Ethics in Health Care: Transplantation
Ethics in Health Care: Transplantation
Every day, health care is faced with a lot of moral ambiguity. It can never be as easy as right and wrong. Patients have certain rights and expectations when it comes to their health care. When patients enter into a new health related situation, they have a lot of questions that they expect to be answered. They want someone to help them, guide them in the right direction. They expect to be closely involved with the outcome of their health and have a right to make the decisions based on their knowledge, judgment and morals. As technology advances, patients seem to have even more expectations. These expectations do not come without a price. A lot of advancements are being made, but a lot of the processes are being questioned ethically. From stem cell research to types of organ donation. There are a lot of people in the United States who are a live today because of the use of an animal organ, or part of one. This process is called xenotransplantation and is a heated discussion for many groups. When it comes to healthcare logistics, and helping a patient to make the decision whether or not to participate in a xenotransplantation, the principles of autonomy, fidelity and confidentiality play a big role.
Xenotransplantation is any procedure that involves the transplantation, implantation or infusion into a human recipient of either live cells, tissues, or organs from a nonhuman animal source (FDA, 2009). The reason xenotransplantation even became such a big strive for the medical community is because of the increasing need for organs. “Currently ten patients die each day in the United States while on the waiting list to receive lifesaving vital organ transplants (FDA, 2009).” The process of using animal tissues and cells are also known to be beneficial for humans.
Studies have suggested that cells and tissues can be therapeutic for neurodegenerative disorders and diabetes. This is a big discovery considering human materials are very hard to come by for such diseases.
“End-stage organ failure is one of the most important public health problems facing Americans today. Heart failure, for example, kills four times as many people as does HIV infection and three times as many people as does breast cancer; it is a disease with an increasing incidence, and the cost of taking care of affected patients is 8 to 35 billion dollars each year. The single most effective therapy for it is transplantation (Michler, R., 2004).” This being said, the lack of human organs is a major problem. People do not want to have to wait around for someone to die, and if they do, the patient ends up dying before a donor match can be found. It is only natural to expect that someone somewhere is going to start looking for non-traditional ways to fix the problem.
When a patient finds out they are in need of a transplant, they become scared, panicked and confused. They rely on their doctor to lead them in the right direction for them, answer their questions in a way they can understand. The physician is also obligated to give them options that will best suit their needs and beliefs. These things should be provided without a question because it is within the patient's “bill of rights” to have them (American Cancer Society, 2008). Using the principle of autonomy (“the right of an individual to make his or her own decisions (Pozgar, 2010).”), a good doctor will give their patient every option available to them. Be it waiting for years on a donor list or having an animal organ (or partial organ) replacement. There is even the option of bridge treatment. A bridge treatment is the process of using all or part of an animal organ until a human one can be provided. Based off of a close doctor-patient relationship, the patient will take every piece of information the doctor gives them at face value. They will process and think about the information they are given in their own way. They can then use that information to make a well informed decision.
There have been only a few full organ xenotransplantations in the world, however, xenografts (replacement of part of the human organ with part of an animal organ) in the heart, kidney, and liver, have been able to extend the life of a patient who is waiting on a donor list. “By providing temporary heart, kidney, or liver support as a bridge-to-transplantation, these biological devices may allow patients to recover end-organ function and await allograft transplantation in a more stable clinical state, thus improving their chances of survival . Cross-species transplantation does offer the possibility of eventual long-term organ replacement. Success in this more ambitious goal would help alleviate the human organ donor shortage (Michler, R., 2004).” Choosing to take this route could have a “best of both world” type of outcome. The patient will be able to overcome their end-stage organ failure long enough to be able to wait a few years for a human organ.
With any type of transplant be it from human to human or animal to human, there are infection and immunity risks involved. Biologic cardiac replacement poses the immunologic problems of rejection and infection associated with transplantation.
However, clinical experiences all over the world have proven that the rejection and infection can be managed in most cases when the patient receives human cardiac xenografts. Medications such as cyclosporine used as the primary immunosuppressive drug for the cardiac transplant have resulted in outstanding survival rates almost 85% 1-year survival (Michler, R., 2004). There have also been a decrease in the illnesses associated with infection and tissue rejection. This fact is helping break down the barriers. Many people who are a live today are walking around with pig heart valves when they should otherwise be dead.
