Reconsidering the Ethical Framework of DMV-based First-Person Authorization for Organ Donation

Saving lives is more important than abstract moral concerns: financial incentives should be used to increase organ donation.

The Limits of Confidentiality: Informed Consent and Psychotherapy.

Organ Donation Breakthrough Collaborative

An organ for change

Viewpoint: How to avoid a dichotomy between autonomy and beneficence: from liberalism to communitarianism and beyond

Mass media campaigns are widely and successfully used to change health decisions and behaviors for better or for worse in society. In the United States, media campaigns have been launched at local offices of the states' department of motor vehicles to promote citizens' willingness to organ donation and donor registration. We analyze interventional studies of multimedia communication campaigns to encourage organ-donor registration at local offices of states' department of motor vehicles. The media campaigns include the use of multifaceted communication tools and provide training to desk clerks in the use of scripted messages for the purpose of optimizing enrollment in organ-donor registries. Scripted messages are communicated to customers through mass audiovisual entertainment media, print materials and interpersonal interaction at the offices of departments of motor vehicles. These campaigns give rise to three serious concerns: (1) bias in communicating information with scripted messages without verification of the scientific accuracy of information, (2) the provision of misinformation to future donors that may result in them suffering unintended consequences from consenting to medical procedures before death (e.g, organ preservation and suitability for transplantation), and (3) the unmanaged conflict of interests for organizations charged with implementing these campaigns, (i.e, dual advocacy for transplant recipients and donors). We conclude the following: (1) media campaigns about healthcare should communicate accurate information to the general public and disclose factual materials with the least amount of bias; (2) conflicting interests in media campaigns should be managed with full public transparency; (3) media campaigns should disclose the practical implications of procurement as well as acknowledge the medical, legal, and religious controversies of determining death in organ donation; (4) organ-donor registration must satisfy the criteria of informed consent; (5) media campaigns should serve as a means of public education about organ donation and should not be a form of propaganda.

