D. ETHICS OF TRANSPLANTATION

Question 1

what is the 4 stage decision making model

Answer 1

1. gather relevant information
   - Criminal Law
   - Administrative Law
   - Professional Law
   - Civil Law
   - Professional/clinical knowledge
   - Situational information (patient)
   - Ethical frameworks
   - Availability of help
2. prioritise and ascribe values
3. generate options
4. select option and action

Question 2

what type of principles are the 4 bioethical principles

Answer 2

prima facie

Question 3

what is autonomy

Answer 3

• right of a patient to make decisions about themselves
• capacity to think and decide and to act on the basis of such thought and decision
• need informed consent
• patients have rights to disagree with a health professionals advice
• person’s autonomy can be restricted by certain circumstances

Question 4

what are the restrictions of autonomy

Answer 4

• To prevent people from harming others (harm principle)
• To prevent that person from harming themselves (soft paternalism)
• To benefit that person (hard paternalism)
• To benefit others (social welfare principle)

Note: paternalism overrides the principle of respect for autonomy, soft paternalism is overriding an incompetent person’s wishes; hard overriding a competent person’s wishes

Question 5

what is beneficence

Answer 5

• duty to promote the health and welfare of the patient, not merely to avoid harm
• act in best interest of patient
• may conflict with autonomy
• patient interest isn’t always 1st principle here

Question 6

what is non-maleficence

Answer 6

• duty not to harm anyone
• expresses the commitment to the protection of patients from harm
• affirms the requirement of competence and the standard duty of care

Question 7

what issues concern the principle of non-maleficence

Answer 7

• withdrawing or withholding life sustaining treatment
• treatment of terminally ill patients
• provision of futile treatment (NICE requires professionals to stop prescribing medicines of dubious efficacy)
• what about surgery
• what about potential adverse drug events

Question 8

what is justice

Answer 8

• moral obligation to act on the basis of fair adjudication between competing interests
• equality/equity
• important to treat equals equally
• important to treat unequals unequally in proportion to the morally relevant inequalities
• requires that morally defensible differences among people be used to decide who gets what

Question 9

what is the difference between equality and equity

Answer 9

• Equality: each individual or group of people is given the same resources or opportunities
• Equity recognizes that each person has different circumstances and allocates the exact resources and opportunities needed to reach the same outcome

Question 10

what are the 3 types of justice

Answer 10

• distributive justice (fair distribution of scarce resources)
• rights-based justice (respects for peoples rights)
• legal justice (respect for morally acceptable laws)

Question 11

4 types of basis’ for distributive justice

Answer 11

• Needs Based – distribution to those that need it most
• Maximisation based – distribution to maximise outcomes
• Egalitarian based – distribution based on equality
• Merit-based – distribution based on merit

Question 12

example of rights-based justice

Answer 12

• if a patient has the right to be excused work because they are unfit to work, then doctor ought to provide medical certificate, but if fit to work, then that right does not exist
• more and more merging into legal justice with incorporation in legislation (e.g. ECHR)

Question 13

example of legal justice

Answer 13

• provision of healthcare for foreign visitors
• NHS act allows for emergency treatment only - at taxpayers expense

Question 14

what is utilitarianism

Answer 14

• consequentialism: the view that morality is all about producing the right kinds of overall consequences
• principle of utility = degree to which an action “produces good”/ “avoids evil”
• actions should be judged on “happiness” conferred
• originally “all forms of happiness are equivalent”, now accepted there will/must be variations
• very commonly used argument for decision making at population level

Question 15

can you discriminate on the basis of age according to equality act

Answer 15

No

Question 16

what is it called when you choose someone based on ability and talent, rather than wealth, social class, or race

Answer 16

meritocracy

Question 17

conditions for a liver transplant

Answer 17

• alcoholically clear
• promise to the contract

Question 18

what can be transplanted

Answer 18

heart
lungs
pancreas
liver
small bowel
corneas
skin and bone

Question 19

where do most organ donations come from

Answer 19

people who have died while on a ventilator in a hospital ICU
(living donors - kidney and split liver)

Question 20

why is there decreased available donor organs

Answer 20

• increased road safety and medical information

Question 21

where are registrations made for organ donors

Answer 21

65% via driving license
13% through boots advantage card

Question 22

why do people need kidney transplants

Answer 22

• CKD
• kidney failure
  *normally been on CAPD first

Question 23

2 types of renal transplant

Answer 23

• cadaveric donor
• living donor

Question 24

cadaveric donor

Answer 24

• DCD: donor circulatory (cardiac) death, damage to other areas other than brain (distributed regionally)
• DBD: donor brain stem death, other organs in good state, distributed nationally

Question 25

what does the points-based system for allocation of donor organs include

Answer 25

• Waiting time
• HLA match and age combined
• Donor-recipient age difference
• Location of patient relative to donor
• Other HLA criteria

Question 26

survival rates for kidney transplant for deceased vs living donor

Answer 26

QoL and length significantly better when living donors used

Question 27

what conditions need to be met to have a kidney transplant

Answer 27

• they are well enough to withstand the effects of surgery
• the transplant has a relatively good chance of success
• the person is willing to comply with the recommended treatments required after the transplant – such as taking immunosuppressant medication and attending regular follow-up appointments

Question 28

exclusion criteria for a transplant

Answer 28

• ongoing infection (this will need to be treated first)
• heart disease
• liver failure
• cancer that has spread to several places in your body (metastatic cancer)
• AIDS (however, people who have HIV that is being effectively controlled with medication can often have a kidney transplant)

Question 29

2 types of living donors

Answer 29

• paired/pooled donation (PPD)
• altruistic donor chains (ADC)
• D1 TO R1
• D1 is a living donor to recipient 1, usually will know each other

Question 30

what is the new approach to organ and tissue donation in England

Answer 30

• From spring 2020 everybody will be considered willing to donate their organs after they die unless
  they have recorded a decision not to do so or are in an excluded group:
  <18 years old
  Lacking mental capacity
  People who have not been ordinarily resident in England for at least 12 months (for example tourists and short-term visitors)
• while the default position will change, there will always be a discussion involving the family, the specialist nurse, and clinicians, if donation is a possibility on someone’s death
• Wishes of the deceased will be respected unless family can produce compelling evidence to the contrary
• since faith often plays an important part in one’s organ donation decision, we have proposed measures
  to make sure people feel confident that their faith will be considered, if they sign up to be a donor”
• Faith leaders can be consulted to advise on how donation can go ahead whilst meeting faith obligations