Transplantes de órgãos vitais exigem morte do doador, adverte Bento XVI

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A morte encefálica foi criada em função dos interesses transplantadores de alta complexidade e custo, no final da década de 60, por Comitê Ad Hoc de Harvard.  A forma mais simples de explicar este imperativo é de que os órgãos vitais únicos apenas podem ser retirados viáves para transplantação se a atividade cardiorrespiratória estiver preservada.

Celso Galli Coimbra

OABRS 11352

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ZP08110708 – 07-11-2008
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http://www.zenit.org/article-19996?l=portuguese

De qualquer forma, nestes casos, esclareceu citando o
«deve assumir-se como critério principal o respeito pela vida do doador,
de maneira que a extração de órgãos só aconteça após
se ter constatado sua morte real».

Transplantes de órgãos vitais exigem morte do doador, adverte Bento XVI


Pede que se chegue a um consenso científico claro «para constatar a morte do paciente»

CIDADE DO VATICANO, sexta-feira, 7 de novembro de 2008 (ZENIT.org).- Bento XVI insistiu em que os transplantes de órgãos vitais podem acontecer eticamente sob a condição de que se tenha constatado a morte do doador e com o consentimento informado de suas famílias.

O Papa tocou nesta sexta-feira um dos debates bioéticos mais candentes, ao receber no Vaticano os participantes do congresso internacional sobre «Um dom para a vida. Considerações sobre a doação de órgãos», realizado de 6 a 8 de novembro, por iniciativa da Academia Pontifícia para a Vida, em colaboração com a Federação Internacional das Associações Médicas Católicas e o Centro Nacional Italiano de Transplantes.

Em primeiro lugar, ao falar da doação de órgãos vitais, o pontífice explicou que «o consentimento informado é uma condição da liberdade para que o transplante se caracterize por ser um dom e não se interprete como um ato coercitivo ou de abuso».

Em segundo lugar, recordou, «os diferentes órgãos vitais só podem ser extraídos ex cadavere [do cadáver, N. da R.], que possui uma dignidade própria que deve ser respeitada».

«A ciência, nestes anos, fez progressos para constatar a morte do paciente», constatou, sem entrar no debate sobre qual o critério científico deve adotar-se para isso: a morte cerebral ou o cessar de funções vitais: a respiração, a circulação, a atividade do sistema nervoso.

O que o Papa pediu é que «os resultados alcançados recebam o consenso de toda a comunidade científica para favorecer a busca de soluções que dêem certeza a todos».

Agora, «em um âmbito como este», reconheceu, «não se pode dar a mínima suspeita de arbítrio e, quando não se tenha alcançado ainda a certeza, deve prevalecer o princípio de precaução».

«Para isso, é útil aumentar a busca e a reflexão interdisciplinar, de maneira que se apresente à opinião pública a verdade mais transparente sobre as implicações antropológicas, sociais, éticas e jurídicas da prática do transplante.»

De qualquer forma, nestes casos, esclareceu citando o Compêndio do Catecismo da Igreja Católica (n. 476), «deve assumir-se como critério principal o respeito pela vida do doador, de maneira que a extração de órgãos só aconteça após se ter constatado sua morte real».
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The Dead Donor Rule and Organ Transplantation

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In this issue of the Journal, Boucek et al. (pages 709–714) report on three cases of heart transplantation from infants who were pronounced dead on the basis of cardiac criteria. The three Perspective articles and a video roundtable discussion at http://www.nejm.org address key ethical aspects of organ donation after cardiac death. Bernat and Veatch comment on the cases described by Boucek et al.; Truog and Miller raise a fundamental question about the dead donor rule. In a related Perspective roundtable, moderator Atul Gawande, of Harvard Medical School, is joined by George Annas, of the Boston University School of Public Health; Arthur Caplan, of the University of Pennsylvania; and Robert Truog. Watch the roundtable online at http://www.nejm.org.