PHOTO ID 121339257© Designer491| Dreamstime.com ABSTRACT When physicians use their clinical knowledge and skills to advance the well-being of their patients, there may be apparent conflict between patient autonomy and physician beneficence. We are skeptical that today’s medical ethics education adequately fosters future physicians’ commitment to beneficence, which is both rationally defensible and fundamentally consistent with patient autonomy. We use an ethical dilemma that was presented to a group of third-year medical students to examine how ethics education might be causing them to give undue deference to autonomy, thereby undermining their commitment to beneficence. INTRODUCTION The right of patients to choose which treatments they prefer is rooted in today’s social mores and taught as a principle of medical ethics as respect for autonomy. Yet, when physicians use their clinical knowledge and skills to advance the well-being of their patients, there may be a conflict between patient autonomy and physician beneficence. We are skeptical that today’s medical ethics education adequately fosters a commitment to beneficence, which is both rationally defensible and fundamentally consistent with patient autonomy. I. An Ethical Dilemma The impetus for this paper arose when students who were completing their third clinical year discussed a real-life ethical dilemma. A middle-aged man developed a pulmonary hemorrhage while on blood thinners for a recently placed coronary stent. The bleeding was felt to be reversible, but the patient needed immediate intubation or he would die. The cardiologist was told that the patient previously expressed to other physicians that he never wanted to be intubated. However, the cardiologist made the decision to intubate the patient anyway, and the patient eventually recovered.[1] Students were asked if they believed that the cardiologist had acted ethically. Their overwhelming response was, “No, the patient should have been allowed to die.” We looked into how students applied ethical reasoning to conclude that this outcome was ethically preferred. To explore how the third-year clinical experience might have formed the students’ judgment, we presented the same case to students who were just beginning their third year. Their responses were essentially uniform in recommending intubation. While there is likely more than one reasonable view in this case, we agree with the physician and the younger medical students that intubation was the ethically appropriate decision and will present an argument for it. But first, we explain the reasoning behind the more advanced medical students’ decision to choose patient autonomy at the expense of beneficence. II. Medical Ethics Education and the Priority of Autonomy Beauchamp and Childress’s Principles of Biomedical Ethics, first published in 1979 and now in its 8th edition, is a significant part of the formal ethics education in medical school.[2] Students learn an ethical decision-making approach based on respect for four ethical principles: autonomy, beneficence, nonmaleficence, and justice. While Beauchamp and Childress officially afford no prima facie superiority to any principle, the importance of respect for patient autonomy has increased through the editions of their book. For example, early editions of their book opposed the legalization of physician-assisted death compared to recent editions that defended it.[3] As another example, Beauchamp and Childress make paternalism harder to justify by adding an autonomy-protecting condition to the list of conditions for acceptable paternalism.[4] Authority, they contend, need not conflict with autonomy—provided the authority is autonomously chosen.[5] “The main requirement,” they write, “is to respect a particular patient’s or subject’s autonomous choices, whatever they may be.[6] In the principlism of Beauchamp and Childress, autonomy now seems to have a kind of default priority.[7] However, the bioethics discourse has strong counternarratives, noting some movement to elevate the role of beneficence and to respect the input of stakeholders, including the family and the healthcare team. Ethics education achieves particular relevance in the third clinical year when students become embedded in the care of patients and learn from what has been called the informal curriculum. They observe how attending physicians approach day-to-day ethical problems at the patient’s bedside. In this context, students observe the importance of informed consent for serious treatments or invasive procedures, a practice that highlights the principle of patient autonomy. In both the formal and informal curriculum, medical students observe how, in the words of Paul Wolpe, “patient autonomy has become the central and most powerful principle in ethical decision-making in American medicine.”[8] In short, students appear to learn a deference for patient autonomy. This curricular shift in favor of autonomy coincides with legal developments that protect patients’ rights and decision-making with respect to their healthcare choices. The priority of autonomy in medicine benefits patients by reflecting their choices and, in some cases, their fundamental liberty. III. The Practice of Medicine and the Commitment to Beneficence There are many critiques of the dominant place that autonomy has in biomedical ethics,[9] especially considering that autonomy seems to be biased toward individualistic, Western, and somewhat American culture-driven values.[10] In addition, many bioethical dilemmas are cast as a conflict between autonomy and beneficence. Our point is that medical students bring to their study of medicine a commitment to beneficence that seems to be suppressed by practical ethics education. We think this commitment is rationally defensible and should be nurtured. It is striking that young medical students have a pre-reflective commitment to beneficence at all. For, as we mentioned, it is not just medicine but Western culture generally that prioritizes autonomy in settling ethical dilemmas. In wanting to act for the good of others (rather than simply agreeing to what others want), physicians are already swimming somewhat against the cultural tide.[11] However, doing so makes sense, given the nature of medicine and the profession of healing. When prospective medical students are asked why they wish to become physicians, the usual answer is some variation on caring for the sick and preventing disease. It is unlikely that a reason to become a physician is to respect a patient’s autonomy. It would be easy to dismiss medical students’ commitment to beneficence as a mere intuition and contrary to a more reasoned and deliberative approach. Beauchamp and Childress seem to minimize the value of physician intuition, stating that justifications for certain procedures are “…supported by good reasons. They need not rest merely in intuition or feeling.”[12] Henry Richardson writes that “situational or perceptive intuition…leaves the reasons for decision unarticulated.”[13] We think this is a crude and rather thin way of understanding intuition. Some bioethicists have defended intuition as essential to the practice of medicine and not something opposed to reason.[14] In the case we describe, we believe the ethical justifications s for the patient’s intubation are fundamentally sound: the patient did not have a “do not intubate” order written in the chart, the emergency intubation had not been foreseen, so the patient did not have the opportunity to consent to or reject intubation; the patient had consented to the treatment for his cardiac disease so his consent for intubation could have been assumed;[15] and the consequences of respecting his autonomy did not justify allowing him to die.[16] While it is possible to have more than one reasonable view on this case, we think the case for beneficence is strong and certainly should not be dismissed out of hand. We do not deny that if a patient makes a clearly documented, well-informed decision to forgo intubation that this decision ought to be respected by the physician (even if the physician disagrees with the patient’s decision). But, in this situation, as in many others in the practice of medicine, the patient’s real wishes and preferences are not well-articulated in advance. There are many cases where a physician acts based on what she believes the patient, or the surrogate, would want, sometimes in situations that do not allow much time for reflection. An example might be resuscitation of a newborn at the borderline of viability. In their ethics education, beneficence would mean acting first to save a life. If the patient or surrogate makes an informed decision to the contrary, a beneficent physician respects that autonomous decision. In the case presented, the patient expressed gratitude to the cardiologist when extubated. But what if he had expressed anger at the physician for violating his autonomy? There are those who could argue that not only was intubation ethically wrong but that the cardiologist put himself in legal jeopardy by his actions (especially if there had been a written refusal applicable to the specific situation). In the example we use, we point out that the cardiologist may not have escaped a lawsuit if the patient had died without intubation. His family, when hearing the circumstances, may have sued for failure to act and dereliction of the cardiologist’s duty to save him. Beyond a potential legal challenge for either action or inaction, there is an overriding ethical question the cardiologist had to address: what course would be most satisfying to his conscience? Would he rather allow a patient to die for fear of recrimination, or act to save his life, regardless of the personal consequences? In the absence of real knowledge about the patient’s considered wishes, it is most reasonable to err on the side of promoting patient well-being. A physician’s co

