Regional ethics of surgeon resuscitation for organ transplantation after lethal injury.

BACKGROUND: Trauma patients may present with nonsurvivable injuries, which could be resuscitated for future organ transplantation. Trauma surgeons face an ethical dilemma of deciding whether, when, and how to resuscitate a patient who will not directly benefit from it. As there are no established guidelines to follow, we aimed to describe resuscitation practices for organ transplantation; we hypothesized that resuscitation practices vary regionally. METHOD: Over a 3-month period, we surveyed trauma surgeons practicing in Levels I and II trauma centers within a single state using an instrument to measure resuscitation attitudes and practices for organ preservation. Descriptive statistics were calculated for practice patterns. RESULTS: The survey response rate was 51% (31/60). Many (81%) had experience with resuscitations where the primary goal was to preserve potential for organ transplantation. Many (90%) said they encountered this dilemma at least monthly. All respondents were willing to intubate; most were willing to start vasopressors (94%) and to transfuse blood (84%) (range, 1 unit to >10 units). Of respondents, 29% would resuscitate for ≥24 hours, and 6% would perform a resuscitative thoracotomy. Respect for patients' dying process and future organ quality were the factors most frequently considered very important or important when deciding to stop or forgo resuscitation, followed closely by concerns about excessive resource use. CONCLUSION: Trauma surgeons' regional resuscitation practices vary widely for this patient population. This variation implies a lack of professional consensus regarding initiation and extent of resuscitations in this setting. These data suggest this is a common clinical challenge, which would benefit from further study to determine national variability, areas of equipoise, and features amenable to practice guidelines.

Impassable scientific, ethical and legal barriers to body-to-head transplantation.

This article consists of four parts. In the first part it briefly describes the history of body-to-head transplantation (BHT) and the surgical plan proposed by Drs. Sergio Canavero and Ren Xiaoping on a human subject. In the second part it argues that the BHT procedure that they propose is scientifically invalid and technically infeasible so therefore would end in failure. In the third part it argues that the present conceivable procedure of BHT cannot be ethically justified because it would bring great harm to the human subject, it is uncertain who would be the possible beneficiary, and valid informed consent cannot be obtained. In the fourth part it argues that the action of performing the procedure of BHT might violate China's current criminal and civil laws. The conclusion that follows from the arguments above is that BHT should be prohibited now and also in the near future. However, this conclusion does not preclude scientists, neurosurgeons and bioethicists doing research into scientific, technical, surgical and ethical issues raised by BHT.

Head Transplantation: The Ultimate Level that Medicine has not yet Achieved.

The process of head transplantation is reviewed according to Cartesian philosophy. Recent developments in head transplantation were followed with great interest in the media and society. The surgeon Sergio Canavero stated that he could perform head transplantation. His ethical approaches to the procedure are evaluated, and the methodological suitability of the procedure with regard to the scientific ethics is discussed. The perception of the head transplantation process in the media and society is described as a phenomenon, and the relationship between society and science is evaluated. Ethical duties and responsibilities are highlighted as an area of knowledge. According to the perspective of Cartesian philosophy, it is not yet possible to perform head transplantation under the conditions of today’s medicine.

From Experimental Technique to Clinical Practice: Which Pathway in Transplant Surgery?

The question of whether a medical procedure is to be considered experimental or routine practice has enormous practical implications. In transplant surgery, as compared with pharmacologic clinical trials, the transition from experimental procedure to normal care is far from clear cut. Clinical trials comprise 4 well-established phases of evaluation going from phase I, aimed at assessing safety and identifying side effects in a few healthy volunteers, to phase IV, which involves entire populations and is aimed at long-term postmarketing surveillance. In transplant surgery, technical progress and experimentation follow more atypical and individual routes. As compared with pharmacologic research, the decision about "routine practice readiness" of a surgical procedure does not rely on a standardized formal act but rather on experts' capacity to find a consensus based on best practices and on ad-hoc criteria as well. Independent assessment by a panel of experts and oversight by an institutional review board are key to facilitating meaningful protection of transplant recipients and allowing the research to go forward. The framework of the human subjects protection regulations should also consider the transplant of organs that have previously been part of a research project.

[Neuroethics of body transplantation]. / Neuroetica del trasplante de cuerpo.

