Between Scylla and Charybdis: charting an ethical course for research into financial incentives for living kidney donation.

New approaches to address the kidney scarcity in the United States are urgently needed. The greatest potential source of kidneys is from living donors. Proposals to offer financial incentives to increase living kidney donation rates remain highly controversial. Despite repeated calls for a pilot study to assess the impact of financial compensation on living kidney donation rates, many fear that financial incentives will exploit vulnerable individuals and cast the field of transplantation in a negative public light, ultimately reducing donation rates. This paper provides an ethical justification for conducting a pilot study of a federally regulated approach to providing financial incentives to living kidney donors, with the goal of assessing donors' perceptions.

Death in the eyes of the beholder.

The US Uniform Determination of Death Act provides two alternatives for determining death-the circulatory criteria and the neurological criteria-yet history and the public's current understanding of death in the US may mean that only brain death criteria can be relied upon without raising public suspicion that the medical profession is sacrificing the well-being of one group of patients (i.e., those dying after traumatic injury) to save another group (i.e., those in need of organs). The problem is exacerbated by existing debate on the appropriate waiting time after which death is inevitable and when the brain should be actually considered dead through prolonged absence of autoresuscitation. Given the difficulty of definitive determination of the time when brain function has ceased, two solutions are proposed: abandon the Dead Donor Rule or redefine death. Implementing the former would mean convincing the public to accept organ harvesting before the dying patient is completely brain dead through the writing of advance directives to permit organ harvest when death is inevitable though not confirmed. For the latter, reeducation would be necessary to persuade the public to accept the circulatory criteria for death as an independent determinant for death or the medical community would need to reconsider if the cessation of higher brain function is enough to be the basis for determining death. In conclusion, organ retrieval policies, no matter how medically sound, should seek to avoid the possibility of a public backlash that could result in fewer organs available for transplant.

Ethics consultation: an update on accountability issues.

Nurses in a community hospital pediatric unit are struggling with the issue of how to care for a severely handicapped newborn. The parents are confused and cannot decide whether to approve a series of operations that will extend the infant's life or to request only palliative care. Where can the nursing staff go for help with these issues? Does the hospital have a bioethics service? What should nurses expect if they avail themselves of this service? Would members of the bioethics service decide what should be done? How would the family be involved?

Legal trends in bioethics.

PIP: Directives given in advance of need and substituted consent cases include: the New York trial court that denied the request of a patient's son for an order revoking the health care proxy his mother had given to his sister, the tape-recorded telephone conversation between the son and his mother was ruled to be insufficient evidence of the mother's desire to revoke the proxy, the mother was not fully responsive or articulate enough to convey her thoughts concerning the proxy. By the end of 1991, all states except Pennsylvania and Nebraska had enacted some form of advance directive legislation. The article highlights legislation from Arizona, California, Connecticut, Illinois, Hawaii, Louisiana, Nevada, New Hampshire, New Jersey, North Carolina, Ohio, and Virginia. A study from Mount Sinai School of Medicine in New York comparing the views of surrogate decision makers with the decisions of currently competent, chronically ill, elderly patients found that surrogates were unable to predict the patients' wishes about resuscitation. AIDS developments include: The Centers for Disease Control (CDC) abandoning its plan to publish a list of categories of exposure-prone invasive procedures. The appropriation bill for the Treasury, Postal Service and General Government requires that states adopt CDC's guidelines or their equivalent within one year, or risk losing all Public Health Service funding. The article highlights 2 court cases relating to AIDS questions. The section on assisted suicide discusses the medical license suspension of Jack Kevorkian and his "suicide" machine. On the discontinuation of treatment, the authors discuss several court cases. patients' rights examples include the Washington State decision imposing a duty on the examining doctor to disclose abnormal test results to the person being examined, regardless of whether a doctor-patient relationship exists. Other topics include reproductive issues, the right to treatment, and treatment refusals.^ieng