Transplant eligibility for patients with affective and psychotic disorders: a review of practices and a call for justice.

BACKGROUND: The scarcity of human organs requires the transplant community to make difficult allocation decisions. This process begins at individual medical centers, where transplant teams decide which patients to place on the transplant waiting list. Each transplant center utilizes its own listing criteria to determine if a patient is eligible for transplantation. These criteria have historically considered preexisting affective and psychotic disorders to be relative or absolute contraindications to transplantation. While attitudes within the field appear to be moving away from this practice, there is no data to confirm that eligibility criteria have changed. MAIN BODY: There are no nationwide guidelines detailing the manner in which affective and psychotic disorders should impact transplant eligibility. Individual transplant centers thus form their own transplant eligibility criteria, resulting in significant inter-institution variability. Data from the 1990s indicates that the majority of transplant programs considered certain psychiatric illnesses, such as active schizophrenia, to be absolute contraindications to transplantation. A review of literature reveals that no comprehensive data has been collected on the topic since that time. Furthermore, the limited data available about current practices suggests that psychiatric illness continues to be viewed as a contraindication to transplantation at some transplant centers. In light of this finding, we review psychiatric literature that examines the impact of affective and psychotic disorders on transplant outcomes and conclude that the presence of these disorders is not an accurate predictor of transplant success. We then discuss the requirements of justice as they relate to the creation of a just organ allocation system. CONCLUSION: We conclude that transplant eligibility criteria that exclude patients with affective and psychotic disorders on the basis of their psychiatric diagnosis alone are unjust. Just listing criteria must incorporate only those factors that have a causative effect on posttransplant morbidity and mortality. Justice also demands that we eliminate current inter-institution practice variations in favor of national transplant eligibility criteria. Given the limited data available about current practices, we call for an updated study investigating the manner in which affect and psychotic disorders impact transplant eligibility determinations.

Moral Mentation: What Neurocognitive Studies of Psychopathy May Really Offer the Internalism/Externalism Debate.

A persistent debate about moral capacity - and neuroethics - focuses upon the internalism-externalism controversy. Internalism holds that moral judgments necessarily motivate an agent's actions; externalism views moral judgments as not inherently motivating an agent to perform moral actions. Neuroethical discussions of the putative cognitive basis of moral thought and action would be better informed if neurocognitive research would yield data sufficient for validating one side or the other. Neuroscientific studies of psychopaths have been employed in this regard. However, it seems that neuroscientific investigations to date have been inadequate to wholly define the nature of moral knowledge, and thus fail to preferentially support (or foster) an exclusively internalist or externalist view. Thus, moving forward it will be necessary to carefully define questions that neuroscience is employed to address and answer, and to ensure that empirical findings are not distorted to support preconceived theoretical assumptions. In this way, neuroscientific investigations can be used in a conciliatory way to both balance views of processes operative in moral cognition, and raise ethical, legal, and social questions about what research findings actually mean, and what medicine - and societies - will do with such information and meanings.

Shouldn't Dead Be Dead?: The Search for a Uniform Definition of Death.

In 1968, the definition of death in the United States was expanded to include not just death by cardiopulmonary criteria, but also death by neurologic criteria. We explore the way the definition has been modified by the medical and legal communities over the past 50 years and address the medical, legal and ethical controversies associated with the definition at present, with a particular highlight on the Supreme Court of Nevada Case of Aden Hailu.