RESUMEN
Donation after circulatory determination of death (DCDD) is an accepted practice in the United States, but heart procurement under these circumstances has been debated. Although the practice is experiencing a resurgence due to the recently completed trials using ex vivo perfusion systems, interest in thoracoabdominal normothermic regional perfusion (TA-NRP), wherein the organs are reanimated in situ prior to procurement, has raised many ethical questions. We outline practical, ethical, and equity considerations to ensure transplant programs make well-informed decisions about TA-NRP. We present a multidisciplinary analysis of the relevant ethical issues arising from DCDD-NRP heart procurement, including application of the Dead Donor Rule and the Uniform Definition of Death Act, and provide recommendations to facilitate ethical analysis and input from all interested parties. We also recommend informed consent, as distinct from typical "authorization," for cadaveric organ donation using TA-NRP.
Asunto(s)
Trasplante de Corazón , Perfusión , Obtención de Tejidos y Órganos , Humanos , Trasplante de Corazón/ética , Obtención de Tejidos y Órganos/ética , Preservación de Órganos/ética , Estados Unidos , Donantes de Tejidos/ética , Consentimiento Informado/ética , Muerte , CadáverRESUMEN
Xenotransplant covers a broad ethical territory and there are several ethical questions that have arisen in parallel with the technological advances that have allowed the first porcine transplants to occur. This brief communication highlights ethical considerations regarding heart and lung xenotransplantation, with an emphasis on unresolved value-based concerns in the field. The aim of this text is therefore to encourage the readers to consider the vast potential of this emerging technique to do good, but also the risk of doing harm, and to participate in a discussion. The list of questions presented here is not exhaustive but hopefully represents some of the questions that appear to be most pressing as the field advances. The focus is on the value-based, or ethical questions, not the questions related to the practical medical procedures.
Asunto(s)
Trasplante de Corazón , Trasplante de Pulmón , Trasplante Heterólogo , Trasplante Heterólogo/ética , Humanos , Trasplante de Pulmón/ética , Animales , Trasplante de Corazón/ética , PorcinosRESUMEN
Xenotransplantation offers the potential to meet the critical need for heart and lung transplantation presently constrained by the current human donor organ supply. Much was learned over the past decades regarding gene editing to prevent the immune activation and inflammation that cause early organ injury, and strategies for maintenance of immunosuppression to promote longer-term xenograft survival. However, many scientific questions remain regarding further requirements for genetic modification of donor organs, appropriate contexts for xenotransplantation research (including nonhuman primates, recently deceased humans, and living human recipients), and risk of xenozoonotic disease transmission. Related ethical questions include the appropriate selection of clinical trial participants, challenges with obtaining informed consent, animal rights and welfare considerations, and cost. Research involving recently deceased humans has also emerged as a potentially novel way to understand how xeno-organs will impact the human body. Clinical xenotransplantation and research involving decedents also raise ethical questions and will require consensus regarding regulatory oversight and protocol review. These considerations and the related opportunities for xenotransplantation research were discussed in a workshop sponsored by the National Heart, Lung, and Blood Institute, and are summarized in this meeting report.
Asunto(s)
Trasplante de Corazón , Trasplante de Pulmón , Trasplante Heterólogo , Trasplante Heterólogo/ética , Humanos , Trasplante de Pulmón/ética , Animales , Estados Unidos , Trasplante de Corazón/ética , National Heart, Lung, and Blood Institute (U.S.) , Investigación Biomédica/ética , Donantes de Tejidos/provisión & distribución , Donantes de Tejidos/éticaAsunto(s)
Beneficencia , Asignación de Recursos para la Atención de Salud , Insuficiencia Cardíaca , Trasplante de Corazón , Justicia Social , Justicia Social/ética , Justicia Social/normas , Trasplante de Corazón/ética , Trasplante de Corazón/normas , Estados Unidos , Asignación de Recursos para la Atención de Salud/ética , Asignación de Recursos para la Atención de Salud/normas , Insuficiencia Cardíaca/cirugíaRESUMEN
This Viewpoint examines how pediatrics should prepare for the prospect of cardiac xenotransplant, including its ethical implications.