Since its inception, organ transplantation has been guided by the overarching ethical requirement known as the dead donor rule, which simply states that patients must be declared dead before the removal of any vital organs for transplantation. Before the development of modern critical care, the diagnosis of death was relatively straightforward: patients were dead when they were cold, blue, and stiff. Unfortunately, organs from these traditional cadavers cannot be used for transplantation. Forty years ago, an ad hoc committee at Harvard Medical School, chaired by Henry Beecher, suggested revising the definition of death in a way that would make some patients with devastating neurologic injury suitable for organ transplantation under the dead donor rule.1

The concept of brain death has served us well and has been the ethical and legal justification for thousands of lifesaving donations and transplantations. Even so, there have been persistent questions about whether patients with massive brain injury, apnea, and loss of brain-stem reflexes are really dead. After all, when the injury is entirely intracranial, these patients look very much alive: they are warm and pink; they digest and metabolize food, excrete waste, undergo sexual maturation, and can even reproduce. To a casual observer, they look just like patients who are receiving long-term artificial ventilation and are asleep.

The arguments about why these patients should be considered dead have never been fully convincing. The definition of brain death requires the complete absence of all functions of the entire brain, yet many of these patients retain essential neurologic function, such as the regulated secretion of hypothalamic hormones.2 Some have argued that these patients are dead because they are permanently unconscious (which is true), but if this is the justification, then patients in a permanent vegetative state, who breathe spontaneously, should also be diagnosed as dead, a characterization that most regard as implausible. Others have claimed that “brain-dead” patients are dead because their brain damage has led to the “permanent cessation of functioning of the organism as a whole.”3 Yet evidence shows that if these patients are supported beyond the acute phase of their illness (which is rarely done), they can survive for many years.4 The uncomfortable conclusion to be drawn from this literature is that although it may be perfectly ethical to remove vital organs for transplantation from patients who satisfy the diagnostic criteria of brain death, the reason it is ethical cannot be that we are convinced they are really dead.

Over the past few years, our reliance on the dead donor rule has again been challenged, this time by the emergence of donation after cardiac death as a pathway for organ donation. Under protocols for this type of donation, patients who are not brain-dead but who are undergoing an orchestrated withdrawal of life support are monitored for the onset of cardiac arrest. In typical protocols, patients are pronounced dead 2 to 5 minutes after the onset of asystole (on the basis of cardiac criteria), and their organs are expeditiously removed for transplantation. Although everyone agrees that many patients could be resuscitated after an interval of 2 to 5 minutes, advocates of this approach to donation say that these patients can be regarded as dead because a decision has been made not to attempt resuscitation.

This understanding of death is problematic at several levels. The cardiac definition of death requires the irreversible cessation of cardiac function. Whereas the common understanding of “irreversible” is “impossible to reverse,” in this context irreversibility is interpreted as the result of a choice not to reverse. This interpretation creates the paradox that the hearts of patients who have been declared dead on the basis of the irreversible loss of cardiac function have in fact been transplanted and have successfully functioned in the chest of another. Again, although it may be ethical to remove vital organs from these patients, we believe that the reason it is ethical cannot convincingly be that the donors are dead.

At the dawn of organ transplantation, the dead donor rule was accepted as an ethical premise that did not require reflection or justification, presumably because it appeared to be necessary as a safeguard against the unethical removal of vital organs from vulnerable patients. In retrospect, however, it appears that reliance on the dead donor rule has greater potential to undermine trust in the transplantation enterprise than to preserve it. At worst, this ongoing reliance suggests that the medical profession has been gerrymandering the definition of death to carefully conform with conditions that are most favorable for transplantation. At best, the rule has provided misleading ethical cover that cannot withstand careful scrutiny. A better approach to procuring vital organs while protecting vulnerable patients against abuse would be to emphasize the importance of obtaining valid informed consent for organ donation from patients or surrogates before the withdrawal of life-sustaining treatment in situations of devastating and irreversible neurologic injury.5

What has been the cost of our continued dependence on the dead donor rule? In addition to fostering conceptual confusion about the ethical requirements of organ donation, it has compromised the goals of transplantation for donors and recipients alike. By requiring organ donors to meet flawed definitions of death before organ procurement, we deny patients and their families the opportunity to donate organs if the patients have devastating, irreversible neurologic injuries that do not meet the technical requirements of brain death. In the case of donation after cardiac death, the ischemia time inherent in the donation process necessarily diminishes the value of the transplants by reducing both the quantity and the quality of the organs that can be procured.

