The ethical obligation of the dead donor rule.

The dead donor rule (DDR) originally stated that organ donors must not be killed by and for organ donation. Scholars later added the requirement that vital organs should not be procured before death. Some now argue that the DDR is breached in donation after circulatory determination of death (DCDD) programs. DCDD programs do not breach the original version of the DDR because vital organs are procured only after circulation has ceased permanently as a consequence of withdrawal of life-sustaining therapy. We hold that the original rendition of the DDR banning killing by and for organ donation is the fundamental norm that should be maintained in transplantation ethics. We propose separating the DDR from two other fundamental normative rules: the duties to prevent harm and to obtain informed consent.

Clinical Research in Acute Fatal Illness: Lessons From Extracorporeal Membrane Oxygenation.

Clinical research to evaluate the effectiveness of life support systems in acute fatal illness has unique problems of logistics, ethics, and consent. There have been 10 prospective comparative trials of extracorporeal membrane oxygenation in acute fatal respiratory failure, utilizing different study designs. The trial designs were prospective controlled randomized, prospective adaptive randomized, sequential, and matched pairs. The trials were reviewed with regard to logistics, ethics, consent, statistical methods, economics, and impact. The matched pairs method is the best study design for evaluation of life support systems in acute fatal illness.

Precedent autonomy should be respected in life-sustaining treatment decisions.

In the 2011 landmark case of W v M, the English Court of Protection ruled that it was unlawful to withdraw artificial nutrition and hydration from a woman who had been in a minimally conscious state for 8 years. From the perspective of the court, the absence of a written advance directive negated the woman's previous, autonomous interests and, consequently, emphasis was given to her current welfare and well-being. While life itself is a moral good, prolonging life for a person in regular pain with no hope of recovering to a more complete state of awareness simply because that person only verbalized her wishes about her treatment decisions seems to drastically undervalue the principle of autonomy. We refute the notion that it is the role of the court to prolong life insofar as it can and argue that withholding and withdrawing life sustaining technologies from patients in a minimally conscious state can be ethically justified.

[Ethical aspects in the context of extracorporeal life support systems (ECLS): consensus paper of the DGK, DGTHG and DGAI]. / Ethische Aspekte im Rahmen von extrakorporalen Herz-Kreislauf-Unterstützungssystemen (ECLS): Konsensuspapier der DGK, DGTHG und DGAI.

Extracorporeal life support systems (ECLS) are life-sustaining measures for severe cardiovascular diseases, serving as bridging treatment either until cardiovascular function is restored or alternative treatment, such as heart transplantation or the implantation of permanent ventricular assist devices is performed. Given the insufficient evidence and frequent urgency of implantation without initial patient consent, the ethical challenges and psychological burden for patients, relatives and the interprofessional intensive care team are significant. As with any treatment, an appropriate therapeutic goal for ECLS treatment based on the indications and patient informed consent is mandatory. In order to integrate the necessary ethical considerations into everyday clinical practice, a structured algorithm for handling ECLS is proposed here, which takes ethical aspects into due account.

Should we respect precedent autonomy in life-sustaining treatment decisions?

The recent judgement in the case of Re:M in which the Court held that it would be unlawful to withdraw artificial nutrition and hydration from a woman in a minimally conscious state raises a number of ethical issues of wide application. Central to these is the extent to which precedent autonomous decisions should be respected in the absence of a legally binding advance decision. Well-being interests can survive the loss of many of the psychological faculties that support personhood. A decision to respect precedent autonomy can contradict the well-being interests of the individual after capacity is lost. These decisions raise difficult questions about personal identity and about the threshold of evidence that is required of an earlier decision in order for it to be respected.

Sustaining the Lives of Art Objects.

This article explores the complex process of sustaining the lives of art objects and considers ways in which conservation efforts in art museums parallel cultural humility cultivation among health care professionals. Conservators and scientists at the Art Institute of Chicago grapple with a number of ethical questions that emerge when preserving and caring for objects with complicated histories and entangled networks of stakeholders. What follows is an examination of these issues in relation to objects in the Art Institute's collection and the larger histories of art museums and medicine.

A four-step protocol for limitation of treatment in terminal care. An observational study in 475 intensive care unit patients.

