Vital Organs / Unconscious State? ? After studying the course materials located on Module 5: Lecture Materials & Resources page, answer the following: Name some very important organs that

When to 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

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.

BIOETHICAL ISSUES TOWARD THE END OF HUMAN LIFE

• TRILLIONS OF CELLS

• VITAL ORGANS

• 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