Adam Omelianchuk

Solid organ xenotransplantation may have the potential to help address the shortage of organs for transplantation. There is concern, however, that a novel zoonotic disease could be transmitted from the source organ to the human recipient, and then from the recipient to others. Theoretically, this could result in an epidemic or pandemic. Because of this potential risk, it has been argued that collective consent is required. Our goal is to critically evaluate the claim that collective consent is necessary for xenotransplantation to be ethically permissible. We argue that collective consent is not required and highlight the important roles of public engagement and due diligence in xenotransplant research moving forward.

The articles by Bernat, Busch, Dudzinski et al., and Derse illustrate the difficulties with reconciling normothermic regional perfusion (NRP) with the dead donor rule (DDR) (Bernat forthcoming; Busch forthcoming; Dudzinski et al. forthcoming; Derse forthcoming). I appreciate their arguments because they help illuminate the issues that generate a dilemma: either reject NRP or the DDR. I am convinced that the dilemma is unavoidable because the procurement team is involved with determining and securing the death of the donor when circulation restarts. Evidence for this is found in the reasons and recommendations given for blocking blood flow to the brain, both of which betray a lack of certainty over the donor’s vital status. The surgical activity in NRP therefore conflicts with the values the DDR protects: respect for the donor’s life and avoidance of conflict of interest.

Looking to Scripture through the eyes of contemporary medical experience, I analyze the meaning of the criteria used for determining death, specifically in the light of Jesus’ final moments and the resurrection of the Shunammite’s son in 2 Kings, chapter 4. I argue that four theses are consistent with, and informed by, these passages that can help guide Christian belief and decision-making about how death is determined in the clinical context: (1) death is neither permanent nor irreversible; (2) something like the “brain dead” state is, at best, a confounding state that requires one to “pace and pray” or let go; (3) that the case for determining death by neurologic criteria depends on the “working togetherness” of the body's parts for the sake of impacting its environment; and (4) that the practice of neurologically-based death determination is a response to the problem of disaggregation of the human form into its organ systems that modern critical care medicine makes possible. I end with advice about how Christians might approach the debates over the law and practice even if they cannot come to a consensus.

In transplant medicine, the use of normothermic regional perfusion (NRP) in donation after circulatory determination of death raises ethical difficulties. NRP is objectionable because it restores the donor's circulation, thus invalidating a death declaration based on the permanent cessation of circulation. NRP's defenders respond with arguments that are tortuous and factually inaccurate and depend on introducing extraneous concepts into the law. However, results comparable to NRP's—more and higher‐quality organs and more efficient allocation—can be achieved by removing organs from deceased donors and using normothermic machine perfusion (NMP) to support the organs outside the body, without jeopardizing confidence in transplantation's legal and ethical foundations. Given the controversy that NRP generates and the convoluted justifications made for it, we recommend a prudential approach we call “ethical parsimony,” which holds that, in the choice between competing means of achieving a result, the ethically simpler one is to be preferred. This approach makes clear that policy‐makers should favor NMP over NRP.

Preclinical xenotransplantation research using genetically engineered pigs has begun to show some promising results and could one day offer a scalable means of addressing organ shortage. While it is a fundamental tenet of ethical human subject research that participants have a right to withdraw from research once enrolled, several scholars have argued that the right to withdraw from xenotransplant research should be suspended because of the public health risks posed by xenozoonotic transmission. Here, we present a comprehensive critical evaluation of the claim that xenotransplant recipients should be required to waive their right to withdraw from lifelong biosurveillance. We conclude that if xenotransplantation requires participants to waive their right to withdraw, then clinical trials may not be justifiable, given the ethical and legal obstacles involved with doing so. Consequently, if clinical trials are permitted with a right to withdraw, then they may pose a significant public health risk.

