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Organ Transplantation: Legal and Ethical Challenges (EdX Course)

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My university has recently joined EdX and is offering four courses starting February 2015. I have had the privilege of being selected as one of the instructors. I, along with Alicia Pérez Blanco (a skillful intensive care physician, wonderful colleague and sharp bioethicist), will be teaching a course on the ethical and legal challenges of organ transplantation. This has been possible partly because both of us, at different moments, could benefit from the extraordinary resources and the intellectual environment of the Petrie Flom and the Division of Medical Ethics at Harvard, where I stayed during my sabbatical year in 2011-2012.

The course will be delivered in Spanish (we will vocalize with utmost care and speak very, very slowly, it will sound almost like English…) but we will provide exercises and reading materials in both languages. We will cover a lot of the hot topics (DCD, death determination, organs’ conscription, nudges in organ donation, opting-out, markets of organs, death penalty and organ donation, transplantation tourism, among others) and (hopefully) will have a lot of fun (in spite of the nature of the topic). We are very excited and, I have to confess, a bit anxious about the final result. For more information please visit the EdX official announcement.

Are you my mother? The Spanish Supreme Court and surrogacy tourism

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In a divided opinion (4 dissenting judges out of 9) the Civil Chamber of the Spanish Supreme Court has ruled against the inscription in favor of the intending fathers of children who are born as a result of a surrogacy agreement formed abroad. This conflict is one more in the already long list of cases caused by the phenomenon of surrogacy tourism (there are currently 4 cases pending before the European Court of Human Rights) but I think it contains some interesting features that make worth delving into it (an updated and thorough report on the legal regime of surrogacy in EU Member States can be found here).

The case involved a married gay couple from Spain (Ramón and César) who traveled to California in 2008 circumventing the current ban on surrogate motherhood in Spain. The woman who acted as the surrogate gave birth to twins that were registered as sons of the intending couple in compliance with the rules and procedures established in Section 7630 of the California Family Code (it is unknown at this point whether Ramón or César donated the sperm and, if they did, who is the genetic father). Subsequently the couple attempted to register the US birth certificate in the Spanish Consular Registry in Los Angeles but the Consul rejected it arguing that the recognition of a foreign legal act should be made in compliance with Spanish Law, and that was not the case. As I said, in Spain, surrogacy agreements, irrespective of its commercial or non-commercial nature, are legally considered null and void and legal motherhood corresponds in any case to the gestational carrier (article 10 of the Assisted Reproduction Act of 2006). That decision ignited a complex legal battle that has now come to an end, although the couple has announced their intention to make an appeal before the Constitutional Court. Read More

Fetuses, Organs and Brain-Death

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One of the things that strikes me in the debate over whether a State has a sufficiently compelling interest in sustaining the physiological functions of a dead-brain pregnant woman in order to protect the life of the fetus, is that this very same rationale is not appealed to when we consider the many lives that are at stake when the deceased, or someone else — typically the next-of-kin — decides not to donate its organs after death. So, if the commitment of Texas — or any other State — with the protection of “human life” is sincere, if we can finally agree on that interest as being as compelling as to permit legislation restraining the woman’s right to refuse or terminate end-of-life care when she is pregnant, and their families’ right to bury or cremate their relative once it is pronounced legally dead, wouldn’t that rationale also legitimize the confiscation of dead-brain people in general in order to harvest their organs for the sake of saving the lives of others? I think coherence mandates so.

Actually, our reasons for such conscription in the case of organs’ harvesting are much more compelling than in the case of Marlise Muñoz if we take into account the fatal prognosis of the fetus, the experimental character of the continuation of pregnancy in a brain-dead woman, and the better expectations that we might nowadays have when we transplant organs.

This post is part of The Bioethics Program‘s Online Symposium on the Munoz and McMath cases. To see all symposium contributions, click here.

ART, lesbians and justice in the distribution of health care

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In the wake of our seemingly everlasting economic crisis, the Spanish health authorities have decided to exclude single women to access ART treatments – mainly artificial insemination- in the public health care system. “The lack of a male partner is not a medical problem”, has said Ana Mato, our Secretary of Health. Coming from a devout Catholic and extremely conservative politician, her remark, and ultimately, her Department’s policy, have been widely interpreted as another vindication of the idea that only traditional, i. e. heterosexual, families are suitable for rearing children. The spokeswomen of various feminist and lesbian NGOs have entered the public arena to denounce her lesbophobia.

