Bioethics Discussion Blog: Using the Newly Dead

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Saturday, January 28, 2006

Using the Newly Dead


As a segue from the last posting on ethics and law in organ donation of the deceased, I want to bring to the attention to my visitors the full picture of the issues involved in the practice of “using the newly dead”. Are my visitors also aware that the newly dead are used for other medical purposes, in addition to organ procurement? Did you know about medical research and medical training to perform procedures?

First, with regard to tissue and/or organ procurement, this is performed on patients who are pronounced dead by classical cardio-respiratory criteria (spontaneous absence of heart beat and respiration), they are also obtained from patients who are pronounced dead by neurologic criteria (absence of whole brain function including brain stem), so-called “brain dead”, and finally from those who are dead by cardio-respiratory criteria but which was the result of the voluntary and intentional turning off of all life-support and awaiting for the heartbeat and respiration to stop. This latter criteria is used for the “donation by cardiac death”(DCD). There is still concern by the public and also by some medical professionals about the ethics of procurement using death by neurologic criteria and the DCD mechanism of producing death. The concerns involved in “brain death” is that the heart is still beating and the patient is being ventilated up to and as the organs are being removed. The patient doesn’t seem “as dead” as with the classical criteria. The concerns about DCD is whether the patient has been observed long enough (usually 5 to 10 minutes) to be sure there is no spontaneous revival of heart function before the organs are removed. Since the intentional turning off of life-support in a patient, as a candidate for DCD. who is terminal or has no chance for any meaningful recovery, is done because of the previous autonomous request of the patient or on the substituted judgment of a legal surrogate or with approval of the family as being in the patient’s best interest, there usually is no controversy about this act itself. But there is concern about the “premature” removal of the organs.

Now we come to another use of the newly dead. For years now, particularly since the advent of ventilator support and the concept of death by neurologic criteria, patients who are “brain dead” are being used for a great variety of research projects in which because the heart and respiration can be maintained for some time, the body can be functionally almost normal despite the absence of brain function. This means that medical research, though various techniques, can be performed on these newly dead which would be unethical or harmful if performed on live volunteers. For more details and examples of this use, you might want to read the Chicago SunTimes article “Ethical Frontier: Research on the Dead” by Jim Ritter in the Jan 3, 2006 issue. There are many ethical issues involve with this use. There have been various ethical guidelines set up by ethics groups to attempt to make sure that the research team follows certain ethical and legal standards. A discussion of the ethical considerations and the presentation of another, more recent, guideline is written in November 2005 issue of Nature Medicine by the multidisciplinary expert Consensus Panel on Research with the Recently Dead.

Respect for the dead is an important moral point.“ Such respect requires that research with the dead abide by the deceased person’s life goals and treats his or her body in a dignified manner.” Other reasons for maintaining the dignity of the person is that “many living people have preferences about the disposition of their bodies after they die; an aversion to disrespectful treatment is commonly among them. Honoring such preferences after death expresses respect for the person who once lived and may prevent emotional distress among the living.” In addition this behavior with regard to honoring preferences may avoid mistrust by the living, without which might generate research opposition. Disrespect may also “cause family and friends anguish and feelings of guilt (for failing to protect a deceased loved one). Some points based on ethical concerns that are covered in the guideline is the need for the research to address an important clinical problem and there should be formal unbiased review by a research board before the research is started. In addition, amongst other points is that prior consent by the patient or surrogates is necessary and there should be confidentiality and an opportunity for health care workers who find the research against their moral values to have an opportunity to opt out.

Finally, another use of the newly dead is that of the use for medical training of students, interns and residents to perform important potentially life-saving procedures such as endotracheal intubation or various other procedures which could cause harm in a living patient if they were performed improperly. To read more about the ethics of this use, go to Virtual Mentor. Prior consent is an ethical requirement, however there is literature which suggests that often prior consent is not obtained. If there is no consent from an advance directive by the patient, an argument that may be offered is that attempting to get such consent from a often distraught and grieving family at the last minute may not be in the family’s best interest.

I hope that this posting gives my visitors some idea of what is being done with the newly dead in medical practice. Since all these uses are clearly done for the benefit of society and we may all have the opportunity to benefit from the results of them, I would be interested to read from my visitors what concerns they may have about the practices involved in organ procurement, medical research and medical training using the newly dead. ..Maurice.

