Rapid Responses to:
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Rapid Responses: Rapid Responses published:
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![[Read Rapid Response]](/icons/misc/sectionDOWN.gif)
Ethical considerations in transplant surgery
- Richard M Lindley (28 November 2003)
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The measurement of health
- Derek J Ward (29 November 2003)
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The End of Medicine; Blood Donation
- Michael Potts (11 December 2003)
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Richard M Lindley, SpR in Paediatric Surgery Sheffield Children's Hospital, S11 7AX
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Michael Potts argues that live liver donor (but presumably by extension, all live donor transplants) are unethical because they violate the principles of beneficence and non-maleficence. His argument is incorrect as he conflates differing ethical theories and misunderstands the principles behind an axiomatic, rule based theory of medical ethics. Firstly, he is wrong when he states that "Utilitarian considerations... no not change this fact..." [that surgery on a live donor violates principles of beneficence and non-maleficence]. Utilitarianism is an ethical theory in its own right, and is mutually exclusive to the other commonly accepted, axiomatic theory of medical ethics (that there are four important principles: autonomy, justice, non- maleficence and beneficence). According to a utilitarian argument, live donor transplants in many situations would be eminently justifiable, given the benefits they can bring. A mother or father donating a kidney to their child is acting for a greater "good" in an ethical fashion in this theory. Secondly, Potts implies from his letter that non- maleficence/beneficence are more important and take priority over justice and autonomy. Potts concedes that autonomy is not an absolute right, but insists that his two favorite axioms are. This is not a correct application of this ethical theory, as all four axioms are fundamental but subject to an alteration in emphasis. We may argue about which should take precedence in a particular situation, but this has not been done. Indeed, many ethicists would place autonomy above the other axioms in most situations. So, if an individual wishes to make a live organ transplant then they may exercise their autonomy to do so. They may come to some physical harm, but they may feel that the mental/emotional benefit they experience outweighs this. This is true for many related live donors. The principle of justice (unmentioned by Potts) is also well-served by live donor transplants. In both utilitarian and axiomatic ethical theories live donor transplants are therefore ethically justified. If any readers are still swayed by the argument put forth by Potts, they should bear in mind that this also condemns blood donation as an immoral act(a cannula insertion causes physical harm, and there is no medical benefit to the donor)! Finally, I would like to disagree with the premise that "The fundamental end of medicine is to help an individual sick or injured patient..." We have a wider responsibility to society. I would also argue that the fundamental aim of medicine is to relieve suffering: a compassionate utilitarianism, if you will, but I would accept that this is also controversial. Competing interests: None declared |
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Derek J Ward, SpR Public Health South Worcestershire Primary Care Trust, Worcester, WR4 9RW
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In his rapid review (above), Lindley outlines a clear critique of the ethical principles applied by Potts in his judgement upon living liver donation. However, there is an additional issue that should also be raised. Potts argues that the act of donation does not benefit the health of the donor, but this relies on an limited view of health as simply the absence of physical disease or impairment. The notion of health goes far beyond this biomedical construct. Health implies the capacity to live as one would wish and expect, and yes, this includes the capacity to make ones own decisions regarding the benefit/harm ratio of any action. This is a very personal trade-off, even though it may be rooted in social and cultural values and expectations. Personal health gain can involve decisions that seem irrational to others, but others have no part in deeming some aspects of health (the physical/medical) as more important that others (psychological/social/spiritual factors) to the individual. Competing interests: None declared |
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Michael Potts, Head, Philosophy and Religion Department Methodist College, Fayetteville, NC USA 28311
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In response to Richard N. Lindley, first of all, I would note that a utilitarian might agree with the four principles approach to medical ethics, as long as using that approach increased the sum total of utility in the world. The degree of emphasis a utilitarian would place on autonomy vs. justice or nonmaleficence, say, in a given case would then depend on what would increase overall utility. Lindley points out a major problem with the four principles approach—that it is difficult to order the principles without a fuller account of morality and its role in human life. The emphasis on the priority of autonomy, for example, fits well into a post-Enlightenment individualism, but does not fit as well into competing world-views. My claim concerning the priority of nonmaleficence and beneficence over autonomy in the practice of medicine is based on the position that medicine has as its fundamental end helping a sick or injured person in need. Thus, I grant that my position implies that in medicine, societal considerations, without being ignored, should be subsumed under this fundamental telos. Lindley claims that my position would also prohibit giving blood. But donating blood carries with it a very low risk of harm, and the body replenishes blood in a relatively short period of time. The level of "invasiveness" into the patient's body is much less as well. The risks of transplantation surgery are of a different order of magnitude entirely, with significant risk of morbidity and, in the case of liver donation surgery, a nontrivial risk of mortality. I am not opposed to giving blood, but if there were some other means to obtain the equivalent of blood (such as a workable "artificial blood"), that would be the preferable situation. But I am not convinced that the extremely low risks associated with blood donation are of the same order as the significantly higher risks stemming from surgery. Competing interests: None declared |
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