assignment
APA
Whento Disconnect? Bioethical Distinction between
Assisting or Substituting
Vital Organs
Rev. Alfred Cioffi, SThD, PhD
Institute for Bioethics
St. Thomas University
Miami Gardens, Florida
Introduction
Without a doubt, in the United States, life expectancy has been steadily increasing over
the past half century: in 1950, the average life span for Americans was about 68.2 years;
in 2015, it was 79.1.i As more people tend to live into old age, we are experiencing a
larger number of patients on life support systems toward the end of their life. For
example, a Frontline report of the Public Broadcast System recently stated that nearly
70% of all Americans die in a hospital, nursing home or long-term care facility.ii
Often, persons who have a terminal illness or are approaching the end of their life, and
their loved ones, do not know how much treatment is too much, and they struggle as to
when to finally stop treatment and allow the patient to die in peace.iii Conversely,
healthcare professionals during such times may tend to slide into “extraordinary means”
of life support –bioethically speaking– perhaps simply due to legal/fiscal concerns
regarding potential lawsuits, or due to the patients’ family requesting futile care.iv A
general bioethical principle that is very useful in these situations is the fact that there is
no moral obligation to substitute vital organs. Substituting a vital organ, in this context,
means totally replacing the vital function of the dying organ, with either a transplant or
with medical machinery.v This article seeks to explain how this rule may be applied in
deciding when to stop treatment, and thus allow a patient
to die in peace.
Vital Organs
By definition, a functioning vital organ is essential for maintaining life. Examples of vital
organs in the human body are: brain, brain stem, heart, both lungs, liver, whole stomach,
whole intestines, pancreas, both kidneys. It is well known that, once the death process has
begun, each one of these vital organs has an expected lifespan, in terms of minutes or
hours, even after the brain and stem have stopped functioning irreversibly. For example,
without oxygen, within the range of minutes, the lifespan of a human brain may be less
than four to six minutesvi; for the heart, within twenty minutes.vii In the range of hours
could be the stomach, intestines, liver and kidneys.viii It is also well known that each vital
organ of the human body functioning by itself is not sufficient to maintain life; rather,
each one of these organs must function within its proper organ system, and all systems
must be integrated –by the nervous system– so as to maintain human life.
The Death Process
Regardless of how long each vital organ may last after anoxia (lack of oxygen), when a
vital organ begins to fail irreversibly, one can say that the death process has begun. One
may never kill an innocent being, but one may allow a person to die.ix When a moral
dictate is not clear to some, it helps to pose the statement in the reverse. For example,
imagine if we could not allow people to die; that is an untenable situation! Therefore,
morally, one may allow people to die. One may have to provide the means possible for
the dying person to die in peace, but one may certainly allow a dying person to die.
Hence, whenever a vital organ begins to fail irreversibly, we can say that the dying
process has begun for that person. Family and friends, and the healthcare professionals
attending the dying person, in conscience, may allow that person to die in peace.
Clinically, this may include disconnecting vital support systems, save those that are
merely assisting the patient (i.e., a respirator, a Foley, or analgesics).
Assisting versus Substituting
Morally speaking, it is essential to distinguish between assisting or substituting vital
organs. In other words, assisting vital organs may be considered standard medical
practice, or the standard of care, including the normal use of clinical procedures, devices
and/or medications. Bioethically, these are ordinary means of life support because they
are considered vital or necessary for maintaining life.x
However, when it comes to substituting one or more vital organs, this typically involves
more elaborate clinical equipment and procedures, including such sophistications as
general anesthesia and surgery. Typically this becomes extraordinary means of life
support and, by definition, does not oblige morally.xi Essentially, the reason why
extraordinary means are not obligatory is because all vital organs fail naturally sooner or
later; experience inexorably demonstrates that to be so.xii When this is so, there is no
moral obligation to substitute the dying organ(s) with a healthy one, or equivalent devices
or machinery.
General Moral Obligation
There is a bioethical obligation to assist vital organs when possible, but there is no moral
obligation to substitute vital organs when failing irreversibly. Again, when a moral
dictate is not clear, it helps to pose the statement in the reverse. For example, imagine if
there was a moral obligation to substitute all vital organs when failing irreversibly; that
too is untenable! Therefore, there is no moral obligation to substitute vital organs when
failing irreversibly. One may try to substitute them (i.e., transplants), xiii but there is
no moral obligation to do so.
Exception
A possible exception to this bioethical principle is when certain vital organs are failing in
an otherwise healthy person, and a temporary substitution presents a positive prognosis.
