Elective non-therapeutic intensive care and the four principles of medical ethics

Abstract

The chronic worldwide lack of organs for transplantation and the continuing improvement of strategies for in situ organ preservation have led to renewed interest in elective non-therapeutic ventilation of potential organ donors. Two types of situation may be eligible for elective intensive care: patients definitely evolving towards brain death and patients suitable as controlled non-heart beating organ donors after life-supporting therapies have been assessed as futile and withdrawn. Assessment of the ethical acceptability and the risks of these strategies is essential. We here offer such an ethical assessment using the four principles of medical ethics of Beauchamp and Childress applying them in their broadest sense so as to include patients and their families, their caregivers, other potential recipients of intensive care, and indeed society as a whole. The main ethical problems emerging are the definition of beneficence for the potential organ donor, the dilemma between the duty to respect a dying patient's autonomy and the duty not to harm him/her, and the possible psychological and social harm for families, caregivers other potential recipients of therapeutic intensive care, and society more generally. Caution is expressed about the ethical acceptability of elective non-therapeutic ventilation, along with some proposals for precautionary measures to be taken if it is to be implemented.

Non-therapeutic intensive care for organ donation

“…37,38 Therefore, checking for unequivocal information from advance directives such as Mental Capacity Act, or the family or other close relatives' testimony of the patient's strong desire to donate seems critical. 2 Finally, our survey confirms the feeling of healthcare professionals highlighted by previous studies that caring for end-of-life potential organ donor is more difficult than simply caring at the end of life, perhaps partly because of the conflicts of duties and the blurry limits of the two types of care. 9 Role of healthcare professionals In our study, despite a deficit of training on families' support, brain death and NTIC, two-thirds of the healthcare professionals want to partake in organ donation discussions with families.…”

“…2 NTIC covers two different types of situations: patients definitely evolving towards brain death and patients suitable as controlled non-heart-beating organ donors after life-supporting therapies have been assessed as futile and withdrawn. 2 Practically, its interest is to increase the number of organ donation.…”

Cardio-pulmonary resuscitation of brain-dead organ donors: a literature review and suggestions for practice

“…We deliberately avoid terminology such as "Elective" or "nontherapeutic," to prevent any confusion between the present discussion and other debates. In some literature, "ElectiveIntensive care," "Nontherapeutic intensive care" [10][11][12][13], and "Elective mechanical ventilation" [14] refer to the use of intensive care or mechanical ventilation not for the patient's benefit but to preserve his or her organs for transplantation purposes, but the definitions of each of these modalities are often unclear.…”

Does comfort therapy during controlled donation after circulatory death shorten the life of potential donors?

“…Controlled DCD may raise several important ethical issues (3,4). First, the possibility of deliberately planning the withdrawal of life support and therefore to medically determine the timing of a patient's death may be subject to debate and is legally forbidden at present in some countries, such as Germany (5).…”