Many will object that transplantation surgeons cannot legally or ethically remove vital organs from patients before death, since doing so will cause their death. However, if the critiques of the current methods of diagnosing death are correct, then such actions are already taking place on a routine basis. Moreover, in modern intensive care units, ethically justified decisions and actions of physicians are already the proximate cause of death for many patients — for instance, when mechanical ventilation is withdrawn. Whether death occurs as the result of ventilator withdrawal or organ procurement, the ethically relevant precondition is valid consent by the patient or surrogate. With such consent, there is no harm or wrong done in retrieving vital organs before death, provided that anesthesia is administered. With proper safeguards, no patient will die from vital organ donation who would not otherwise die as a result of the withdrawal of life support. Finally, surveys suggest that issues related to respect for valid consent and the degree of neurologic injury may be more important to the public than concerns about whether the patient is already dead at the time the organs are removed.

In sum, as an ethical requirement for organ donation, the dead donor rule has required unnecessary and unsupportable revisions of the definition of death. Characterizing the ethical requirements of organ donation in terms of valid informed consent under the limited conditions of devastating neurologic injury is ethically sound, optimally respects the desires of those who wish to donate organs, and has the potential to maximize the number and quality of organs available to those in need.

No potential conflict of interest relevant to this article was reported.

The opinions expressed in this article are those of the authors and do not necessarily reflect the policy of the National Institutes of Health, the Public Health Service, or the Department of Health and Human Services.

Source Information

Dr. Truog is a professor of medical ethics and anesthesia (pediatrics) in the Departments of Anesthesia and Social Medicine at Harvard Medical School and the Division of Critical Care Medicine at Children’s Hospital Boston — both in Boston. Dr. Miller is a faculty member in the Department of Bioethics, National Institutes of Health, Bethesda, MD.

References

     

  1. A definition of irreversible coma: report of the ad hoc committee of the Harvard Medical School to examine the definition of brain death. JAMA 1968;205:337-340. [Free Full Text]
  2. Truog RD. Is it time to abandon brain death? Hastings Cent Rep 1997;27:29-37. [Web of Science][Medline]
  3. Bernat JL, Culver CM, Gert B. On the definition and criterion of death. Ann Intern Med 1981;94:389-394. [CrossRef][Web of Science][Medline]
  4. Shewmon DA. Chronic “brain death”: meta-analysis and conceptual consequences. Neurology 1998;51:1538-1545. [Free Full Text]
  5. Miller FG, Truog RD. Rethinking the ethics of vital organ donation. Hastings Cent Rep (in press).

http://content.nejm.org/cgi/content/full/359/7/674?query=TOC

This article has been cited by other articles:

  • Abiola, S., Chernyak, I. (2008). Recent developments in health law.. J Law Med Ethics 36: 856-865
  • Chrispin, E, Conlon Vaswani, N, English, V, Harrison, C, Sheather, J, Sommerville, A (2008). Ethics briefings. J. Med. Ethics 34: 829-830 [Full Text]
  • Curfman, G. D., Morrissey, S., Drazen, J. M. (2008). Cardiac Transplantation in Infants. NEJM 359: 749-750 [Full Text]

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Rabbis divided on organ donation law

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“Today, with all the recent advances in medical science, a person who is brain-dead can be saved by doctors”

Neta Sela

Published: 03.25.08, 22:20 / Israel Jewish Scene

” Following the passage Monday of the bill proposed by MK Otniel Schneller (Kadima), which deems brain death as actual death for all legal and other purposes, MK Moshe Gafni (United Torah Judaism), speaking on behalf of Lithuanian rabbi Yosef Sholom Eliashiv, Tuesday urged all Jewish people to “ask doctors to keep treating a brain-dead relative until he either recovers or his heart stops beating.”

The new law passed in the Knesset allows families to decide, in accordance with their own beliefs and values, whether they deem brain death or cardiac death to be the actual moment of passing. MK Gafni, fiercely objecting to this notion, stated that “this in essence means that someone who has suffered a stroke or aneurysm can in essence be declared dead.”

At the heart of this controversy stands a long-running dispute between medical science and Torah law. Whereas medically a person is deemed dead when brain activity ceases, the Torah only views death as having taken place when cardiac activity and respiration no longer take place.