The fact of the matter is that women in Spain, whether married to another woman or single, will still be authorized to be artificially inseminated (in some European countries such as France, Austria or Sweden, for instance, single women are excluded from medically assisted reproduction). Even the fertile, married heterosexual woman might still get artificial insemination – maybe she just wants to do things differently, for a change- although they will all have to bear the costs. The public health care system has, therefore, reconfigured ART as a pure medical remedy for a medical condition: infertility. The days of IA as an “alternative means of reproduction” for “alternative life-styles” are over. But with this new policy the demand made by economically disadvantaged lesbian couples willing to procreate finds an answer along the following lines: “go find a male”. A crude response if there is one. Read More

Organ Donation Euthanasia

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ELPAT (Ethical, Legal and Psycho-social aspects of Transplantation) is a division of the European Society of Organ Transplantation (ESOT). During the last weekend, the third ELPAT Conference has been held in Rotterdam. It has been a fascinating meeting that has gathered a group of prestigious scholars from many countries around the world to debate several ethical and legal topics involved in transplantation. Glenn Cohen has been one of the key speakers, along with Robert Truog, Alex Capron, Jennifer Radcliffe Richards and many others.

One of the issues which has been hotly debated is “organ donation euthanasia”, a practice that is currently being developed, albeit still marginally, in Belgium, where, as you know, euthanasia is legal since 2002. The issue which intrigued me more is the possibility of adding those organs to the common European pool for their eventual transplantation in a patient from a country in which euthanasia is still forbidden. In a way, our reluctance to such scenario seems to be analogous to the use of organs from executed prisoners. There are even more perplexing alternatives. As is well known, many British citizens travel abroad in order to get euthanasia (Switzerland is the main destination but also The Netherlands and Belgium). Should they also become eligible donors, would it be possible for British citizens to receive the organs? How can we handle that with the allegedly criminal behavior of the travel companions of the “suicide tourist”?

Euthanasia is not permitted in the US, although some States have enacted “aid in dying” statutes. I was wondering, first, if it might be possible in those States to be an “aided in dying organ donor”. What happens if the person who is prescribed the lethal dose requests it? Is it possible to arrange things in such a way that that request is feasible and honored (maybe the individual ingests the pills in an ICU)? Secondly, what about the organs? Should they remain in the State in which aid in dying has been legalized? What do you think?

Pool of Siloam in Tennessee? Brute luck in health care distribution

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I had recently come across this piece in the NYT. The first thing that came to my mind is the biblical story about the pool of Siloam, a tale that, with all due respect to believers, illustrates the unfair distribution of health, but mostly the unfair distribution of health care (if we take as “health care” the healing powers of the pool). I have tried to adapt the story, as told in the Bible (John 5, 1-8) to the crude reality of the Tennessee of our days, in which, as reported by the NYT, many of its citizens lack access to basic health care services and have to trust in a sort of “phony miracle”. My paraphrasing experiment gave the following result:

“Now there is in Tennessee a program ran by the State Government, called TennCare, which has a hotline for applications. In these lay a multitude of invalids–blind, lame, and paralyzed [waiting for the opening of the line;] [for the Governor went down at certain seasons and opens the line: whoever gets in first after the opening of the line was helped for whatever disease he had.] One man was there who had been an invalid for thirty-eight years. When people from the Legal Aid Society in Nashville saw him lying there and knew that he had already been there a long time they told him, “Do you want to be helped?” The sick man answered him, “Sir, I have no one to put me into the pool when the line is open, and while I am trying to go through another connects before me.” The people from Legal Aid said to him, “Get up, take up your bed, and dial.” And at once the man was healed, and he took up his bed and walked…”

[The original King James version’ of the Gospel can be read here]

Slipping Euthanasia in Belgium

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Happy New Year billofhealthfans!!

As you all know Belgium legalized euthanasia in 2002 following the path of The Netherlands. The legalization came in the midst of a huge controversy. The influence of the Catholic Church is significant in Belgium. You might recall that in 1990 King Balduino refused to sign an Act legalizing abortion, something unseen in the history of Belgium. The solution could not be more ingenious: the King resigned for a couple of days, the Act was signed by the Prime Minister, and then Parliament restored Balduino in his throne.