Approximately 6,000 patients per year, or 16 per day, with end-stage organ failure die because of the lack of available organs. Each year only 35% to 50% of potential donors consent to donation (1). During the last 20 years, vigorous educational campaigns, both voluntary and legislative, designed to increase organ donation have failed to increase donation rates significantly. The need for organs has grown nearly five times faster than the number of cadaveric donors: the annually compounded rate (1990–2000) of increase in number of patients on waiting lists has averaged 14.1% a year, whereas the rate of increase of donors has averaged 2.9% a year (2). The American Medical Association (AMA) has been concerned about this problem for many years and has developed several policies addressing it in the past decade (3). AMA policy has supported certain forms of financial incentives for cadaveric organ donation since 1993 (Policy E-2.15, AMA Policy Database), but they have never been implemented because federal law prohibits them. AMA policy specifically prohibits payment to living donors (4). Most initiatives to increase organ donation have focused on what motivates or hinders the decision to donate. Programs to improve organ donation rates have been aimed at public and professional groups. These have included widespread educational campaigns aimed at motivating individuals to become donors. They also have included mandated choice legislation, the establishment of the Organ Procurement and Transplantation Network (OPTN), donor card programs, donor registries, and the creation of specialized organ donation teams within hospitals that discuss organ donation with families and patients. Despite these efforts, cadaveric donation rates have remained nearly stable during the past decade. This report encourages the medical and scientific communities to reexamine the motivation for cadaveric organ donation. Building on the work of the Council on Ethical and Judicial Affairs (CEJA) in 1993, which led to Opinion E-2.15, “Financial Incentives for Organ Donation,” this report identifies reasons why ethical objections to financial incentives, for cadaveric organ donation only, should be reexamined. In particular, this report considers the need to study the impact of financial incentives through limited research trials. Such studies would help measure the effect of incentives not only on donation rates but also on public perception of the transplant enterprise and of the meaning of organ donation. For the purposes of this report, donation and procurement of organs are considered completely independent from the allocation of organs. The report neither suggests nor supports any change in the current system of organ distribution, as developed and administered by the United Network for Organ Sharing (UNOS). Even if financial incentives were found to have a positive impact on cadaveric organ donation rates, allocation algorithms developed by the OPTN would continue to govern organ distribution and transplant recipients would continue to be selected according to ethically appropriate criteria related to medical need rather than ability to pay. Physicians have an obligation to hold their patients’ interests paramount and to support access for all patients to medical care (Principles VIII and IX) (5). To discharge these obligations, physicians should participate in efforts to increase organ donation, including education of their patients and the general public regarding the importance of organ donation and promotion of voluntary donation of organs. Beyond educational programs, however, physicians should support innovative approaches to encourage organ donation. Such efforts include encouragement and, if appropriate, participation in the conduct of ethically designed research studies of donor motivation. A potential impetus for cadaveric organ donation that has not been adequately explored (because of federal prohibition) is financial incentives. Such incentives are not intrinsically unethical; AMA policy has supported them since 1993. Whether a particular incentive is ethical or not depends upon the balance of benefits and harms that result, and these are currently unknown because they have never been investigated.