For example, the otherwise healthy person with pneumonia who, as a patient, becomes
intubated. One could argue that the ventilator is indeed substituting the lungs, at least at
first, but the hope is that this intubation be temporary. Another example could be dialysis,
at least until a matching kidney is found. So, for certain vital organs and under certain
conditions, one can understand that a temporary substitution of a failing vital organ may
obligate morally.
Even so, it is also important to further distinguish between short term and long term
protocols. For example, the intubation of a pneumonia or COPD patient may be
considered short term (typically, one to two weeksxiv), whereas dialysis in a patient with
renal failure –considering the current extended waiting lists for renal transplants– may be
indeed long term (typically, in the range of yearsxv). In such long term protocols, an
argument could me made that there may come a time when these procedures no longer
obligate, bioethically speaking. This is also an area where one finds a possible
discrepancy between standard clinical practice (i.e., dialysis) and morally extraordinary
means (i.e., substitution of failed kidneys). In such cases, prudence calls for a patient-by-
patient assessment, including such factors as age, blood type, genetic makeup, and even
the patient’s own subjective estimation of how burdensome the procedure is becoming. xvi
Conclusion
Sometimes, patients in healthcare facilities or at home, and their loved ones, just do not
know when to stop burdensome treatments. If the patient is terminal but the death process
is not obvious, one can ask the attending physician; “doctor, has his/her vital organs
begun to shut down irreversibly?” If the answer is, “yes,” then treatments may be stopped
morally. Bioethically, comfort care always obligates, and this patient can then be allowed
to die in peace.
i http://www.data360.org/dsg.aspx?Data_Set_Group_Id=195, accessed 5
June 2016
ii http://www.pbs.org/wgbh/pages/frontline/facing-death/facts-and-figures/, accessed 5
June 2016
iii Rodriguez KL, Young AJ. Patients’ and healthcare providers’ understandings of life-
sustaining treatment: are perceptions of goals shared or divergent? Soc Sci Med. 2006
Jan;62(1):125-33
ivWillmott L1, et al., Reasons doctors provide futile treatment at the end of life: a
qualitative study.Med Ethics. 2016 May 17. doi: 10.1136/medethics-2016-103370. [Epub
ahead of print]
v Please note that, for bioethical purposes, the emphasis is on the function of the vital organ, rather than on
its structure. Thus, a dialysis machine substitutes the kidneys functionally; conversely, one can say that a
transplanted heart that has been rejected by the patient’s body, has failed so substitute the dying heart
functionally, even though the structural substitution was successful.
vi http://www.nlm.nih.gov/medlineplus/ency/article/000013.htm, accessed 5 June 2016
vii
http://www.pathology.washington.edu/research/labs/murry/index.php?a=research&p=inf
o, accessed 5 June 2016
viii http://www.dcids.org/facts-about-donation/frequently-asked-questions/, accessed 5
June 2016
ix Declaration on Euthanasia, Congregation for the Doctrine of the Faith (1980), Section
IV
x Ethical and Religious Directives for Catholic Health Care Services (Fifth Ed.), US
Conference of Catholic Bishops (2009), No. 56
xi ERD, 57
xii It is not the scope of this article to delve into why, if all living cells posses an inherent
reparatory mechanism, do all vital organs end up failing sooner or later. For inquiry into
this topic, the reader may look up: telomeres and cellular aging.
xiii ERD, 63
xiv http://www.nhlbi.nih.gov/health/health-topics/topics/vent/whoneeds, accessed 5 June
2016
xv http://www.kidneylink.org/TheWaitingList.aspx, accessed 5 June 2016
xvi ERD, 27
http://www.data360.org/dsg.aspx?Data_Set_Group_Id=195
http://www.pbs.org/wgbh/pages/frontline/facing-death/facts-and-figures/