According to a recent survey in Flanders, euthanasia and assisted suicide in Belgium follows a classical pattern: cancer patient between 65 and 79 years of age. The cases in which the individual is not in the terminal stage of his illness and requests assistance in dying are rare. Nothing significantly deviant from what is going on in other jurisdictions in which aid in dying (in its various forms) is permitted. At least that was the trend until last December 14th… Read More

Should autopsies prevail over organ donation? A drama in three acts

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Picture the scene (I). Its 4 am, November 1st. 4 young girls in their Halloween costumes are being rushed to the hospital after the tragic stampede that took place minutes ago at the “Madrid Arena”, a huge disco in which more than 10,000 people gathered to listen to a super DJ which goes by the name of “Aoki”. You can read here the whole story. Three of the girls were pronounced dead on arrival, and the fourth, although not dead yet, suffers from devastating brain injury due to the anoxia. She is placed on a ventilator and the subsequent tests confirm the horrible prognosis. Her family, members of the ultraorthodox catholic sect known as “Opus Dei” (remember “The Da Vinci Code”?), agrees to the withdrawal of Belen’s life sustaining treatment and to donate her organs. Pedro Almodovar would not have written the script in a better fashion. But wait… Read More

Should the Government enforce “moral doping”?

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Forget Lance Armstrong for a second and think about “biomedical moral enhancement”, a proposal recently defended by Ingmar Persson and Julian Savulescu in Unfit for the Future. The Need for Moral Enhancement. In this book Persson and Savulescu claim that neither our current moral software – our morality of common sense as they call it- nor the institutions of liberal democracies are capable of coping with what they label as “ultimate harms”: the perils of terrorism and climate change which might efface human species from Earth.

The reason is that according to Persson and Savulescu we suffer from certain cognitive biases which prompt our moral blindness towards the suffering of those who are not near and dear. Also that we remain hooked to a causal conception of responsibility which gives us the perfect excuse for not blaming ourselves for our tiny – albeit jointly necessary- contributions to the causation of big disasters: from the emission of pollutants to the consumption of red meat. In a nutshell: Evolution did not equip us with the sense of justice and altruism that global poverty and the environmental destruction demand. The solution? Read More

Disability, fetuses and discrimination

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By Pablo de Lora

Is “eugenic abortion” better described as discrimination against the disabled? That is one of the hottest issues currently debated in Spain (yes, we sometimes have some spare time to avoid discussing our financial crisis), now that the conservative party is attempting to amend our latest legislation on abortion (2010).

Down España, among many other advocacy groups for the disabled, is encouraging the Spanish Government to enforce the Convention on the Rights of Persons With Disabilities (2006) which states (article 10) that “every human being has the inherent right to life” and that States “shall take all necessary measures to ensure its effective enjoyment by persons with disabilities on an equal basis with others”. In support of their position, these groups refer to the recent Recommendations made by the Committee on the Rights of Persons with Disabilities as regards to the Report submitted by Spain (Sixth Session, 19-23 September 2011). It is worth quoting the Committee’s own phrasing: “[it is recommended] that the State Party [Spain] abolish the distinction made in Act 2/2010 in the period allowed under law within which a pregnancy can be terminated based solely on disability” (the full text can be found here).

Interestingly enough, in the United States, far from relying on the Convention to fuel their cause, some pro-life groups despise it as a pro-choice instrument and are urging their representatives not to ratify it (see here and here).

Very broadly, since 2010, a woman in Spain may abort in the first 14 weeks of pregnancy (with the requirement of receiving advice and waiting for three days to mature her decision). Beyond that term, and up to week 22, terminating a pregnancy is legally permitted either if the mother’s life or health is at serious risk or the fetus has been diagnosed with some “anomaly”. When the disease is life-threatening (think, for instance, anencephalic fetuses or the fatal condition known as “bilateral renal agenesis”) or extremely severe and incurable, the abortion might be performed even after the 22 weeks threshold. So, as opposed to a “normal fetus”, a “disabled fetus” – so to speak – is not given the same opportunity to be safe after 14 weeks of gestation. Is that a form of morally impermissible discrimination? I think not. Read More