Presumed consent for organ donation: an incoherent justification / Presunción del consentimiento para la donación de órganos: una justificación incoherente / Consentimento presumido na dação de órgãos: uma justificação incoerente

Abstract: 15. The difference between supply and demand of transplantable organs is a global problem, and one of the most discussed measures aiming to solve it is the implementation of a presumed consent (opt-out) policy in cadaveric organ donation. This type of system is controversial when it comes to its direct effects on organ donation rates as well as its ethical base. We aim to present the latest perspectives concerning the ethical implications of the policy, especially regarding consent: its need, the coherence of presuming it and the policy's capacity to fulfill its requirements. From a community perspective, we advocate a default change in societies with an opt-out system, with a strong population education in that direction. The potential rights of family objection are also approached as well as the differences between theoretical discussion and concrete application of public policy.

Resumen: 19. El desfase entre la oferta y la demanda de órganos para trasplantes es un problema mundial, y una de las medidas más discutidas para solucionarlo es la aplicación de una política de consientimiento presumido (opt-out) de la donación de órganos de cadáveres. Este tipo de sistema es controvertido teniendo en cuenta sus efectos directos sobre las tasas de donación de órganos, así como su base ética. Nuestro objetivo es presentar las últimas perspectivas sobre las implicaciones éticas, especialmente en lo que respecta al consentimiento: su necesidad, la consistencia de su presunción y la capacidad de cumplir sus requisitos. Desde el punto de vista comunitario, abogamos por un cambio por defecto en las sociedades con un sistema de opt-out, con una fuerte educación de la población a tal efecto. También se abordan los posibles derechos de la objeción familiar, así como las diferencias entre el debate teórico y la aplicación concreta de las políticas públicas.

Resumo: 23. A diferença entre a oferta e a procura de órgãos para transplantação é um problema global, e uma das medidas mais discutidas com vista à sua resolução é a implementação de uma política de consentimento presumido (opt-out) na doação de órgãos de cadáver. Este tipo de sistema é controverso ponderando os seus efeitos diretos nas taxas de doação de órgãos, bem como da sua base ética. O nosso objetivo é apresentar as últimas perspetivas relativas às implicações éticas, especialmente no que diz respeito ao consentimento: a sua necessidade, a coerência da sua presunção e a capacidade em cumprir os seus requisitos. Numa perspetiva comunitária, defendemos uma mudança de default nas sociedades com um sistema opt-out, com uma forte educação da população nesse sentido. Os direitos potenciais da objeção familiar também são abordados, bem como as diferenças entre a discussão teórica e a aplicação concreta da política pública.

Presumed consent: licenses and limits inferred from the case of geriatric hip fractures.

BACKGROUND: Hip fractures are common and serious injuries in the geriatric population. Obtaining informed consent for surgery in geriatric patients can be difficult due to the high prevalence of comorbid cognitive impairment. Given that virtually all patients with hip fractures eventually undergo surgery, and given that delays in surgery are associated with increased mortality, we argue that there are select instances in which it may be ethically permissible, and indeed clinically preferable, to initiate surgical treatment in cognitively impaired patients under the doctrine of presumed consent. In this paper, we examine the boundaries of the license granted by presumed consent and use the example of geriatric hip fracture to build an ethical framework for understanding the doctrine of presumed consent. DISCUSSION: The license to act under presumed consent requires three factors: patient incapacity, clinical urgency and clarity on the correct course of action. All three can apply to geriatric hip fracture. The typical patient frequently lacks capacity. Delays in initiating surgical treatment are associated with markedly increased mortality rates. Last, there appears to be consensus that surgery is the preferred treatment. Nonetheless, because there is a window of safe delay during which treating physicians can stabilize the patient, address reversible causes of cognitive impairment and identify surrogate decision makers, presumed consent should be invoked only as a method of last resort. CONCLUSIONS: A medical situation need not be characterized by risk of imminent and certain death for presumed consent to be relevant. Rather, there are two distinct windows that must be considered: the time interval in which action may be delayed without danger, and the time interval needed to obtain a better form of consent. Presumed consent is appropriate only when the latter exceeds the former.

[End-of-life decisions and practices in critically ill patients in the cardiac intensive care unit. A nationwide survey]. / Begrenzung und Abbruch lebenserhaltender Maßnahmen bei kritisch kranken kardiochirurgischen Patienten. Ergebnisse einer bundesweiten Umfrageaktion.