http://www.ncbi.nlm.nih.gov/pubmed/?term=Rodriguez%20KL%5BAuthor%5D&cauthor=true&cauthor_uid=15993530
http://www.ncbi.nlm.nih.gov/pubmed/?term=Young%20AJ%5BAuthor%5D&cauthor=true&cauthor_uid=15993530
http://www.ncbi.nlm.nih.gov/pubmed/15993530
http://www.ncbi.nlm.nih.gov/pubmed/?term=Willmott%20L%5BAuthor%5D&cauthor=true&cauthor_uid=27188227
http://www.ncbi.nlm.nih.gov/pubmed/27188227
http://www.nlm.nih.gov/medlineplus/ency/article/000013.htm
http://www.pathology.washington.edu/research/labs/murry/index.php?a=research&p=info
http://www.pathology.washington.edu/research/labs/murry/index.php?a=research&p=info
http://www.dcids.org/facts-about-donation/frequently-asked-questions/
http://www.nhlbi.nih.gov/health/health-topics/topics/vent/whoneeds
http://www.kidneylink.org/TheWaitingList.aspx
BIOETHICAL ISSUES TOWARD THE END OF HUMAN LIFE
• TRILLIONS OF CELLS
• MAJOR CAUSES OF DEATH
• DISTINCTION BETWEEN ASSISTING OR SUBSTITUTING VITAL ORGANS
REVIEW:
BIOLOGICAL UNIT OF LIFE = CELL
LEVELS OF BIOLOGICAL ORGANIZATION (HIERARCHY OF LIFE):
CELLS -> TISSUES -> ORGANS -> SYSTEMS (ORGAN SYSTEMS) -> ORGANISM
(INDIVIDUAL)
• VITAL ORGANS
VITAL ORGANS:
• BRAIN
• BRAIN STEM
• BOTH LUNGS
• HEART
• LIVER
• PANCREAS
• STOMACH
• SMALL INTESTINE
• LARGE INTESTINE
• BOTH KIDNEYS
• MAJOR CAUSES OF DEATH
% Primary Organ
1. Diseases of the heart 28.5 HEART
2. Malignant tumors 22.8 ANY VITAL ORGAN
3. Cerebrovascular diseases 6.7 BRAIN
4. Chronic lower respiratory diseases 5.1 LUNGS
5. Accidents (unintentional injuries) 4.4 ANY VITAL ORGAN
6. Diabetes mellitus (Type II Diabetes) 3 PANCREAS
7. Influenza and pneumonia 2.7 LUNGS
8. Alzheimer’s disease 2.4 BRAIN
9. Nephritis, nephrotic syndrome and nephrosis 1.7 KIDNEYS
10. Septicemia (blood poisoning) 1.4 BLOOD
11. Suicide 1.3 ANY VITAL ORGAN
12. Chronic liver disease and cirrhosis 1.1 LIVER
13. Primary hypertension and hypertensive renal disease 0.8 ANY VITAL ORGAN
14. Parkinson’s disease (tied) 0.7 BRAIN
15. Homicide (tied) 0.7 ANY VITAL ORGAN
All others 16.7 ANY VITAL ORGAN
100
(Source: CDC/NHS National Vital Statistics System)
15 Major Causes of Death (USA)
• DISTINCTION BETWEEN ASSISTING OR SUBSTITUTING VITAL ORGANS
DIALYSIS: SUBSTITUTES KIDNEYS
RESPIRATOR; ASSISTS IN PROVIDING OXYGEN
VENTILATOR; DEPENDS ON THE SETTINGS: ASSIST OR SUBSTITUTE BREATHING
RESPIRATORS: ASSIST BREATHING
(NOT VENTILATOR)
VENTILATOR: PERFUSION
WEANING PROCESS
VENT ~ 2-3 WEEKS BEFORE
TRACHEOTOMY
EXTUBATION
TRACHEOTOMY
(TRACHEOSTOMY)
CARDIOPULMONARY RESUSCITATION (CPR):
• ASSISTS / SUBSTITUTES HEART
Defibrillation
Automated External Defibrillator (AED)
Implantable Cardioverter Defibrillator (ICD)
Wearable Cardioverter Defibrillator (WCD)
• treatment for cardiac dysrhythmias
• Ex. ventricular fibrillation (VF) and ventricular tachycardia (VT)
• delivers a dose of electric current to the heart
• VITAL ORGANS
• DISTINCTION BETWEEN ASSISTING OR SUBSTITUTING VITAL ORGANS
• ASSISTING VITAL ORGANS GENERALLY OBLIGATES BIOETHICALLY
• SUBSTITUTING VITAL ORGANS GENERALLY DOES NOT OBLIGATE
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The Unconscious States
Awareness of self and the environment: internal / external (difficulties)
(lack of response to painful stimulus)
clinical definitions of:
• coma (Glasgow Coma Scale) (induced coma)
• persistent vegetative state (PVS)
• traumatic head injury
• brain hypoxia
• epileptic seizure
• syncope
• other unconscious states (ex. Locked-in syndrome)
CONSCIOUSNESS:
Awareness of self and the environment: internal / external
(difficulties; how to measure?)
UNCONSCIOUSNESS:
Lack of response to painful stimulus
Coma (Glasgow Coma Scale) (induced coma)
persistent (permanent) vegetative state (PVS)
VS MCS
MAGNETIC RESONANCE IMAGING
(MRI)
Traumatic Brain Injury (TBI)
• complex injury
• broad spectrum of symptoms
• and disabilities
Mayo Clinic: TraumaticBrainInjury.com
TBI
mild
severe
~ 30 min.
