BRAIN DEATH DONORS (ETHICAL POINTS) G.POURMAND, M.D. Urology Research Center, Medical Sciences/University of Tehran Tehran, IRAN The 2 nd International.

BRAIN DEATH DONORS

(ETHICAL POINTS)

G.POURMAND, M.D.Urology Research Center,

Medical Sciences/University of Tehran

Tehran, IRAN The 2nd International Congress of Medical Ethics in Iran (Apr. 2008)

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1994 1995 1996 1997 1998 1999 2000 2001 2002 2003

Waiting Transplanted Died While Waiting

CANADIAN TRANSPLANT NUMBERS (1994-2003)

Wait List atYear End

CadavericTransplants

CadavericOrgan Donors

Number of Patients

0

10,000

20,000

30,000

40,000

50,000

60,000

1990 1991 1992 1993 1994 1995 19961997 1998 1999

70,000

DONORS, ORGANS & WAITING PATIENTS

Organ shortage — the main limitation to saving

lives of critically ill patients — is due to

individuals and their families not considering

organ donation out of fear,

ignorance

misunderstanding.

THE ORGAN SHORTAGE

60 people daily transplant,

13 die non-availability of organs. 5,984 deceased organ donors;

22,953 lifesaving organ transplants performed in 2000 (17,255

cadaveric donor transplants, 5,653 living donor transplants);

77,179 on waiting list as of June 3, 2001;

5,597 deaths while on Wait List at end of 2000.

THE CRITICAL ORGAN SHORTAGE

Japan - 12,974

Taiwan - 7000

Saudi Arabia - 4248

Korea - 4000

Pakistan - 1650

Hong Kong - 1018

Singapore - 666

Bangladesh - 125

Waiting Time

Taiwan – 1.9 yrs

Korea – 2.2 yrs

Hong Kong – 4.3 yrs

Singapore – 5.8 yrs

No Waiting list in Iran for No Waiting list in Iran for

Kidney Tx.Kidney Tx.

KIDNEY TX WAITING LIST IN ASIA (2002)

Waiting List #’s

# of donors per population

AustraliaAustralia 1,764 10 per 1,000,000

CanadaCanada 3,990 13.5 per 1,000,000

United StatesUnited States 75,000 34.3 per 1,000,000

KIDNEY TX WAITING LIST IN THE WORLD (2002)

Deceased donorsDonor has been declared dead by two physicians

independent of the transplant teamUsually occurs only in cases of neurologically

determined death (the brain stops working 1st but the donor is still on artificial support such as a ventilator to allow the other organs to maintain a blood supply and remain suitable for transplant)

Live donorsPatient chooses to donate one or part of an organ

to someone on a transplant waiting list Can only occur with organs when removal will

NOT cause grave harm to the donor

DONATION

Prevalence: 357 PMP Incidence: 59 PMP

Currently, 50% on HD 47.5% transplanted 2.5% on PD

INCIDENCE OF ESRD IN IRAN

Annual Number of kidney transplantations per

million population (pmp) per year -

USA - 52 Predominantly Deceased Donors

Europe - 27 Predominantly Deceased Donors

Asia - 3 Predominantly Living Donors

WORLD STATUS OF RENAL TRANSPLANTS

The number of deceased donors has increased steadily in recent years. Between 2003 and 2006, there has been a 24 percent increase in donation from deceased donors. Living donation rose sharply in the 1990s and has

remained at a steady level the last few years.

