Thursday 7 August 2008

Proposal to widen a patient’s “best interests…beyond the purely medical”

Alarm bells began ringing for me earlier this week when The Times reported that Chris Rudge, the new National Clinical Director for Transplantation, favours defining a patient’s “best interests” more widely to encompass aspects “beyond the purely medical” with a view to honouring a patient’s wish that his or her organs can be used to help others.

The Times says: “He believes that broadening the definition would … enable a critical care doctor to keep a patient alive for an hour or two longer, even when hope of recovery was gone, to enable organs to be collected”

And Mr Rudge observes: “We may need to seek legal advice. The Mental Capacity Act doesn’t define the phrase clearly.” Exactly, Mr Rudge. And that’s when the alarm bells got pretty deafening.

As SPUC’s adviser on bioethics, Dr Greg Pike, put it to me: “I think one of the concerns about too widely construing best interests is that there is currently a strong drive to implement living wills in practice and in legislation. One of the key problems with living wills is their application in circumstances where it would obviously be contrary to best medical practice enacted in the best interests of the patient. It is no surprise that the pro-euthanasia people are very interested in living wills because they see an opportunity to use the denial of treatment - that would be encouraged as the content of a living will - as a form of soft euthanasia.”

Kimberley Pfeiffer, a research officer at Southern Cross Bioethics Institute, offers another perspective on Chris Rudge’s comments: “This article suggests changes should be made to the life support laws so that organ donors’ wish to donate their organs can be granted – because removing organs for transplant may be in a donor’s ‘best interests’.

“The central issue here is - is it in the best interests of an organ donor to have their organs donated when they die? Organ donation is a wonderful gift of life to another, but a gift must be freely given (donated) and is only ‘useful’ if a matched transplant recipient is willing and able to receive the donation.

“It is bizarre to suggest that the giving of organs will benefit the giver so much that it is essential - in their best interest - when they are dead. The needy recipient of an organ is the only one who benefits from this type of donation. If the donor were living, they too may benefit because they might find joy in the service they have done for the other person (gift giving) but this is a secondary good and is a side effect of the primary good (the recipient’s gift). The family of a dead organ donor may find joy in the gift their deceased loved one gave to an organ transplant recipient, but this too is secondary to the primary recipient’s benefit. This backward concept of ‘gift-giving’ seems to be a self-interested perspective of altruism, not the Judaeo-Christian altruism which holds a concern for others for the sake of themselves.

“Chris Rudge suggests that donors' best interests should be ‘drawn more widely, to include honouring a wish that his or her organs should be used to help others’. Is honouring a dead or dying person’s wishes the same as serving the donor’s best interests? Practically speaking, these changes could lead to a donor being held on life-support for an indefinite period of time until organ transplantation can be arranged. But what can be said about this state of limbo between life and death? Are they physically dead if brain death has been declared – yet have their living organs preserved?

“It should be the dying donor’s best interest to be honoured and respected in life and death because of their inherent human dignity. And if this is contradicted by manipulation or exploitation of the dead person’s body in order to harvest organs, then it is not in the best interest of the donor to have their organs donated. It is worrying that this ‘best interest’ language could be used to trade-off respect for the dead and harbour living ‘dead’ cadavers in order to increase organ donation transactions.”

Bernard Farrell-Roberts of the Maryvale Institute, whose serious concerns on presumed consent for organ donation I blogged on last week, also told me he’s worried: “Alarm bells rang when I read ‘I would like to see a recognition that a patient’s best interests can encompass aspects beyond the purely medical’ Another slippery slope I fear. I … understand what Chris Rudge is trying to achieve, but I believe a change such as this would be extremely dangerous. A move away from ‘purely medical’ would open a real can of worms.

“Living wills, euthanasia (Holland springs to mind here as having something similar), etc. would all be made much easier to introduce. Abortions too up to full term, and even infant killings could be justified under such a policy. Who would judge the global best interest of a patient? A doctor, a panel ... ? And would anything written or expressed then become legally the patient's best interest, or even legally binding, even though in reality it isn't? At a time when the state wishes to take control over our bodies [see my earlier post] and has made consistent progress in this direction for years now, it would be so easy for them to further their aims if this were to become the norm. I feel that Chris Rudge is thinking one-dimensionally at present, and doesn't seem to have considered the broader picture yet.”