Some of the most difficult consultations for an ethics consultant to resolve are those in which the patient is ready to leave the acute-care setting, but the patient or family refuses the plan, or the plan is impeded by deficiencies in the healthcare system. Either way, the patient is “stuck” in the hospital and the ethics consultant is called to help get the patient “unstuck.” These encounters, which we call “complex discharges,” are beset with tensions between the interests of the institution and the interests of the patient as well as tensions within the ethics consultant whose commitments are shaped both by the values of the organization and the values of their own profession. The clinical ethics literature on this topic is limited and provides little guidance. What is needed is guidance for consultants operating at the bedside and for those participating at a higher organizational level. To fill this gap, we offer guidance for facilitating a fair process designed to resolve the conflict without resorting to coercive legal measures. We reflect on three cases to argue that the approach of the consultant is generally one of mediation in these types of disputes. For patients who lack decision making capacity and lack a surrogate decision maker, we recommend the creation of a complex discharge committee within the organization so that ethics consultants can properly discharge their duties to assist patients who are unable to advocate for themselves through a fair and transparent process.

In a recent article Steven Cowan defended the claim that female subordination and male authority are merely functional differences. Drawing insights from Natural Law, I argue that complementarianism typically speaks of these as proper functions of male and female designs, thus making men and women metaphysically unequal in being. Furthermore, I maintain that the function "serving as a means to an end" is less valuable than the function "having the authority to direct the end." Hence, Cowan fails to defeat the objection that the claim that women are equal to men in being, but subordinate in role is incoherent.

It is envisioned that one day xenotransplantation will bring about a future where transplantable organs can be safely and efficiently grown in transgenic pigs to help meet the global organ shortage. While recent advances have brought this future closer, worries remain about whether it will be beneficial overall. The unique challenges and risks posed to humans that arise from transplanting across the species barrier, in addition to the costs borne by non-human animals, has led some to question the value of xenotransplantation altogether. In response, we defend the value of xenotransplantation research, because it can satisfy stringent welfare conditions on the permissibility of animal research and use. Along the way, we respond to the alleged concerns, and conclude that they do not currently warrant a cessation or a curtailing of xenotransplantation research.

Smith argues that death caused by transplant surgery will not harm permanently unconscious patients, because they will not suffer a setback to their interests in the context of donation. Therefore, so the argument goes, the dead donor rule can be abandoned, because requiring a death declaration before procurement does not protect any relevant interest from being thwarted. Smith contends that a virtue of his argument is that it avoids the controversies over defining and determining death. I argue that it does not and explain why no change in policy is justified.

Joshua Mezrich is a practicing transplant surgeon who draws on his experiences, and those of his patients, to provide a "here's where we're at" moment in the story of transplant medicine. In so doing, he explains what it is like to practice while telling the stories of his patients, donors, and the pioneering surgeons who persisted in the face of failure to make what Mezrich does a work of healing. Written for a popular audience, When Death Becomes Life is perhaps the most accessible work yet on the modern history of organ transplantation and what the current "standard of care" actually looks like. Indeed, it rounds out a "trinity" of quality books about the transplant experience, this one from the surgeon's...

The dead donor rule (DDR) prohibits retrieval protocols that would be lethal to the donor. Some argue that compliance with it can be maintained by satisfying the requirements of double‐effect reasoning (DER). If successful, one could support organ donation without reference to the definition of death while being faithful to an ethic that prohibits intentionally killing innocent human life. On the contrary, I argue that DER cannot make lethal organ donation compatible with the DDR, because there are plausible ways it fails DER's requirements. A key takeaway is that the theories of intention and proportionality assumed in DER matter for its plausibility as a constraint on practical reasoning.

