Located on this page are my previously written views on the subjects of brain death, cloning, capitation and physician assisted suicide.
| The question "when is death, death?" may at first appear as a ridiculous expression. However, in these times of organ transplant and autonomous rejection of futile life support, the definition of death has become extremely important from both legal and ethical perspectives. The standard criterion for death through the ages has been the permanent cessation of both heart beat and respiration. With the advent of technical support of the heart and lung function, it is possible to continue circulation and respiration for long periods of time in patients who would otherwise have no heart beat or respiration. The question arises, are these patients on life support really dead? In order to clarify the ambiguity of death in these cases and also to provide a legal and ethical basis for the retrieval of useful organs for transplant, there has been developed a "whole brain death" as the necessary criterion for death. That is, once it can be established that the entire brain has permanent cessation of function, that individual may be pronounced as dead. The explanation is that if the whole brain is permanently and completely destroyed, the respiration ceases and circulation will soon cease and thus the standard criterion will also be met. If the patient is "whole brain dead" and is thus legally dead then useful organ retieval can be carried out while the circulation and respiration is still maintained without considering the organs are being removed from a living person. Also, if the patient is "whole brain dead" then the patient can logically be disconnected from life support technology since the patient is now dead. | There has been discussed another criterion for death. This
criterion is based on the concept that if an individual is permanently
unconscious (such as in a patient in a "permanent vegetative state"--permanently
unconscious but having the ability to maintain breathing and circulation)
or never has and never will attain consciousness (such as in a anencephalic
baby--no brain except for brain stem centers to breath and have a heart
beat for a while) that individual will never be a "person" and therefore
can be considered dead.
There are numerous arguments for and against each criterion. Therefore, the answer to the question "when is death, death?" is one which can and is being debated. But the debate should not involve only the scientists and philosophers or politicians. Because of the significance of how death is defined in affecting organ retrieval or allocation of other resources, all of society..that means all of us.. should participate in expressing our personal understanding of what is death and how we think it should be defined. As a beginning, I will start a polling question to see what criterion the visitors to this site think would be a most appropriate. (April 13, 1997) Click here to go to Polling Question For further discussion click to go to "Brain Death: Is That Dead Enough?" |
| It was recently announced by a team of scientists at the
Roslin Institute near Edinburgh, Scotland, that for the first time an adult
mammal has been successfully cloned by anyone. The procedure is simple
enough that it would be easy for a human being now to be cloned.
This means that the genetic material from a person could be easily obtained and inserted into an ovum from which the genetic material has been removed and that ovum now would behave like a fertilized egg and could develop, when implanted into a womb, into a person with the exact genetic makeup of the person from which the material was obtained--a clone. No fertilization by a male with different genetic makeup would be necessary. The issues are whether such cloning of humans should be allowed and if so, what are the biologic and ethical implications of such cloning. |
Off hand, it seems that there must be great ethical implications,
however, I wonder if this is more psychological because of the uniqueness
of this manipulation of human reproduction. The ability for humans to create
humans without the normal process of fertilization and to create copies
virtually at will has almost a sci-fi or better yet, a Frankenstein odor.
We may look at this kind of biologic autonomy as something "against nature"
and the results as something different than, for example, spontaneous single
ovum twins. Maybe human cloning would, in practice, have minimal ethical
implications.
One use of human cloning that I think would be immoral would be to create the clone primarily for organ use and then not respect it and treat it as a individual human being with all the rights of any other human including the right of informed consent. (February 27, 1997) In the past year since I originally posted my comments above, there has been a lot written by our visitors on this topic, "Cloning of Humans: Is it Ethical? Should it be Done?. Much of the response has been an expression of fear about the motivations and consequences of human cloning. It appears that much of the concern has been generated by irrational and unscientific expositions by the popular media. In order to get a better perspective of how the media has handled the issue of human cloning, I would suggest the visitor read "Bad Copies: How Popular Media Represent Cloning as an Ethical Problem" by Patrick D. Hopkins, Hastings Center Report March-April 1998. (May 22, 1998) |
| Capitation is a form of payment to health care providers
by health maintenance organizations (HMOs) and insurance companies. Unlike
fee-for-service where the patient or insurance company pays the health
care provider a fee based on what services the provider rendered, capitation
pays the provider a certain amount of money each month for each of the
provider's patients regardless of the amount of care rendered. In the case
of physicians, the HMO expects that the provider to pay out from this amount
visits, tests, treatments, drugs and hospitalizations. Essentially what
is left over represents the monies the provider can keep for overhead and
profit. There also may be incentive payments to those who meet certain
utilization targets. The details of capitation are a bit more complicated
but this is the general idea.
There is an initiative on the ballot in the State of Oregon to be voted on by the residents November 5 1996 to ban capitation. The ethical argument against capitation is that capitation rewards doctors for providing less care and therefore may lead to management that is against the best interests of the patient but favoring the financial advancement of the physician and the HMO. On the other hand, fee-for-service was associated with health care providers rendering services which were at times excessive and not needed, |
subjecting patients to unnecessary risks and raising the
cost of medical care but at the same time favoring the physician financially.
Also, with fee-for-service less attention was given to determining which
treatments produced the better outcome relative to the costs involved.
Societal issues, such as concern for the utilization of scarce resources
were also not frequently evaluated.
As with the contrast between "managed care" and "private care", the ethics of capitation vs fee-for-service is dependent on what are the ethical goals of the HMO and the providers. If the primary goal is always towards doing the very best for the patient within the limits of available resources with the lesser concern for the "bottom line" profit then both forms of payment can co-exist. It is when the patient is taken for granted as a secondary issue where the attention is given to salary and investor interests that both methods of payment are ethically faulted. (September 1, 1996) Addendum (November 10, 1996): The voters of Oregon rejected the ballot initiative to ban capitation. |
| The U.S. 9th Circuit Court of Appeals ruled 8 to 3 that the
Washington State law, which makes physician-assisted suicide of competent,
terminally-ill adults a felony, represents a denial of due process of law
under the 14th Amendment to the U.S. Consititution. This ruling, despite
poll evidence of general public acceptance of such physician-assisted suicide,
does raise some rather disconcerting possibilities, if sustained by the
Supreme Court.
For example, Robert Beezer, one of the dissenting judges, wrote about reexamining "the historic presumption that all human lives are equally and intrinsically valuable." He continued, "Viewed most charitably, this reexamination may be interpreted as our struggle with the question whether we as a society are willing to excuse the terminally ill for deciding that their lives are no longer worth living. Viewed less charitably, the reexamination may be interpreted as a mere rationalization for housecleaning, cost-cutting and burden-shifting--a way to get rid of those whose lives we deem worthless." |
Additionally, one can also consider that this decision,
if sustained, may encourage doctors and patients to look upon choosing
death as a preferred way of dealing with serious and terminal illness rather
than attempting alternatives. These possibilities could be included in
a "slippery-slope" argument. That is, this ruling might lead to further
legal rulings which would find for termination of life in other groups
beyond the competent terminally ill such as the incompetent, the mentally
defective, the severly handicapped, the social misfits and others.
Physician-assisted suicide is known to have been going on without fanfare and without legal support for many, many years. I wonder if it wouldn't be better to leave this matter as it has been, on a case-by-case basis between physician and patient, rather than spotlight and promote this action with court approbation? Any comments? (March 16, 1996) |