A DIVISE MATTER

To date only doctors could declare a patient dead. While rabbis were wary of doctors being overly hasty in pronouncing the deaths of their patients, which is tantamount to murder according to halacha, doctors resented “rabbinical supervision” in their hospital rooms.

All organ donations in Israel are carried out strictly with the consent of family members, based on medical evidence offered by the doctors involved. MK Schneller’s new law will allow families to attain their loved one’s medical documentation, and take it to a rabbi if they so wish in order to make sure that the doctor’s point of view in regards to organ donation does not run contrary to halacha.

Schneller consulted with a whole host of rabbis in drafting this new law, in an attempt to bridge the daunting chasm between Jewish law and medical science. While both Rabbi Ovadia Yosef and Chief Sephardic Rabbi Shlomo Amar endorsed the bill, Lithuanian chief rabbi Yosef Sholom Eliashiv objected to it, preferring to adhere to the traditional definition of death as occurring with the cessation of cardiac activity. This limits vastly the range of organs that can remain viable for donation.

MK Gafni, in keeping with Eliashiv’s views, objected to this law at every stage of the legislative process. “Death should only be declared with the cessation of cardiac activity,” he said. “From the Torah’s point of view a brain-dead individual is still alive. Today, with all the recent advances in medical science, a person who is brain-dead can be saved by doctors.

In spite of this dissent, the new law will make it easier for orthodox families to donate their loved ones’ organs in face of halachic concerns. It provides for the establishment of a state run medical steering committee that will train doctors in various facets of determining respiratory and brain deaths in their patients, as well as to better balance ethical, halachic and legal concerns arising from organ donation.

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Eda Haredit: Organ donation is murder

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Following ‘Zionist rabbinate’s shocking seal of approval’ to recognize brain-respiratory death, Badatz rabbis issue announcement saying brain dead patients ‘alive in every way, life support must not be disconnected’

Kobi Nahshoni

Published: 11.01.09, 16:19 / Israel Jewish Scene

 

Following a Ynet report on the Chief Rabbinate’s decision to recognize brain-respiratory death, thus allowing organ donations in accordance with Jewish religious laws, the Badatz, the Eda Haredit’s high court, ruled that taking organs from a person in such a condition or removing him or her from life support is murder.

In an announcement published in the ultra-Orthodox organization’s journal, ‘HaEda’, the Badatz, headed by Yitzhak Tuvia Weiss reiterated the ruling that was given almost two-years ago, “in light of the Zionist rabbinate’s shocking seal of approval”.

The announcement said, “We have already ruled and given a clear Torah judgment… that brain death or brain stem death are not defined as death, and if organs are taken from (a person in such a condition) it is murder.

“We repeat that such a ruling already exists, and life support must not be disconnected, the person is alive in every way.”

The Eda Haredit’s firm stance is in line with that of the mainstream ultra-Orthodox public’s position, as it expressed in the community’s Yated Ne’eman daily paper.

An editorial published after the Chief Rabbinate’s ruling titled “Caution: Bloodshed” criticized the rabbis’ debate over the matter, saying, “There is no place of discussions or debates in this matter” and protested the fact that “Every student is allowing himself to give ‘educated opinions’ and present ‘halachic studies’ in the matter as they please.”

The editorial said that paper would “continue to express the Torah and the halacha’s stance against these dangerous initiatives, as part of its role and its mission as a form of expression of the Torah world and the God-fearing public standing on the front lines of the struggle for the sanctity of life according to halacha.”

Last month the Chief Rabbinate ruled that the Organ Donation Law’s definition of brain death at the moment of death is in line with that of the halacha. However, arbiter Yosef Sholom Elyashiv maintains his objection to the ruling, and views cessation of cardiac rhythm as moment of death.

The Chief Rabbinate’s decision ratifies a ruling given by the council in 1987 on determining the moment of death. At the time, the rabbis ruled out organ donation after the medical establishment objected to having a rabbinical representative join the team that determines death.

Now that the law has been approved, there is no concern that doctors may pronounce someone dead against halacha, and the rabbinate decided to introduce a new organ donation initiative, parallel to that of the National Transplant and Organ Donations Center.
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