoring system (the criteria for cadaveric organ allocation) e.g. Liver transplant Each patient will be assigned the status probability of pretransplant death derived from a mortality risk score corresponding to the degree of medical urgency
11 http://www21.ha.org.hk/files/PDF/more%20disease%20zone/Liver_Transplanteng__revised%209%20Dec%2009.pdf

Whatdoyouthink
should someone who has received one organ transplant be given a second transplant? should people who have not had a transplant be given priority over those who have already had one? should people who have young children to be given a priority over a single person? Over an elderly person? should people whose lifestyle choices (smoking, drinking, drug use, obesity, etc.) damaged their organ be given a chance at an organ transplant?

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WhyistheorgandonationrateinHongKongsolow comparedwithotherdevelopedcountries?

Hong Kong people usually want to preserve a 'complete body' after death. The family members or relatives do not like to cause any 'mutilation' to the deceased after death. The family members or relatives were reluctant to give consent for organ donation because they do not know the wish of the deceased.

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Generalmisconceptionsonorgandonation
Iamtooyoung/toooldtohavetothinkaboutorgan donation. OnceIhavesignedtheorgandonationcard,Iwillnotbe takencareofifIhaveanaccident. The transplant of an organ from one body to another may not be acceptable according to my religious belief.
Sources:Organdonation,DepartmentofHeath http://www.organdonation.gov.hk/eng/faq.html 15

Generalmisconceptionsonorgandonation
I have a history of medical illness and my organs or tissues may not be suitable for donation. I am worried that the removal of an organ will affect the appearance of the body and look in the funeral. I am worried that all my organs will be taken away even if I only wish to donate one of them.
Sources:Organdonation,DepartmentofHeath http://www.organdonation.gov.hk/eng/faq.html 16

Generalcriteriafordeceaseddonation
No age limit in general Brain Death donors ( with organ function temporarily maintained by respiratory machines and drugs support) can donate both organs and tissue When cardiac death occurs, the deceased can mostly donate tissue only, such as corneas, skin and bones Has adequate organ function No severe / systemic infection No HIV infection No cancer (except primary brain tumors)
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Howtodeterminedeath?
Lay persons typically regard the permanent cessation of heart and lung function as determining death; the law and the medical profession regard the permanent cessation of brain function (brain death) as determining death. Once brain death has been diagnosed, and consent for organ retrieval received, every effort is made to stabilize patients before they are taken to theatre for organ removal.
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Isthesignedorgandonationcardororgandonationform legallyvalidinHongKong? Yes, both the card and the organ donation form are legally valid. However, even with a legally valid document, doctors in Hong Kong will not remove any organ if the close relatives object. In any event, the authorization from the close relatives will be obtained before the organs are removed.
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Reasonsforsupportingorgandonation
Addextrameaningtolife Amoralact/Actofcharity Givingpeoplehope,andkeep otherliving Agiftoflife Setgoodexample Feelproudofoneself Lifeisvaluable
http://streetanatomy.com/author/luis/page/7/
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Reasonsagainstorgandonation
Alackofknowledgeofthe wishesofthedeceased. Thebeliefthatremovaloforgan violatessanctityofdeceased/ bodyissacred. Fearsofbodilymutilation,e.g. concernaboutbodybeingcut upafterdeath,wanttopreserve a'completebody'afterdeath, bodydisfigured. Dislikeofideaoforgansinside anotherperson. Wrongconceptofbraindeath. Againstreligiousconviction,e.g. beliefsthatthebodymustnot bemutilated. Fearofmedicalneglect,e.g.less likelytoreceivemedicalcare, pronouncedeathevenalive.

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20120224()

http://orientaldaily.on.cc/cnt/news/20120224/00176_030.html
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Sincethereisashortageoforgans
ShouldSellingHumanOrgansBeLegal? Shouldwepayfororgans?

Isitethicaltoletorgansbesoldontheopenmarket?

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Livedonortransplant
HumanOrganTransplantOrdinance
Preventorgantrading Protectselfdetermination
Arelateddonation(haveaclosestatusrelationship)his allowedtoproceedsubjectedtocertainpreconditions; AnrelateddonationisprohibitedunlesstheHuman OrganTransplantBoardapproves.
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HongKongHumanOrganTransplantOrdinance (Chapter465)
Section:4Prohibitionofcommercialdealingsinhumanorgans The government prohibits commercial dealings in human organs intended for transplanting, to restrict the transplanting of human organs between persons who are not genetically related. Section:5AOrgantransplantsbetweenspousesorgeneticallyrelated persons The living donor should be genetically related or is, at the time of the transplant, the spouse of the donor and their marriage has subsisted for not less than 3 years.
http://www.legislation.gov.hk/blis_pdf.nsf/6799165D2FEE3FA94825755E0033E532/9C78C1E7B 25 F94FF05482575EF000A9DE2/$FILE/CAP_465_e_b5.pdf

Livingorgandonation
Advantages Thedonationcanbe prearranged.The patientcantakethe antirejectiondrugin Psychological:Family advance Bettermatchesbetween pressure,guiltorresentment donorsandrecipients (geneticallyrelatedto Pressure: family members may feel pressure to donate thepatients) Psychologicalbenefitfor when they have a sick family member bothdonorsand recipients No donor advocate (Vastag,26 2003) Disadvantages Physical: Pain, discomfort, infection, bleeding, potential future health complications

OrgandonationinHongKong
In Hong Kong, as in most other communities, family consent is a necessity for organ donation, irrespective of an individuals intention as indicated by a donor card. Cadaveric organs and tissues are treated as public assets, but the individual or family may prohibit organ removal, thereby preserving autonomy. Organ donation by living donors presents a unique ethical dilemma, in that physicians must risk the life of a healthy person to save or improve the life of a patient.

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References:
HumanOrganTransplantOrdinance,administrativeguidelines(2011) http://www.dh.gov.hk/english/links/files/HOTO_Administrative_Guidelines _English.pdf HongKongMedicalAssociation www.hkma.org/chinese/care/care.htm HongKongHumanOrganTransplantOrdinance(Chapter465) http://www.legislation.gov.hk/index.htm Organdonationwebsite[] http://www.organdonation.gov.hk/eng/lightuplives.html Kim,J.R.,Fisher,M.J.,&Elliott,D.(2006).Attitudesofintensivecarenursestowardsbraindeath andorgantransplantation:Instrumentdevelopmentandtesting.JournalofAdvancedNursing, 53(5),571582. Vastag B. (2003) Livingdonor transplants reexamined: experts cite growing concerns about safety of donors. JAMA. Vol .290(2), pp.1812,
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