Asunto(s)
Trasplante de Corazón , Trasplante Heterólogo , Niño , Humanos , Trasplante Heterólogo/ética , Trasplante de Corazón/éticaRESUMEN
BACKGROUND: Inclusion of BMI as criterion in the determination of heart transplant candidacy in children is a clinical and ethical challenge. Childhood obesity is increasing and children with heart disease are not spared. Currently, many adult heart transplant centers consider class II obesity and higher (BMI > 35 kg/m2 ) to be a relative contraindication for transplantation due to risk of poor outcome after transplant. No national guidelines exist regarding consideration of BMI in pediatric heart transplant and outcomes data are limited. This leaves decisions about transplant candidacy in obese pediatric patients to individual institutions or on a case-by-case basis, allowing for bias and inequity. METHODS: We review (a) the prevalence of childhood obesity, including among heart transplant candidates, (b) the lack of existing BMI guidelines, and (c) relevant literature on BMI and pediatric heart transplant outcomes. We discuss the ethical considerations of using obesity as a criterion using the principles of utility, justice, and respect for persons. RESULTS: Existing transplant outcomes data do not show that obese children have different or poor enough outcomes compared to non-obese children to warrant exclusion. Moreover, obesity in the United States is unequally distributed by race and socioeconomic status. Children already suffering from health disparities are therefore doubly penalized if obesity denies them access to life-saving transplant. CONCLUSION: Insufficient data exist to support using any BMI cutoff as an absolute contraindication for heart transplant in children. Attention should be paid to health equity issues when considering excluding a patient for transplant based on obesity.
Asunto(s)
Discusiones Bioéticas , Análisis Ético , Trasplante de Corazón/ética , Selección de Paciente/ética , Obesidad Infantil , Niño , Contraindicaciones de los Procedimientos , Trasplante de Corazón/efectos adversos , Humanos , Obesidad Infantil/epidemiología , Prevalencia , Estados Unidos/epidemiologíaRESUMEN
PURPOSE OF REVIEW: Simultaneous heart-liver (SHL) transplants are only a small proportion of overall heart and liver transplantation, they have been increasing in frequency and thus challenge the equitable allocation of organs. RECENT FINDINGS: The incidence of SHL transplants is reviewed along with the outcomes of SHL transplants and their impact on the waitlist, particularly in the context of solitary heart and liver transplantation. The ethical implications, most importantly the principles of utility and equity, of SHL transplant are addressed. In the context of utility, the distinction of a transplant being life-saving versus life-enhancing is investigated. The risk of hepatic decompensation for those awaiting both solitary and combined organ transplantation is an important consideration for the principle of equity. Lastly, the lack of standardization of programmatic approaches to SHL transplant candidates, the national approach to allocation, and the criteria by which programs are evaluated are reviewed. SUMMARY: As with all multiorgan transplantation, SHL transplantation raises ethical issues of utility and equity. Given the unique patient population, good outcomes, lack of alternatives, and overall small numbers, we feel there is continued ethical justification for SHL, but a more standardized nationwide approach to the evaluation, listing, and allocation of organs is warranted.
Asunto(s)
Toma de Decisiones/ética , Trasplante de Corazón/ética , Trasplante de Hígado/ética , Trasplante de Corazón/métodos , Humanos , Trasplante de Hígado/métodosRESUMEN
This paper uses the history of kidney transplantation in South Africa as a lens through which to write a racialized, micro history that illustrates the politics of medical discoveries and medical research at one of South Africa's most prestigious medical research universities, the University of the Witwatersrand (Wits) in Johannesburg. Between 1966 and the 1980s, the Wits team became the most advanced and prolific kidney transplant unit in the country. Yet the racist, oppressive Apartheid system fundamentally shaped these developments. Transplantation, as this paper shows, became an elite medical procedure, performed by a select group of white doctors on mostly white patients. For these doctors, transplantation showed their medical prowess and displayed the technical advancements they were able to make in research and clinical practice as they strove to position South Africa as a significant international player in medical research, despite academic boycotts and increasing sanctions. Transplantation became a symbol of white supremacy in a country where the black majority were excluded from anything but the most basic health care.