INTRODUCTION: Recent contributions to the specialised literature address the topic of body transplantation, mostly produced by Sergio Canavero and a group of researchers from China. For several years they have been announcing that they will carry out the procedure, but it has still not been performed. AIMS: The aim of this study is to perform a neuroethical analysis of body transplantation, based on the methodology of Diego Gracia on ethics and bioethics and an analysis of facts, values and duties. Furthermore, we also propose that, with the knowledge available today, body transplantation must be addressed from the perspective of research ethics. DEVELOPMENT: As regards the facts, it can be said that, although the history of attempts to perform a body transplant dates back almost a century, there are many limitations preventing it from being performed with our current knowledge. This is due to the fact that no serious and rigorous preclinical research has been conducted (at most some anecdotal data can be found). With the data that is available, it does not even seem possible to think of designing a protocol to include human beings for body transplantation. In terms of values, according to the model developed by Emanuel, who proposes eight requirements that must be met to comply with the ethics of clinical research, it is not even possible to comply with one of them. Regarding duties, it would be wise to recommend that such a procedure should not be carried out on humans. CONCLUSIONS: Considering the scientific knowledge currently available and the values of research ethics, a body transplantation should not be performed in human beings either as clinical research or as clinical practice.

TITLE: Neuroetica del trasplante de cuerpo.Introduccion. Existe bibliografia reciente en revistas especializadas acerca del trasplante de cuerpo, generada fundamentalmente por Sergio Canavero y un grupo chino. Desde hace un par de años vienen anunciando que realizaran el procedimiento, pero aun no ha ocurrido. Objetivo. Realizar un analisis neuroetico sobre el trasplante de cuerpo, proponiendo la metodologia de Diego Gracia en etica y bioetica analizando hechos, valores y deberes. Se propone ademas que, con el conocimiento actual, el trasplante de cuerpo debe tratarse desde la etica de la investigacion. Desarrollo. Aunque desde hace casi un siglo hay antecedentes de intentar conseguir un trasplante de cuerpo, existen numerosas limitaciones para poder realizarlo con el conocimiento actual porque no hay investigacion preclinica seria y rigurosa (se encuentran a lo sumo datos anecdoticos). Con los datos disponibles, ni siquiera parece que pueda pensarse en el diseño de un protocolo de inclusion de seres humanos para el trasplante de cuerpo. En cuanto a valores, atendiendo al modelo de Emanuel, quien propone ocho requisitos para cumplir con la etica de la investigacion clinica, no es posible siquiera cumplir uno cabalmente. Lo mas prudente es recomendar que no debe realizarse un procedimiento asi en seres humanos. Conclusiones. Considerando el conocimiento cientifico disponible y los valores de la etica de la investigacion, no debe realizarse un trasplante de cuerpo en seres humanos, ni como investigacion clinica ni mucho menos como practica clinica.

[Human head transplantation].

Since the beginning of the 20th century, head transplantation (cephalosomatic anastomosis) has been studied in animal models including mice, rats and monkeys. A recently proposed protocol for head transplantation in humans has revived the interest for the procedure. However, key elements in the procedure, such as functional spinal cord fusion, sufficient neuroprotection and post-operative pain control are still undocumented. Ethical issues remain concerning the scientific validity of the proposed project as well as general concerns regarding the entire concept of human head transplantation.

Facial Disfigurement and Identity: A Review of the Literature and Implications for Facial Transplantation.

Facial disfigurement can significantly affect personal identity and access to social roles. Although conventional reconstruction can have positive effects with respect to identity, these procedures are often inadequate for more severe facial defects. In these cases, facial transplantation (FT) offers patients a viable reconstructive option. However, FT's effect on personal identity has been less well examined, and ethical questions remain regarding the psychosocial ramifications of the procedure. This article reviews the literature on the different roles of the face as well as psychological and social effects of facial disfigurement. The effects of facial reconstruction on personal identity are also reviewed with an emphasis on orthognathic, cleft, and head and neck surgery. Finally, FT is considered in this context, and future directions for research are explored.

Uterine Transplantation: Surgical Innovation in the Treatment of Uterine Factor Infertility.

Uterine factor infertility (UFI) is a condition that affects thousands of women and is estimated to have a prevalence as high as one in five hundred reproductive-aged women. A wide range of circumstances can lead to UFI and include women with congenital absence of a uterus (Mayer Rokitansky Kuster Hauser or MRKH syndrome), women who have undergone iatrogenic removal of the uterus, or women who have uteri that are in situ but have been damaged by infection or surgical instrumentation. There have been 17 published reports of human uterine transplantation in the world. This article will summarize the history of human uterine transplantation and discuss our current understanding of the medical, surgical, and ethical considerations surrounding this innovative procedure.