In ‘Dilemma for Appeals to the Moral Significance of Birth’, we argued that a dilemma is faced by those who believe that birth is the event at which infanticide is ruled out. Those who reject the moral permissibility of infanticide by appeal to the moral significance of birth must either accept the moral permissibility of a late-term abortion for a non-therapeutic reason or not. If they accept it, they need to account for the strong intuition that her decision is wrong as well as deny the underlying normative principle that killing a viable fetus requires good reason, and not wanting to care for the child when the child could be easily placed for adoption is not a good enough reason to abort. If they reject the moral permissibility of the late-term abortion, they need to explain why her decision is wrong. Doing so, however, will undermine their own project of denying infanticide by appeal to birth. Walter Veit argues that the dilemma relies too much on intuition and does not live up to biological continuity. We explain why his criticisms are unconvincing.

There are increasing calls for rejecting the ‘dead donor’ rule and permitting ‘organ donation euthanasia’ in organ transplantation. I argue that the fundamental problem with this proposal is that it would bestow more worth on the organs than the donor who has them. What is at stake is the basis of human equality, which, I argue, should be based on an ineliminable dignity that each of us has in virtue of having a rational nature. To allow mortal harvesting would be to make our worth contingent upon variable quality of life of judgments that can only be based on properties that come in degrees. Thus, rejecting the ‘dead donor’ rule comes at the expense of our egalitarian principles with respect to the value each individual human life has in relation to the protections against killing.

Giubilini and Minerva argue that the permissibility of abortion entails the permissibility of infanticide. Proponents of what we refer to as the Birth Strategy claim that there is a morally significant difference brought about at birth that accounts for our strong intuition that killing newborns is morally impermissible. We argue that strategy does not account for the moral intuition that late-term, non-therapeutic abortions are morally impermissible. Advocates of the Birth Strategy must either judge non-therapeutic abortions as impermissible in the later stages of pregnancy or conclude that they are permissible on the basis of premises that are far less intuitively plausible than the opposite conclusion and its supporting premises.

In this paper, I introduce the ideas to be discussed in the articles of this journal with reference to an imaginary case involving a pregnant woman declared dead on the basis of neurological criteria. I highlight the fact that although these ideas have proved useful for advancing certain claims in bioethical debates, their implications are not always well understood and may complicate our arguments. The ideas to be discussed are an ethic internal to the profession of medicine; the difference between killing and letting die; the organism as a whole; and the “lives” and interests of the dead.

The biophilosophic justification for the idea that “brain death” is death needs to support two claims: that what dies in human death is a human organism, not merely a psychological entity distinct from it; that total brain failure signifies the end of the human organism as a whole. Defenders of brain death typically assume without argument that the first claim is true and argue for the second by defending the “integrative unity” rationale. Yet the integrative unity rationale has fallen on hard times. In this article, I give reasons for why we should think of ourselves as organisms, and why the “fundamental work” rationale put forward by the 2008 President’s Council is better than the integrative unity rationale, despite persistent objections to it.

Although much has been written on the dead-donor rule in the last twenty-five years, scant attention has been paid to how it should be formulated, what its rationale is, and why it was accepted. The DDR can be formulated in terms of either a Don’t Kill rule or a Death Requirement, the former being historically rooted in absolutist ethics and the latter in a prudential policy aimed at securing trust in the transplant enterprise. I contend that the moral core of the rule is the Don’t Kill rule, not the Death Requirement. This, I show, is how the DDR was understood by the transplanters of the 1960s, who sought to conform their practices to their ethics—unlike today’s critics of the DDR, who rethink their ethics in a question-begging fashion to accommodate their practices. A better discussion of the ethics of killing is needed to move the debate forward.

Walter Sinnott-Armstrong and Franklin G Miller recently argued that the wrongness of killing is best explained by the harm that comes to the victim, and that ‘total disability’ best explains the nature of this harm. Hence, killing patients who are already totally disabled is not wrong. I maintain that their notion of total disability is ambiguous and that they beg the question with respect to whether there are abilities left over that remain relevant for the goods of personhood and human worth. If these goods remain, then something more is lost in death than in ‘total disability,’ and their explanation of what makes killing wrong comes up short. But if total disability is equivalent with death, then their argument is an interesting one.