Asunto(s)
Centros Médicos Académicos/historia , Apartheid/historia , Ética Médica/historia , Trasplante de Riñón/historia , Racismo/historia , Investigación Biomédica/ética , Investigación Biomédica/historia , Población Negra , Trasplante de Corazón/ética , Trasplante de Corazón/historia , Historia del Siglo XX , Humanos , Terapia de Inmunosupresión/historia , Trasplante de Riñón/ética , Sudáfrica , Población BlancaRESUMEN
To understand the challenges for thoracic transplantation and mechanical circulatory support during the current coronavirus disease 2019 pandemic, we propose separating the effects of the pandemic into 5 distinct stages from a healthcare system perspective. We discuss how the classical ethical principles of utility, justice, and efficiency may need to be adapted, and we give specific recommendations for thoracic transplantation and mechanical circulatory support centers to balance their clinical decisions and strategies for advanced heart and lung disease during the current pandemic.
Asunto(s)
Circulación Asistida/ética , Betacoronavirus , Infecciones por Coronavirus/epidemiología , Accesibilidad a los Servicios de Salud/ética , Trasplante de Corazón/ética , Trasplante de Pulmón/ética , Neumonía Viral/epidemiología , COVID-19 , Humanos , Pandemias , Selección de Paciente/ética , SARS-CoV-2Asunto(s)
Anomalías Múltiples , Actitud Frente a la Salud , Consenso , Familia/psicología , Trasplante de Corazón/ética , Síndrome del Corazón Izquierdo Hipoplásico/complicaciones , Síndrome del Corazón Izquierdo Hipoplásico/cirugía , Cuidados para Prolongación de la Vida/ética , Grupo de Atención al Paciente/ética , Síndrome de Turner/complicaciones , Discusiones Bioéticas , Femenino , Humanos , Recién Nacido , PronósticoRESUMEN
It is estimated that nearly 6.5 million Americans over the age of 20 suffer from heart failure. Heart failure is the leading cause of hospitalization in patients over 65 years of age, and carries with it a 5-year mortality of nearly 50%. Despite advances in medical therapy, treatment for medically refractory end-stage, advanced heart failure is limited to heart transplant, mechanical circulatory support (MCS), or palliative care only. Patient selection in advanced heart failure (AHF) therapy is complex. Not only are the patients medically complicated, but providers are biased by their individual and collective experience with similar and dissimilar patients. Clinicians caring for AHF patients balance competing clinical and ethical demands, which appropriately leads to professional debate and disagreement. These debates are constructive because they clarify ethical and professional commitments and help to ensure fair and equitable treatment of AHF patients.
Asunto(s)
Insuficiencia Cardíaca/terapia , Trasplante de Corazón/ética , Corazón Auxiliar/ética , Hospitalización/estadística & datos numéricos , Defensa del Paciente/normas , Selección de Paciente , Guías de Práctica Clínica como Asunto/normas , Adulto , Cardiotónicos/uso terapéutico , Femenino , Trasplante de Corazón/tendencias , Corazón Auxiliar/tendencias , Humanos , Masculino , Cuidados Paliativos , Pronóstico , Adulto JovenRESUMEN
We present the case of a 19-month-old boy with complex congenital heart disease. His single father is skeptical of traditional medicine and does not offer the social support needed to make heart transplantation successful for his son. After the father demonstrates commitment to transplant success and provides enhanced social support, doctors place the child on a Berlin Heart (a biventricular assist device) as a bridge to transplantation and list him for transplant. When the child is matched to a donor heart, the father refuses transplantation, despite that it is the child's only chance for survival. His doctors report the case to child protective services, but they decline to take protective custody. The father then changes his mind and asks that the child be put back on the waiting list for transplant. By this time, the social supports the father implemented are no longer in place. This case raises a number of issues. First, should courts order heart transplantation when doctors believe that it is in the child's best interest and parents do not consent? Second, once parents refuse a transplant, can they change their minds? Third, if there are uncertainties regarding whether the child has the social support to make transplantation successful, should the child be relisted? Finally, should a child who is not currently a transplant candidate but who may become one in the future be supported with ventricular assist devices?