The risks of xenotransplantation is where the issues of ethics begin to arise. The first and most common issue is the questions of, "Is it inherently wrong to use animals for xenotransplantation or to treat them in a the way that is necessary to make them suitable as organ donors?" This question at it's basic form can be broken down into animal rights and cruelty. There are groups like PETA (People for Ethical Treatment of Animals) who believe an animal's life is just as important as a human's. They do not believe it is right or ethical to kill an animal just to save a human life. There are also religions that forbid the slaying of certain animals. In India for example, killing a cow could land someone in jail facing the death penalty. The other side may argue and say something along the lines that it says in Genesis in the Bible God put animals on Earth to be ruled over by humans, “And God said, Behold, I have given you every herb bearing seed, which is upon the face of all the earth, and every tree, in the which is the fruit of a tree yielding seed; to you it shall be for meat.
And to every beast of the earth, and to every fowl of the air, and to every thing that creepeth upon the earth, wherein there is life, I have given every green herb for meat: and it was so (1 Genesis 29:30).” Another angle is that if it is deemed ethical to kill an animal for food, sustenance to keep a human alive, then why is it not ethical to kill an animal to use its organ to keep someone alive. One can be hopeful and believe that scientists are not being wasteful and are using one animal to save five lives.
In relation to the use of animal organs in itself, doctors need to know what the best species of animal for the transplantation will need to be used. The general debate has shown that, even though primates are genetically closest to humans, there are other factors such as the endangerment of many species, and perhaps most importantly, the idea that "the likelihood of the transfer of infective agents [is] more likely between more closely related species...(Somerville, M., 2007)." Therefore, the transplant animal most choose to use has become the pig.
The organs of a pig are most comparable in size to that of an adult human, they have large litters, grow quickly to maturity, and can be raised in sterile environments. This does not happen in every case, in fact, “90 percent of cases do not result in the production of a retrovirus. Patients are continually monitored after the surgery and throughout life just to evaluate the risk (Carter, L., 2004).”
Another risk with xenotransplantation is xenozoonoses. Xenozoonoses is when an animal viruses crosses the species barrier and causes a human to contract the disease. This is one of the central question raising topics about the process. This raises a lot of discussion about the safety of using animal organs in individuals. A case of xenozoonoses can potentially place, not only the transplant patient but he rest of society at risk as well. The fact that putting living organs into the human body allows pathogens to bypass the bodies natural barriers such as skin and the gastrointestinal tract. Additionally, it is difficult to screen animals for these pathogens when we may not even know what they are, makes the spread of deadly infection quite possible. That is a scary thought. Many believe this was the starting point for how AIDS spread through the human race. It started in monkeys and spread to man. It is no wonder that the ethical debate over this aspect is concerned with whether or not we have the right to risk the health of so many people by pursuing a procedure that involves significant dangers which we know relatively little about.
Besides the potential risks, there are other major ethical issues at hand. The first is the human-animal interface that occurs with xenotransplantation. There are various views regarding whether or not humans have a particular station and position among living organisms to be able to use animal organs into human bodies. Somerville believes, "...the physical realities they [mixings] create, but also with respect to important societal values and, in particular, with respect to maintaining respect for both human and animal life (2007)."
There is one more problem that is seen in xenotransplantation. It is not physical, but psychological. A lot of people view their internal side as an extension to their outer self. Having an organ removed sometimes makes a person feel a void inside. Having someone else's organ in them could make them feel inadequate in a way. Just image how someone with this type of thinking would feel with a pig's heart. Some people even go as far as to take on physiological characteristics of the animal whose part is in them. When things like this happen, the patient will expect the health care professional to abide by the rule of confidentiality, keeping private matters private. We hear this word all over the healthcare field and it is important to keep all of the patients' information private unless it is against the law or going to potentially hurt them or someone else. Other than that it is just wrong to divulge any information about a patient or a patient's case.
Using the principle of fidelity, “being true to our commitments and obligations to others (Pozagar, 2010).”, and while having the best interest of the patient in mind, it is the duty of the health care professional working on the case to explain every possible risk and all of the statistics to the patient before allowing them to agree to participate in a xenotransplantation. It is the patient's right to have a full understanding about the process and the risks involved.
Ethics and the moral ambiguity can be found anywhere with in the health care system. The answers to which can never be as easy as the difference between right and wrong. Patients have rights that need to be taken into consideration.
These patients also have standards and expectations for their health care providers. A patient wants and expects someone to help them, and guide them in the right direction for their individual needs. They expect to be closely involved with the outcome of their health and have a right to make the decisions based on their knowledge, judgment and morals. As technology advances, so do patient expectations, they want to get in and get out so to speak. The process of xenotransplantation is becoming more an more popular, while it still somehow, remains under the radar. As the process becomes more known and practiced, a lot of ethical questions arise. The fact is, there are a lot of people in the United States who are a live today because of the use of an animal organ, or part of one. Using the principles of autonomy, fidelity and confidentiality, and while abiding by the patient's bill of rights, the physician is able to help the patient decide whether or not this is the path for them.