Brain Hypoxia (anoxia)
3 PAIRS OF ARTERIES TO THE HEAD:
• 1 PAIR VERTEBRAL
• 2 PAIRS CAROTID
Epileptic Seizure (epileptic fit)
Neuronal activity:
• Abnormal
• Excessive
• Generalized
• Synchronous
Electro-EncephaloGram (EEG)
Syncope (fainting):
• Temporary loss of consciousness
• Sudden drop in blood pressure
Other unconscious states:
• Non-epileptic seizure
• Locked-in syndrome
• Etc.
LOCKED-IN SYNDROME:
• Aware
• cannot move or communicate verbally
• complete paralysis of nearly all voluntary muscles
• Except for vertical eye movements and blinking
Damage to specific portions of the lower brain
and brainstem, with no damage to the upper
brain (cerebral cortex).
MAGNETIC RESONANCE IMAGING (MRI)
POSITRON EMISSION TOMOGRAPHY (PET)
COMPUTED TOMOGRAPHY (CT)
VEGETATIVE
STATE
MINIMALLY
CONSCIOUS
STATE
LOCKED-IN
SYNDROME
(MRI)
DIAGNOSIS -> PROGNOSIS
MANAGEMENT, RELIEF: PAIN / SUFFERING
BIOETHICAL ANALYSIS: BENEFIT / BURDEN
BIOETHICAL MEANS OF LIFE SUPPORT:
• ORDINARY (PROPORTIONATE) / EXTRAORDINARY (DISPROPORTIONATE)
CLINICAL MEANS OF LIFE SUPPORT:
• STANDARD MEDICAL PRACTICE / EXPERIMENTAL TREATMENT
ETHICAL OBLIGATION RE. VITAL ORGANS: ASSIST / SUBSTITUTE
WHEN TO WITHHOLD OR WITHDRAW LIFE SAVING TREATMENT?
ERD
32. While every person is obliged to use
ordinary means to preserve his or her health,
no
person should be obliged to submit to a health
care procedure that the person has judged,
with a free and informed conscience, not to
provide a reasonable hope of benefit without
imposing excessive risks and burdens on the
patient or excessive expense to family or
community.
33. The well-being of the whole person must
be taken into account in deciding about any
therapeutic intervention or use of technology.
Therapeutic procedures that are likely to
cause harm or undesirable side-effects can be
justified only by a proportionate benefit to
the patient
56. A person has a moral obligation to use
ordinary or proportionate means of preserving
his or her life. Proportionate means are those
that in the judgment of the patient offer a
reasonable hope of benefit and do not entail
an excessive burden or impose excessive
expense on the family or the community.
57. A person may forgo extraordinary or
disproportionate means of preserving life.
Disproportionate means are those that in the
patient’s judgment do not offer a reasonable
hope of benefit or entail an excessive burden,
or impose excessive expense on the family
or the community.
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Vital Organs / Unconscious State
After studying the course materials located on
Module 5: Lecture Materials & Resources
page, answer the following:
1. Name some very important organs that are not vital organs.
2. List the functional description of all the normal vital organs, including today’s exceptions.
3. Is it possible to live without a vital organ? Why? Example?
4. Distinction between assisting or substituting vital organs. Bioethical analysis.
5. Do the following practices assist or substitute the vital organ? Why?
·
Dialysis
· Respirator
· Ventilator
· Tracheotomy
· CPR
6. Read and summarize ERD PART FIVE Introduction.
7. Unconscious state: Definition.
8. Clinical definitions of different states of unconsciousness: Compare and contrast
9. Benefit vs Burden: bioethical analysis.
Submission Instructions:
· The paper is to be clear and concise and students will lose points for improper grammar, punctuation, and misspelling.
· If references are used, please cite properly according to the current APA style. Refer to your syllabus for further detail or contact your instructor.
Module 5: Lecture Materials & Resources
Read
· Ethical and Religious Directives (ERD) for Catholic Health Care Services (6th ed.). (2018).
PART FIVE: Introduction
·
PHI 3633 WK 5-A
·
PHI 3633 WK 5-B
·
DISTINCTION BETWEEN ASSISTING AND SUBSTITUTING VITAL ORGANS
· Cioffi, A. (2019, March 9). BIO 603 VITAL ORGANS ASSIST SUBST 3 9 19 [Video file]. Retrieved from
· BIO 603 VITAL ORGANS ASSIST SUBST 3 9 19
· (Links to an external site.)
·
· Cioffi, A. (2019, March 24). BIO 603 UNCONSCIOUS 3 23 19 [Video file]. Retrieved from
· BIO 603 UNCONSCIOUS 3 23 19