Medical Ethics: Principles of Medical Ethics

Introduction: Organ donation-related education is offered, and decisions are made at state Department of Motor Vehicles; however, little is known about Muslim Americans' attitudes toward these common practices. Research Questions: Are participants comfortable learning about deceased organ donation in the Department of Motor Vehicles setting? Are participants prepared to make deceased organ donation-related decisions at the Department of Motor Vehicles? Design: A survey of Muslim Americans attending an educational workshop at 4 mosques in two US cities. Primary study outcomes were self-reported (a) preparedness to make deceased donation-related decisions and (b) comfort with receiving organ donation education in the license renewal setting. We calculated Pearson product-moment correlations between these primary outcomes and participant characteristics including sociodemographic descriptors, religiosity and religious coping measures, and discrimination measures. Results: Most respondents indicated they were not prepared to make organ donation-related decisions at the Department of Motor Vehicles (79.6%). Preparedness did not vary by age, gender, country of origin or US residency duration, nor by religiosity, negative religious coping, or experiences of discrimination. However, higher scores on positive religious coping were associated with lower ratings of preparedness. A slight majority (58.9%) of respondents were comfortable receiving organ donation education. Conclusions: Muslim Americans are comfortable with learning about organ donation while at the Department of Motor Vehicles but are ill-prepared to make deceased donation-related decisions in the same setting. Further research is required to understand whether changes to the license renewal setting would improve decision-making outcomes in this population.

To identify trends in and factors associated with pediatric organ donation authorization after brain death. Retrospective cohort study of data from Virtual Pediatric Systems, LLC (Los Angeles, CA). Data from 123 PICUs reporting to Virtual Pediatric Systems from 2009 to 2018. Patients less than 19 years old eligible for organ donation after brain death. Of 2,777 eligible patients, 1,935 (70%) were authorized for organ donation; the authorization rate remained unchanged over time (ptrend = 0.22). In a multivariable logistic regression model, hospitalizations lasting greater than 7 days had lower odds of authorization (adjusted odds ratio, 0.5; p < 0.001 vs ≤ 1 d) and White patients had higher odds than other race/ethnicity groups. Authorization was higher for trauma-related encounters (adjusted odds ratio, 1.5; p < 0.001) and when donation was discussed with an organ procurement organization coordinator (adjusted odds ratio, 1.7; p < 0.001). Of 123 hospitals, 35 (28%) met or exceeded a 75% organ donation authorization target threshold; these hospitals more often had an organ procurement organization coordinator discussing organ donation (85% vs 72% of encounters; p < 0.001), but no difference was observed by PICU bed size. Organ donation authorization after brain death among PICU patients was associated with length of stay, race/ethnicity, and trauma-related encounter, and authorization rates were higher when an organ procurement organization coordinator was involved in the donation discussion. This study identified factors that could inform initiatives to improve the authorization process and increase pediatric organ donation rates.

Background: The OneLegacy Organ Procurement Organization (OPO) has experienced increases in its total organ donor registrations, as well as its donor designation rate and share, each year. OneLegacy’s best practices, and the influence of the Department of Motor Vehicles (DMV) and California Organ and Tissue Donor Registry partnership on the OPO, were examined during an 8-year period. Trends of organ transplantation in the state of California were examined during the same time period. Methods: Publicly available data from both Donate Life America for California and OneLegacy were examined from 2009 to 2017. The best practices of the OneLegacy OPO were examined. The total donor designation (TDD) was defined as the sum of the new and existing number of people who were registered organ donors. The donor designation rate (DDR) was defined as the rate at which new individuals joined the California donor registry as a percentage of driver licenses and ID cards issued within a calendar year. The donor designation share (DDS) was defined as the total number of designated donors as a percentage of all residents of the state who were ≥18 years old. Results: In California, the TDD increased by an average of 1.045 million designations each year from 2009 through 2017, reaching a national high >14 million designations in 2017. The DDR increased by an average of 1.1% each year, from 25.5% in 2009 to 34% in 2017 (Figure 1). The DDS increased by an average of 3.125 % each year from 22% in 2009 to 47% in 2017, and is forecasted to reach the 50% national benchmark in 2018 (Figure 2). The donor designations from the California Organ and Tissue Donor Registry (“pink dot” donors) as a percentage of all donors in the OneLegacy service area increased by 3.7% each year from 15% in 2009 to 45% 2017. The number of transplanted organs in California increased from 3058 in 2009 to 3860 in 2017 (> 20% increase in the total number of transplanted organs). Conclusions: California depends on the partnership between the DMV and the online organ donation registry, as well as the efforts put forth by OPOs such as OneLegacy, in order to increase organ donor registration and donation. OneLegacy’s best practices include: 1) building trust and leveraging education and outreach programs tailored to a diverse population; 2) increasing transparency and professionalization; 3) expanding education and outreach to all hospitals in its service area, as opposed to only trauma hospitals; 4) implementing realistic training scenarios through its simulation center. These practices have increased organ donor registrations and total organ donations in OneLegacy’s service area, and should serve as a model to the global organ donation practice community.