BACKGROUND: Ethical and medical criteria in the decision-making process of withholding or withdrawal of life support therapy in critically ill patients present a great challenge in intensive care medicine. OBJECTIVES: The purpose of this work was to assess medical and ethical criteria that influence the decision-making process for changing the aim of therapy in critically ill cardiac surgery patients. MATERIALS AND METHODS: A questionnaire was distributed to all German cardiac surgery centers (n = 79). All clinical directors, intensive care unit (ICU) consultants and ICU head nurses were asked to complete questionnaires (n = 237). RESULTS: In all, 86 of 237 (36.3 %) questionnaires were returned. Medical reasons which influence the decision-making process for changing the aim of therapy were cranial computed tomography (cCT) with poor prognosis (91.9 %), multi-organ failure (70.9 %), and failure of assist device therapy (69.8 %). Concerning ethical reasons, poor expected quality of life (48.8 %) and the presumed patient's wishes (40.7 %) were reported. There was a significant difference regarding the perception of the three different professional groups concerning medical and ethical criteria as well as the involvement in the decision-making process. CONCLUSION: In critically ill cardiac surgery patients, medical reasons which influence the decision-making process for changing the aim of therapy included cCT with poor prognosis, multi-organ failure, and failure of assist device therapy. Further studies are mandatory in order to be able to provide adequate answers to this difficult topic.

Governing the postmortem procurement of human body material for research.

Human body material removed post mortem is a particularly valuable resource for research. Considering the efforts that are currently being made to study the biochemical processes and possible genetic causes that underlie cancer and cardiovascular and neurodegenerative diseases, it is likely that this type of research will continue to gain in importance. However, post mortem procurement of human body material for research raises specific ethical concerns, more in particular with regard to the consent of the research participant. In this paper, we attempt to determine which consent regime should govern the post mortem procurement of body material for research. In order to do so, we assess the various arguments that could be put forward in support of a duty to make body material available for research purposes after death. We argue that this duty does in practice not support conscription but is sufficiently strong to defend a policy of presumed rather than explicit consent.

Entrega de información y voluntariedad en el consentimiento presunto de la ley de donación de órganos en Chile / Information delivery and voluntariness in presumed consent in the Chilean organ donation law

A principios del año 2010 se reformó en Chile la antigua ley de donación y trasplante de órganos de 1996, instaurando una nueva forma de hacer donantes a los ciudadanos a través del llamado consentimiento presunto. A partir de lo anterior se analiza este concepto en relación a los pilares fundamentales del consentimiento informado; información, voluntariedad y capacidad, enfocado principalmente en los dos primeros. Respecto al principio de voluntariedad es claramente violado ya que actualmente no es necesario que la persona se manifieste para ser donante, sino que es posicionada automáticamente como tal a no ser que escoja lo contrario. Continuando con el análisis, se puede ver como la autoridad ha dejado de lado el principio de información, no poniendo énfasis en éste, a pesar de que la evidencia indica que es una forma efectiva de convencer a pacientes no donantes. La promulgación de la ley debe ser complementada con entrega de información y educación a los distintos sectores cívicos.

In early 2010, in Chile, the law of organ donation and transplantation from 1996 was amend ended, establishing a new form of organ donation to citizens through the presumed consent. From the above, this concept is analyzed according to the fundamental pillars of informed consent; information, voluntariness and capacity, mainly focused on the first two. Regarding the principle of voluntary it is clearly violated, as it is no longer necessary that the person chooses to be a donor if one does not manifest their willingness to not be one. Continuing with the analysis, it can be seen how the authority has neglected the principle of information, not emphasizing it, even though the evidence indicates that it is an effective way to convert non-donors. The enactment of the law must be supplemented by providing information and education to civic sectors.(AU)om the above, this concept is analyzed according to the fundamental pillars of informed consent; information, voluntariness and capacity, mainly focused on the first two. Regarding the principle of voluntary it is clearly violated, as it is no longer necessary that the person chooses to be a donor if one does not manifest their willingness to not be one. Continuing with the analysis, it can be seen how the authority has neglected the principle of information, not emphasizing it, even though the evidence indicates that it is an effective way to convert non-donors. The enactment of the law must be supplemented by providing information and education to civic sectors.

Implied consent and nursing practice: ethical or convenient?

Nursing professionals in a variety of practice settings routinely use implied consent. This form of consent is used in place of or in conjunction with informed or explicit consent. This article looks at one aspect of a qualitative exploratory study conducted in a Day of Surgery Admission unit. This article focuses on the examination of nurses' understandings of implied consent and its use in patient care in nursing practice. Data were collected through one-on-one interviews and analysed using a thematic analysis. Nurses participating in this study revealed that they routinely used implied consent in their nursing practice. This article will look at whether implied consent supports or impedes a patient's autonomy.

