One or two types of death? Attitudes of health professionals towards brain death and donation after circulatory death in three countries.

This study examined health professionals' (HPs) experience, beliefs and attitudes towards brain death (BD) and two types of donation after circulatory death (DCD)--controlled and uncontrolled DCD. Five hundred and eighty-seven HPs likely to be involved in the process of organ procurement were interviewed in 14 hospitals with transplant programs in France, Spain and the US. Three potential donation scenarios--BD, uncontrolled DCD and controlled DCD--were presented to study subjects during individual face-to-face interviews. Our study has two main findings: (1) In the context of organ procurement, HPs believe that BD is a more reliable standard for determining death than circulatory death, and (2) While the vast majority of HPs consider it morally acceptable to retrieve organs from brain-dead donors, retrieving organs from DCD patients is much more controversial. We offer the following possible explanations. DCD introduces new conditions that deviate from standard medical practice, allow procurement of organs when donors' loss of circulatory function could be reversed, and raises questions about "death" as a unified concept. Our results suggest that, for many HPs, these concerns seem related in part to the fact that a rigorous brain examination is neither clinically performed nor legally required in DCD. Their discomfort could also come from a belief that irreversible loss of circulatory function has not been adequately demonstrated. If DCD protocols are to achieve their full potential for increasing organ supply, the sources of HPs' discomfort must be further identified and addressed.

Medical malpractice, mistake prevention, and compensation.

Clinicians' fear of malpractice litigation is the most significant obstacle to the open reporting of medical mistakes. Without open reporting of medical mistakes, however, root cause analysis of mistakes cannot be done, thus undermining efforts to implement safeguards to minimize the occurrence of future mistakes. Efforts to prevent medical mistakes, therefore, must first directly address clinicians' fear of malpractice litigation. In this paper, we explore the relationship between the current malpractice system and clinicians' fear of litigation. Ultimately, we argue that both the prevention of medical mistakes and the goals of malpractice litigation itself will be better served if substantial malpractice reform is undertaken.

Commentary: a consensus about "consensus"?

Authors develop the notion of "consensus," which is at the heart of the "ethical consensus method" proposed by Martin, and the three approaches from which it is drawn.

The foundations of bioethics: contingency and relevance.

In this essay, I proceed by, first, laying out H. Tristram Engelhardt's argument for the principle of permission as the proper foundation for a secular bioethic. After considering how a number of commentators have tried to undermine this argument, I show why it is immune to some of these advances. I then offer my own critique of Engelhardt's project. This critique is two pronged. First, I argue that Engelhardt is unable to establish his own foundation for a secular bioethic. This inability leaves him with only contingent points of departure for a secular bioethic, some of the more salient of which he has ignored. Second, I argue that even if Engelhardt's project succeeds, it is in danger of being irrelevant in a practical sense because it ignores important contextual dimensions of the peculiar enterprise we call bioethics. Ultimately, the proper foundations for a relevant secular bioethic. I argue, must appeal to certain contingent features of the context that gives rise to the need for it.

Health care ethics consultation: nature, goals, and competencies. A position paper from the Society for Health and Human Values-Society for Bioethics Consultation Task Force on Standards for Bioethics Consultation.

Patients, families, and health care providers have a right to expect that ethics consultants can deal competently with the complex issues that they are asked to address. The Society for Health and Human Values-Society for Bioethics Consultation Task Force on Standards for Bioethics Consultation explored core competencies and related issues in ethics consultation. This position paper summarizes the content of the resulting Task Force Report, which included nine general conclusions: 1) U.S. societal context makes "ethics facilitation" an appropriate approach to ethics consultation; 2) ethics facilitation requires certain core competencies; 3) core competencies can be acquired in various ways; 4) individual consultants, teams, or committees should have the core competencies for ethics consultation; 5) consult services should have policies that address access, patient notification, documentation, and case review; 6) abuse of power and conflicts of interest must be avoided; 7) ethics consultation must have institutional support; 8) evaluation of process, outcomes, and competencies is needed; and 9) certification of individuals and accreditation of programs are rejected.

Patients, families, and organ donation: who should decide?

Although 69 to 75 percent of U.S. adults say they would be willing to become organ donors, half of the families that are asked to consider donating the organs of a deceased family member refuse to consent. This discrepancy is most noticeable when the refusal of a family conflicts with the known wishes of a patient. It is the practice of nearly all organ procurement organizations in the United States not to procure organs or tissue when families refuse, even if the patient's wishes have been documented. Recently, the Center for Organ Recovery and Education (CORE) adopted a controversial policy of acting on the documented wishes of individuals to donate, independent of family consent. An examination of the moral and political issues raised by this policy lead to the conclusion that the CORE policy is not only justified, but morally required.