DECEASED DONATION

The deceased donors per million population per year

USA - 20.7 Europe - 15.9 Asia - 1.1 South America - 2.6

DECEASED DONOR RATES

Incidence of organ failure

Public and Professionals Attitude to Brain Death &

Organ Donation

Legal Aspects

Trained Transplant Co-ordinators /Counsellors

COMMON PROBLEMS & PLATFORMS IN CADAVER

TRANSPLANT

Media and Scandals

Reporting of Brain Death

Hospital Infrastructure

Religion & Organ Donation

COMMON PROBLEMS & PLATFORMS IN CADAVER

TRANSPLANT

Govt. Problem No Funding for

program

Hospital problem No efforts to identify

& maintain “Brain

Dead” donors

Community Problem No Awareness of

“Brain- Death”

ConceptFor cadaveric donation,

‘ ‘ Society remains a crucial aspect in a Society remains a crucial aspect in a transplant program’transplant program’

PROBLEMS WITH CADAVER ORGAN DONATION PROGRAM IN

ASIA

6 Kidneys have been wasted in the last four

years of the 112 Kidneys shared in the UNOS

due to these problems

Poor Retrieval Technique – 2

No Blood for Cross Match – 2

Poor Packing of Organ - 2

MAKE LOCAL SHARING PROTOCOLS

A large proportion of Physicians are indifferent to A large proportion of Physicians are indifferent to

organ donation process. organ donation process.

Reason cited for this were

Lack of information regarding the donation process

(28.7%),

Concerns about the sale of organs (22.1%),

Islamic religious beliefs (21.6%)

PHYSICIANS ATTITUDE TO ORGAN DONATION

Doctors May Face Murder Charge

Important misconceptions and fears are –

Fear of death,

Belief that removal of organ violates sanctity of

deceased

Concern about being cut up after death,

Desire to be buried whole,

Dislike of idea of kidneys inside another person,

Wrong concept of brain death,

Idea of donation being against religious conviction

PUBLIC ATTITUDE

Religion plays major role in promoting Organ Donation.

Common thread that binds all religions of the world – Saving of life overrides all objections There is no religion that is against organ donation What holds back is cultural reservations – Ignorance of the process of organ donation, Fear of mutilation, Lack of emotional support at time of tragedy, Fear that organs will be sold or used only by the rich Mistrust of hospitals and health professionals Myths

RELIGION AND ORGAN DONATION

Muslims: the most controversial group -

Quran does not forbid tissue donation

Quran states that if by not transplanting an organ or

tissue, the person will die, then it is permissible to

donate. It is allowed for an emergency to save life.

Different interpretations by different religious leaders,

‘ustazs’ and ‘ulamas’

MUSLIMS & ORGAN DONATION

Fatwas declared in several countries

Saudi Arabia : 1985 - permit both living

related and cadaveric donation of organs

Iran – 1989 (parliament legislation: 2000)

Pakistan,

Bangladesh,

Malaysia - 1995

Indonesia

MUSLIMS & ORGAN DONATION

STATEMENT BY POPE JOHN PAUL II –STATEMENT BY POPE JOHN PAUL II –

Full support of organ and tissue donation concluded

with words of Jesus narrated by evangelist and

physician LUKE:

“give…, and it will be given to you; good measure,

pressed down, shaken together, running over, will be

put into your lap (Luke 6 : 38).”

We shall receive our supreme reward from God

according to the genuine and effective love we have

shown to our neighbor.

CHRISTIANITY – ORGAN DONATION

Greek Orthodox, Shinto and Gypsies

are three religions that do not

encourage body donation

Jehovah’s witness is another Christian

sect that is against such acts

RELIGIONS AGAINST ORGAN DONATION

During ancient times, most people agreed that death occurred when a person's heartbeat and breathing stopped.

For the Greeks, the heart was the center of life

For the ancient Hebrews and Christians, the breath was the center of life

HISTORY OF DEATH

In the 12th century, Maimonides pointed toward the head, and the loss thereof, as the reason for lack of central guidance of the soul.

During the Enlightenment, the necessity of heartbeat, breath, and consciousness for the definition of life was questioned, leading to questioning regarding the definition of death.

HISTORY

The cessation of life; the ceasing to exist; defined by physicians as a total stoppage of circulation of the blood, and a cessation of the animal and vital functions consequent thereon, such as respiration, pulsation, etc.

Black’s Law Dictionary (4th edition)

LEGAL DEFINITION OF DEATH

An individual who has sustained either

Irreversible cessation of circulatory and respiratory functions

Irreversible cessation of all functions of the entire brain, including the brain stem is dead. A determination of death must be made in accordance with accepted medical standards.