BackgroundThe existence of a valid instrument to evaluate the attitude of mothers towards compliance with medical ethics during childbirth can lead to appropriate interventions to create a positive attitude. The purpose of this study is to determine the construct validity of the MEAVDQ (Medical Ethics Attitude in Vaginal Delivery Questionnaire).MethodsThe study was carried out with 350 women. The main research instrument was MEAVDQ. This 59-item questionnaire comprises three parts A, B, J. Part A is concerned with the first principles. Part B deals with the second and third principles and part J addresses the fourth principle of medical ethics. Structural Equations Modeling (SEM) was used to determine the construct validity of MEAVDQ.Results The results of SEM revealed that there was a positive correlation between structures A and B. The relationship between structures B and J was also positive and significant. On the other hand, there was a direct and indirect relationship between structures A and J. One-unit increase in structure A led to 0.16 (95% CI: 0.01, 0.33) direct increase in structure J. Also, one-unit increase score increases in structure A caused 0.39 indirect rise (95% CI: 0.26, 0.53) in structure J with the mediating role of the structure B.ConclusionsIt can be suggested to midwifery policy maker and midwives that respect for the first principle of medical ethics and autonomy is the most important principle of medical ethics in childbirth. By respecting the autonomy of mothers, a positive birth experience can be created for them.

Critical care nurses and physicians usually care for those patients whose condition progresses to brain death and are also often responsible for requesting organ donation from the family of a brain-dead patient. We hypothesized that staff support, knowledge, and training levels would be significantly associated with organ donation rates. To assess the readiness of critical care staff to successfully handle requests for organ donation. A total of 1061 critical care staff from 28 hospitals in four separate regions of the United States completed a questionnaire that assessed (1) factual knowledge about organ donation, (2) understanding of brain death, (3) previous training in procedures for requesting donations, and (4) comfort levels with the donation process. Staff training in effective procedures for requesting organ donations was significantly correlated with hospitals' donation rates. Less than a third of respondents, however, had received training in explaining brain death to and requesting organ donation from a grieving family. In hospitals with high rates of organ donation, 52.9% of staff had received training; in hospitals with low rates of organ donation, 23.5% of staff had received training. Levels of factual knowledge about organ donation and brain death were unexpectedly low but were not significantly related to hospitals' rates of organ donation. Training of critical care nurses and physicians in effective procedures for requesting organ donation is significantly associated with higher rates of organ donation, yet two thirds of critical care staff report no relevant training. Consequently, critical care staff cannot be considered ready to effectively handle requests for organ donation.

BackgroundThe occurrence of brain death in patients with hypoxic-ischaemic brain injury after resuscitation from cardiac arrest creates opportunities for organ donation. However, its prevalence is currently unknown.MethodsSystematic review. MEDLINE via PubMed, ISI Web of Science and the Cochrane Database of Systematic Reviews were searched for eligible studies (2002–2016). The prevalence of brain death in adult patients resuscitated from cardiac arrest and the rate of organ donation among brain dead patients were summarised using a random effect model with double-arcsine transformation. The quality of evidence (QOE) was evaluated according to the GRADE guidelines.Results26 studies [16 on conventional cardiopulmonary resuscitation (c-CPR), 10 on extracorporeal CPR (e-CPR)] included a total of 23,388 patients, 1830 of whom developed brain death at a mean time of 3.2 ± 0.4 days after recovery of circulation. The overall prevalence of brain death among patients who died before hospital discharge was 12.6 [10.2–15.2] %. Prevalence was significantly higher in e-CPR vs. c-CPR patients (27.9 [19.7–36.6] vs. 8.3 [6.5–10.4] %; p < 0.0001). The overall rate of organ donation among brain dead patients was 41.8 [20.2–51.0] % (9/26 studies, 1264 patients; range 0–100 %). The QOE was very low for both outcomes.ConclusionsIn patients with hypoxic-ischaemic brain injury following CPR, more than 10 % of deaths were due to brain death. More than 40 % of brain-dead patients could donate organs. Patients who are unconscious after resuscitation from cardiac arrest, especially when resuscitated using e-CPR, should be carefully screened for signs of brain death.Electronic supplementary materialThe online version of this article (doi:10.1007/s00134-016-4549-3) contains supplementary material, which is available to authorized users.