6 Comments:

At Saturday, January 28, 2006 8:31:00 PM, Anonymous Moof said...

Very interesting post! Thank you!

First off, your link to the Chicago Sun Times article goes to a dead page, but I was able to find the article at the following link:

http://www.findarticles.com/p/articles/mi_qn4155/is_20060103/ai_n15975686

Secondly, I personally do not see a problem with the "newly dead" being used to teach medical students various procedures ... however, I do have one area of concern. If the "newly dead" had previously made a "full body donation" to a medical school, or even just an organ donation, then both the extra time and perhaps even the procedures themselves could cause the body, or the organ, to subsequently be rejected. I would have to say that the physician who makes the decision to do such a thing would need to be certain that he's not upsetting the newly dead patient's prior arrangements for body disposition.

Also ... I believe that there's a real need to educate the public about organ and full body donation. If the subject were more "mainstream," we wouldn't have 2-3 year minimum waiting lists for kidney donors, and medical students needing to share donor bodies in schools. Our bodies or vital organs are things that almost all of us can give back to society when we disembark from the Great Mandala.

Also - depending on what school a person has donated his body to, the family could be expecting the disposal of the body to already be arranged ... if something happens to prevent that, they could be presented with details and expenses they had not expected to be faced with.

Other than when a newly dead patient has made previous arrangements for the disposal of their bodies, I see no problem with using the body to teach a vital skill to a young budding physician.

I do agree that all of this should be done respectfully, and I may be a bit naive, but I think that this sort of thing probably is nearly always done in a respectful manner - or else I would not myself be making arrangements to make a full body donation.

 
At Saturday, January 28, 2006 10:02:00 PM, Blogger Maurice Bernstein, M.D. said...

Moof, I made the correction in the link to the Chicago SunTimes and now it works fine. With regard to use of the newly dead person for teaching medical techniques, often the teaching moment arrives with the arrival of a dying patient (for example, in the emergency room) and there is no advance directive permitting such use and there is no family around. The mentor must decide whether to ignore this teaching moment or go and teach the student or resident to perform the procedure with the rationale that there is no further harm to the patient now and the act would dignify the deceased by,in death, enable a contribution to the future living served by the student or resident. ..Maurice.

 
At Sunday, January 29, 2006 10:49:00 AM, Anonymous Moof said...

Dr. Bernstein, may I ask you what your personal (and professional) opinion is on this?

 
At Sunday, January 29, 2006 11:19:00 AM, Blogger Maurice Bernstein, M.D. said...

Personally and professionally, I would like to hear what society wants us to do in that situation. Society can express it's view through legislation and that is exactly what I would recommend. Society may decide that it is more beneficial to all patients in the future that physicians are better trained though this practice. And this may trump whatever psychologic harm to the living at the time. Of course, informed consent for student, intern and resident to practice upon the newly dead is ideal but sometimes because of the immediacy of the situation this is not possible. Just as there is legal acceptance of physicians carrying out potential life-saving, but experimental, procedures as a research project in the emergency room without any prior consent, there should be laws specifying whether practice intubation or other procedures can be carried out as teaching on the newly dead. Once physicians know the rules along with the public, there will be no guessing as to what should be done. ..Maurice.

 
At Tuesday, January 31, 2006 1:33:00 PM, Anonymous Ronny J Sayers MD said...

Nice discussion about a rather new athical area. I have some interesting discussions during my residency with over enthusiastic transplant surgeons about the status of their potential donors. I think the neurological standard of death has some weaknesses that need to be clarified when you have a transplant program in your hospital.
Ronny J. Sayers MD

 
At Tuesday, January 31, 2006 8:48:00 PM, Blogger Maurice Bernstein, M.D. said...

Death by neurologic criteria seems a valid criterion for death, because of its irreversibility and progression to cardiac arrest promptly in the case of removal of ventilator and generally is not prolonged if ventilation is continued. However, the neurologic requirements needs to be carefully followed and documented by neurologists themselves before the declaration is made. Certainly a properly carried out apnea test is essential to prove that there is irreversible brain stem destruction. ..Maurice.

 

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