[Diagnostic and treatment goals in elderly patients]. / Diagnostik- und Therapieziele beim alten Patienten.

Improved quality of life and greater independence are becoming increasingly important as treatment goals in elderly patients, while merely extending life expectancy is only rarely the primary treatment goal. In elderly patients in particular, the patient's wishes are extremely important when deciding on the treatment goals. If patients are no longer able to express their wishes, the treating physician must establish what their presumed wishes are. Relatives and carers are particularly important in determining a patient's presumed wishes. A standardized geriatric assessment and interventions conducted on the basis of this assessment can give patients greater independence in everyday activities (e.g., walking, personal hygiene, eating) and can avoid them having to go into a nursing home or at least delay this move. In addition, the patient's prognosis is improved, which is manifested inter alia in a longer life-span. A basic geriatric assessment should therefore be conducted in all elderly patients. Standardized testing methods are used to examine the following areas: everyday activities, mobility/risk of falling, and cognition. Patients with the relevant risk combinations should also be screened for malnutrition. Comorbidities are a decisive factor influencing the prognosis in tumor patients. The comorbidities should be recorded using a structured method, e.g., the Charlson Comorbidity Index, and taken into account when deciding on treatment.

Ethical issues in organ transplantation.

Clinical organ transplantation has been recognized as one of the most gripping medical advances of the century as it provides a way of giving the gift of life to patients with terminal failure of vital organs, which requires the participation of other fellow human beings and of society by donating organs from deceased or living individuals. The increasing incidence of vital organ failure and the inadequate supply of organs, especially from cadavers, has created a wide gap between organ supply and organ demand, which has resulted in very long waiting times to receive an organ as well as an increasing number of deaths while waiting. These events have raised many ethical, moral and societal issues regarding supply, the methods of organ allocation, the use of living donors as volunteers including minors. It has also led to the practice of organ sale by entrepreneurs for financial gains in some parts the world through exploitation of the poor, for the benefit of the wealthy. The current advances in immunology and tissue engineering and the use of animal organs, xenotransplantation, while offering very promising solutions to many of these problems, also raise additional ethical and medical issues which must be considered by the medical profession as well as society. This review deals with the ethical and moral issues generated by the current advances in organ transplantation, the problem of organ supply versus organ demand and the appropriate allocation of available organs. It deals with the risks and benefits of organ donation from living donors, the appropriate and acceptable methods to increase organ donation from the deceased through the adoption of the principle of 'presumed consent', the right methods of providing acceptable appreciation and compensation for the family of the deceased as well as volunteer and altruistic donors, and the duties and responsibilities of the medical profession and society to help fellow humans. The review also deals with the appropriate and ethically acceptable ways of utilizing the recent advances of stem cell transplantation from adult versus fetal donors, tissue engineering and the use of organs from animals or xenotransplantation. Data provided in support of the concept that clinical organ and tissue transplantation can be more beneficial and life saving if everyone involved in the process, including physicians and medical institutions, respect and consider the best interests of the patients, as well as honor the ethical, moral and religious values of society and are not tempted to seek personal fame or financial rewards.

Law, ethics and epidemiology: the case of the cervical screening audit.

This paper provides a legal and ethical analysis of some controversial aspects of a recent proposal for an independent audit of New Zealand's National Cervical Screening Programme. The analysis reveals the difficulties likely to arise between investigators and ethics committees when the interests served by important public health research compete with the rigorous protection of patients' privacy.

Vaccination and other altruistic medical treatments: should autonomy or communitarianism prevail?

The publication of a report into a case where an organ donor's constraints on the race of potential recipients raises questions about whether respect for autonomy or communitiarianism should prevail in altruistic medical procedures. This article briefly reviews how autonomy and communitarianism are balanced in cadaveric and live organ donation, bone marrow donation, gamete donation, blood donation and vaccination. It criticizes vaccination policy for ostensibly respecting patient autonomy yet in practice compromising that autonomy in various ways. Vaccination is properly viewed as an altruistic medical procedure because some vaccines are of more good to society than to the vaccinee, who runs associated health risks. The conclusion is that there is a spectrum of attitudes to the value of autonomy, depending principally upon the invasiveness of the procedure. In most cases the autonomy-communitarianism balance is satisfactory, but this is not so in respect of cadaveric organ donation and vaccination. The article proposes that cadaveric organ donation should be governed by the communitarian law of well-publicised presumed consent. It proposes two alternatives for vaccination: that vaccination should be compulsory or, preferably, that procedures be modified so that parents have real autonomy in their decisions whether to vaccinate their children.