Asunto(s)
Relaciones Padre-Hijo , Cardiopatías Congénitas/diagnóstico , Trasplante de Corazón/ética , Corazón Auxiliar/ética , Apoyo Social , Listas de Espera , Cardiopatías Congénitas/psicología , Cardiopatías Congénitas/cirugía , Trasplante de Corazón/psicología , Corazón Auxiliar/psicología , Humanos , Lactante , Masculino , Grupo de Atención al Paciente/ética , Grupo de Atención al Paciente/tendenciasRESUMEN
Ethical issues in pediatric heart transplantation (Htx) include resource allocation, benefit, and burden assessment in high-risk recipients, and informed consent. Practice patterns and decision-making was investigated using an internet survey with 47-multiple choice items and vignette-based questions. Of 43 pediatric Htx cardiologists contacted, 28 (65%) responded. Respondents reported that an overall median 1-month survival of 73% (range 50-100%), 1-year survival of 70% (range 50-85%), 5-year survival of 50% (range 40-85%), and 10-year survival of 50% (range 25-85%) was adequate to offer Htx. Based on vignettes presented, 100% of those surveyed would offer Htx to a straightforward 12-year old with end-stage dilated cardiomyopathy and a 7-year old with hypoplastic left heart syndrome with protein losing enteropathy. Thirty percent of physicians would offer Htx to a patient status post a Fontan procedure with mutliple co-morbidities. Seventy-five percent of physicians would offer Htx despite proven non-adherence. Considerable variability exists in the practice patterns of pediatric heart transplant cardiologists with regards to decision-making while evaluating patients for listing. Disagreements among pediatric Htx cardiologists exist when there are concerns for non-adherence and associated multiple co-morbidities. Further work is needed to understand these variations and develop consensus for pediatric Htx organ allocation.
Asunto(s)
Cardiólogos/ética , Toma de Decisiones Clínicas , Trasplante de Corazón/ética , Pautas de la Práctica en Medicina , Adulto , Cardiólogos/normas , Niño , Preescolar , Femenino , Estado de Salud , Trasplante de Corazón/mortalidad , Trasplante de Corazón/psicología , Humanos , Masculino , Pediatría/métodos , Proyectos Piloto , Estudios Retrospectivos , Encuestas y CuestionariosRESUMEN
BACKGROUND: This paper examines the ethical aspects of organ transplant surgery in which a donor heart is transplanted from a first recipient, following determination of death by neurologic criteria, to a second recipient. Retransplantation in this sense differs from that in which one recipient undergoes repeat heart transplantation of a newly donated organ, and is thus referred to here as "reuse cardiac organ transplantation." METHODS: Medical, legal, and ethical analysis, with a main focus on ethical analysis. RESULTS: From the medical perspective, it is critical to ensure the quality and safety of reused organs, but we lack sufficient empirical data pertaining to medical risk. From the legal perspective, a comparative examination of laws in the United States and Japan affirms no illegality, but legal scholars disagree on the appropriate analysis of the issues, including whether or not property rights apply to transplanted organs. Ethical arguments supporting the reuse of organs include the analogous nature of donation to gifts, the value of donations as inheritance property, and the public property theory as it pertains to organs. Meanwhile, ethical arguments such as those that address organ recycling and identity issues challenge organ reuse. CONCLUSION: We conclude that organ reuse is not only ethically permissible, but even ethically desirable. Furthermore, we suggest changes to be implemented in the informed consent process prior to organ transplantation. The organ transplant community worldwide should engage in wider and deeper discussions, in hopes that such efforts will lead to the timely preparation of guidelines to implement reuse cardiac organ transplantation as well as reuse transplantation of other organs such as kidney and liver.
Asunto(s)
Trasplante de Corazón/ética , Reoperación/ética , Adulto , Trasplante de Corazón/efectos adversos , Trasplante de Corazón/legislación & jurisprudencia , Humanos , Japón , Masculino , Propiedad/ética , Propiedad/legislación & jurisprudencia , Seguridad del Paciente , Donantes de Tejidos/ética , Estados UnidosRESUMEN
Donors after brain death (DBD) have been the major source of organ donation due to good perfusion of the organs. However, owing to the mismatch in demand and supply of the organ donors and recipients, donors after circulatory death (DCDDs) has increased recently all over the world. Kidneys, liver, and lungs are being used for transplantation from DCDDs. Recently, heart transplantation from DCDDs has been started, which is under the firestorm of scrutiny by the ethicists. The ethical dilemma revolves around the question whether the donors are actually dead when they are declared dead by cardiocirculatory death criteria for organ procurement. The subsequent literature review addresses all the perspectives by differentiating between the donation methods known as DBDs and DCDDs, explaining the implications of the dead-donor rule on the organ donation pool, and categorizing the determinants of death leading to separation of the arguments under the two methods of donations.