Transplanting the Body: Preliminary Ethical Considerations.

A dissociated area of medical research warrants bioethical consideration: a proposed transplantation of a donor's entire body, except head, to a patient with a fatal degenerative disease. The seeming improbability of such an operation can only underscore the need for thorough bioethical assessment: Not assessing a case of such potential ethical import, by showing neglect instead of facing the issue, can only compound the ethical predicament, perhaps eroding public trust in ethical medicine. This article discusses the historical background of full-body transplantation, documents the seriousness of its current pursuit, and builds an argument for why prima facie this type of transplant is bioethically distinct. Certainly, this examination can only be preliminary, indicating what should be a wide and vigorous discussion among practitioners and ethicists. It concludes with practical suggestions for how the medical and bioethics community may proceed with ethical assessment.

When Marcel Mauss's Essai sur le Don becomes The Gift: variations on the theme of solidarity.

Since the early 1970s, Marcel Mauss's Essai sur le Don (1923), translated into English as The Gift in 1954, has been a standard reference in the social science and bioethical literature on the use of human body parts and substances for medical and research purposes. At that time, three social scientists-political scientist Richard Titmuss in the United Kingdom and sociologist Renée C. Fox working with historian Judith Swazey in the United States-had the idea of using this concept to highlight the fundamental structure of the biomedical practices they were studying, respectively, blood donation, and hemodialysis and organ transplantation. The fact that these first applications of Mauss's essay should emerge in English- rather than in French-speaking countries raises the question of what the translation of the essay, and notably of the word don as gift, may have to do with this fact. Reading Mauss in translation undoubtedly inspired a seminal approach to interpreting medical and research practices based on bodily giving. This article posits that something may have also been lost: a much broader concept of giving with unquestionable links to the Durkheimian concept of solidarity, which Mauss conceptualizes not only as an obligation but also as a liberty to give.

The ethics of extracorporeal membrane oxygenation in brain-dead potential organ donors.

Organ-preserving extracorporeal membrane oxygenation (OP-ECMO) is defined as the use of extracorporeal support for the primary purpose of preserving organs for transplantation, rather than to save the patient's life. This paper discusses the ethics of using OP-ECMO in donation after brain determination of death (DBDD) to avoid the loss of organs for transplantation. We review case reports in the literature and analyze the ethical issues raised. We conclude that there is little additional ethical concern in continuing OP-ECMO in patients already on ECMO if they become brain dead. The implementation of OP-ECMO in hemodynamically unstable brain-dead patients is ethically permissible in certain clinical situations but requires specific consent from relatives if the patient's wish to donate is not clear. If no evidence of a patient's wish to donate is available, OP-ECMO is not recommended. In countries with presumed consent legislation, failure to opt out should be considered as a positive wish to donate. If a patient is not-yet brain-dead or is undergoing testing for brain death, OP-ECMO is not recommended. Further research on OP-ECMO is needed to better understand the attitudes of professionals, families, and lay people to ensure agreement on key ethical issues.

Liver, pancreas and small bowel transplantation: current ethical issues.

We describe the medical state of the art in liver, pancreas and small bowel transplantation, and portray the ethical issues. Although most ethical questions related to these transplantations are not specific for liver, pancreas and small bowel, they do challenge ethical analysis as well as new policies and clinical procedures. Firstly, outcomes continue to be of utmost concern, as information is only limited available, is developing over time and is surrounded by many uncertainties. Secondly, characteristics of donors and recipients should be carefully evaluated. The question of what qualifies a donor and a recipient should be considered against the background of a quest for extended criteria, embracing marginal cases, and a judgment with regard to what counts as a good enough outcome. Thirdly, ethical principles of autonomy and fairness are pushed, given the circumstance of severe scarcity, towards limits that can easily be crossed.

Summary of the British Transplantation Society guidelines for transplantation from donors after deceased circulatory death.

The second edition of the British Transplantation Society Guidelines for Transplantation from Donors after Deceased Circulatory Death was published in June 2013. The guideline has been extensively revised since the previous edition in 2004 and has used the GRADE system to rate the strength of evidence and recommendations. This article summarizes the Statements of Recommendation contained in the guideline, which provide a framework for transplantation after deceased circulatory death in the U.K. and may be of wide international interest. It is recommended that the full guideline document is consulted for details of the relevant references and evidence base. This may be accessed at: http://www.bts.org.uk/MBR/Clinical/Guidelines/Current/Member/Clinical/Current_Guidelines.aspx.