Uniform Determination of Death Act (1980)

UNIFORM DETERMINATION OF DEATH

In 1959, patients were described as being in "coma depasse" or beyond coma.

In 1967, the first successful heart transplantation took place, with the organ coming from a brain-dead, beating-heart donor.

Farrell MM and Levin DL. Critical Care Medicine. 21(12):1951-65, 1993 Dec.

BRAIN DEATH

اJحيJا... نما JاJك Jف اJحياها JنJم و... Vجميعا Jالناس

And he who saves a man’s life shall be considered as one who has saved the

life of mankind as a whole 32سوره المائده آيه

Imam Khomeini’s Imam Khomeini’s (the supreme (the supreme leader of Iran) leader of Iran) positive response positive response to the letter of to the letter of the Iranian ex-the Iranian ex-minister of Health minister of Health on the on the permissibility of permissibility of organ donation organ donation from brain death from brain death patients.patients.

The oldest organ transplant (Cornea) was performed in 1314 (1935).

The first kidney transplantation was performed in Shiraz in 1346 (1967).

The total number of transplants in 2005 was 19501 kidneys, 203 livers,

104 hearts, 13 lungs, 28362 corneas, 1468 bone marrows, 1382 heart

valves and 1283 bone transplants.

One, five and ten years survival rate is reported to be 92.8%, 83.7% and

73.3%, respectively.

Iran is the only country who doesn’t have any waiting list for

kidney transplant & the patients can receive the necessary

organ in less than 2 months.

When the wishes of the deceased are not known,

only 50% of people will agree to organ retrieval

from their relatives

Encouraging people to speak about organ donation

and transplantation and to make their wishes

known to their relatives could change the picture

resulting in 93-94% of people allowing donation

ENCOURAGING PEOPLE TO DISCUSS ORGAN DONATION

Many donor relatives have stated that

donating their loved one's organs does not

make the pain of their death disappear

Bereaved families can experience comfort

that their loved one's gift gave another

person a second chance at life

PROJECT POSITIVE ASPECTS

Most families faced with brain stem death of a relative

find the concept difficult to understand and have trouble

in accepting that their relative is actually dead

Family members were given choice to be or not to be

present during brain stem death testing

It is suggested that presence of family members during

brain stem death testing not only helps families to

accept this concept of death but also promotes the

grieving process

PRESENCE OF FAMILY MEMBER DURING BRAIN DEATH TESTING

Most people are ill- informed about their

religions attitude towards organ donation.

More public education needed to change

cultural beliefs and practices although Islam

does not forbid Organ or tissue donation

Constantly addressing masses through media

by religious head may help to improve

sentiments

ACTION REOUIRED – MUSLIM COUNTRIES

Pre-mortem – via Donor Cards, Driving License

Consent of his family following death

Some form of a combination of the two are necessary

‘Supererogatory permission’ - Underlying premise of

such a consent would be that “organs of dead people

are public goods”, and donation must be considered

“similar to other compulsory civil obligations” within

society

The permission is a moral rather than a legal requirement

CONSENT FOR DONATION

This requires people to state their

’willingness to donate or not’ when filing

some state of institutional return such as a

driving license or income tax form.

The information would be kept on a central

register, accessible at time of death

MANDATED CHOICE

Study shows that blood donors have better knowledge

of organ donation and are more willing to donate their

organs and sign an Donor card than general public.

A substantial proportion of blood donors have not

signed a Donor Card.

It would be useful to design promotion programs to

facilitate blood donors' participation in organ donation.

PROMOTE ORGAN DONATION AMONG BLOOD DONORS

Organ Shortage is a Crisis, however the Crisis has a Cure

We need to Network and start thinking of sharing resources,

expertise and organs

Set up Collaborative projects

Use Television Media for Promotion

Get Religious heads to Participate regularly

Have Transparency in program

Set up regional Transplant coordinators Forums

CONCLUSION