OBJECTIVE: To describe a four-step protocol for withholding and withdrawal of life support (WH/WDLS) in intensive care unit (ICU) terminal patients. DESIGN: Observational study. SETTING: A 10-bed ICU of a general hospital. PATIENTS: Eighty-three patients out of 475 consecutive patients admitted over a 1 year period had WH/WDLS. INTERVENTIONS: The healthcare team chose a pattern of treatment limitation on a four-step protocol for every patient every day. There were four alternatives: group 1: no limitation of care; group 2: patient designated do not resuscitate (DNR) and pressors limited to dopamine at a maximum dose of 20 microg/kg per min; others therapies were continued; group 3: active withdrawal of all therapy except comfort care, i.e., the patient continued to receive nursing, sedation/analgesia, hydration and mechanical ventilation with FIO2=0.21 and no positive end-expiratory pressure (PEEP). Sedation was adjusted to Ramsay 3-4. The group 4 was treated the same as group 3 except that minute ventilation was 5 l/min and sedation/analgesia adjusted to Ramsay 6. WH/WDLS was performed only if the full ICU staff and all family members agreed with the procedure. WH/WDLS was documented in the patient's chart. RESULTS: Withholding and withdrawal of life support was performed in 83 patients (17%): 25 patients in group 2 (15 deaths), 36 patients in group 3 (36 deaths) and 22 patients in group 4 (22 deaths). Finally, 73 patients died after WH/WDLS. ICU stay was 10+/-17 days, time from admission to WH/WDLS was 184+407 h and time from WH/WDLS to death was 64+/-84 h. CONCLUSION: This four-step protocol may promote medical decision making on end-of-life care.

[Advanced directives. Legal and practical aspects of negative instructions concerning medical treatment]. / Schriftelijke wilsverklaringen. Juridische en praktische aspecten van negatieve medische-behandelingsinstructies.

The right of a competent patient to stipulate in advance of possible non-competence, medical treatment he does not want, is based on the fundamental legal principle that a person cannot be medically treated without his informed consent. It is in Dutch law a strong and almost unqualified right. There are indications in the international literature, however, that advance directives in many cases may not have much influence on medical treatment at the end of life. Very little is known about the social practice of advance directives in the Netherlands.

Tratamientos de soporte vital al final de la vida: costos y aspectos éticos. Punto de vista en una unidad de cuidados intensivos basado en la metodología Q / Life-support treatments at end of life: Costs and ethical aspects. Point of view in an intensive care unit based on Q methodology

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Eutanasia y Ética / No disponible

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[Withdrawal of life-support from ALS patients in so called totally locked in state: from the viewpoint of clinical ethics].

In Japanese context, there has been a controversy concerning the withdrawal of life-support, i.e. respiratory system, from ALS patients when, along of the progress of the disease, they have become not able to express themselves at all to people around them, i.e. when they are in so called 'totally locked in state (TLS)'. Basing himself on the system of clinical ethics he has been developing in accord with Japanese culture, the author (1) reconstitutes the logic of justifying the withdrawal in dispute, (2) examines objections against officially recognizing such withdrawal, and (3) proposes an appropriate process of decision making which he hopes to be acceptable to both sides in the controversy.

Bioethical issues concerning death: death, dying, and end-of-life rights.

Ethical issues about death, dying, and a person's right to make end-of-life decisions have become one of the most legally complex and culturally sensitive areas to emerge in our time. Sensitive issues associated with a terminally ill individual's right to make end-of-life decisions and the disposition of those who are unable to make such decisions for themselves will keep healthcare professionals, medical ethicists, counselors, families, lawyers, judges, and legislators busy for years to come. Americans find it difficult to deal with end-of-life issues and would rather focus on what more can be done to save a life.

Respect for the developmentally disabled and forgoing life-sustaining treatment.

A developmentally disabled person should be treated at all times as a unique individual and not as some anonymous "disabled person." The developmentally disabled should not be subjected to invasive medical treatment that is unduly burdensome or nonbeneficial, or be forced to endure a quality of life not meaningful to them as individuals. They have a right to refuse or accept treatment that a surrogate must exercise on behalf of each individual in a responsible and careful manner. Three cases and a preliminary approach to the ethical analysis of decisions to allow developmentally disabled persons to die by forgoing medical treatment are offered. The "best interests" of a developmentally disabled individual, properly understood, can serve as a useful and ethically defensible standard for determining the ethical propriety of surrogate decision making about forgoing life-sustaining medical treatment of the disabled.