Integridade da pessoa: fundamentação ética para a doação de órgãos e tecidos para transplantação

PT. A noção de “pessoa”, pensada a partir do legado antropológico e filosófico do ocidente, afirma-se como uma unidade corporal e espiritual que determina a sua singularidade no seio da comunidade. A “pessoa” assim perspectivada assume uma importância destacada na reflexão ética das aplicações científicas de artificialização da vida humana. Muito concretamente, a noção de “pessoa” deve contribuir para a fundamentação ética das terapêuticas de transplantação. A transplantação representa um dos mais notáveis avanços da medicina do século XX e com um impacto incontornável na prestação de cuidados de saúde. Os transplantes são considerados o tratamento mais eficaz para patologias crónicas que afectam a funcionalidade de determinados órgãos vitais, restituindo ao doente uma melhoria na sua saúde e/ou qualidade de vida. O sucesso desta terapêutica é, no entanto, condicionado pela disponibilização de pessoas que queiram fazer dádiva de si, do seu próprio corpo, para o bem-estar de outrem. Deste modo, a doação, realizada após a morte da pessoa ou ainda em vida, enfrenta vários desafios técnicos, mas também, e principalmente, desafios éticos. A nossa dissertação centra-se na reflexão ética da doação de órgãos e tecidos para transplante e no impacto que a dádiva de uma parte específica do corpo pode comportar na noção de “pessoa”. Deste modo, ao mesmo tempo em que se procura promover a doação de órgãos para aumentar o número de transplantes, também se vão delineando estratégias para salvaguardar a integridade corporal do dador e a eminente dignidade que o constitui como pessoa. As estratégias consistem fundamentalmente num diálogo entre o princípio de autonomia, que determina a singularidade da pessoa, e o princípio de solidariedade, que é desencadeado pela relação com o outro. Estes princípios éticos, articulados e uma vez cumpridos, são os alicerces da doação voluntária e altruísta, e impedem a instrumentalização e exploração da pessoa dadora. EN. The western anthropological and philosophical notion of ‘person’ emerges as a corporal and spiritual entity, which determines his singularity at the level of community. From this perspective, the notion of ‘person’ holds an important place in ethical considerations concerning the scientific applications of artificial manipulation of human life. More precisely, the notion of ‘person’ must contribute towards the ethical basis of transplant therapeutics. The transplantation of human organs and tissues is one of the most notable advances in twentieth century medicine, and, as such, has had an unquestionable impact on health care practice. Transplants are now seen as the best treatment for chronic diseases that impair the function of some vital organs, improving the patient health and/or quality of life. The success of organs transplantation depends entirely upon the altruism of people giving their bodies for the well-being of others. Organ donation, performed during life or after death, raises not only technical, but also mainly ethical challenges. This work focuses on the ethical considerations associated with human organs and tissue donation for transplantation and on the impact that a donation of an organ has on the notion of ‘person’. At the same time that one recognizes the need to increase the number of organs for transplanting, there is also the need to preserve the donor’s corporal integrity and his eminent dignity. Strategies to preserve the donor’s corporal integrity and dignity must take into consideration the dialogue between the principle of autonomy, which is characterized by the singular entity, and the principle of solidarity, born out of one’s relationship with those around you. These ethical principles, once engaged and fulfilled, are the bases of a voluntary and altruistic donation, and prevent the donor from becoming a mere instrument and being exploited as such

Integridade da pessoa : fundamentação ética para a doação de órgãos e tecidos para a transplantação

Tese de mestrado, Bioética, Faculdade de Medicina, Universidade de Lisboa, 2009A noção de pessoa , pensada a partir do legado antropológico e filosófico do ocidente, afirma-se como uma unidade corporal e espiritual que determina a sua singularidade no seio da comunidade. A pessoa assim perspectivada assume uma importância destacada na reflexão ética das aplicações científicas de artificialização da vida humana. Muito concretamente, a noção de pessoa deve contribuir para a fundamentação ética das terapêuticas de transplantação. A transplantação representa um dos mais notáveis avanços da medicina do século XX e com um impacto incontornável na prestação de cuidados de saúde. Os transplantes são considerados o tratamento mais eficaz para patologias crónicas que afectam a funcionalidade de determinados órgãos vitais, restituindo ao doente uma melhoria na sua saúde e/ou qualidade de vida. O sucesso desta terapêutica é, no entanto, condicionado pela disponibilização de pessoas que queiram fazer dádiva de si, do seu próprio corpo, para o bem-estar de outrem. Deste modo, a doação, realizada após a morte da pessoa ou ainda em vida, enfrenta vários desafios técnicos, mas também, e principalmente, desafios éticos. A nossa dissertação centra-se na reflexão ética da doação de órgãos e tecidos para transplante e no impacto que a dádiva de uma parte específica do corpo pode comportar na noção de pessoa . Deste modo, ao mesmo tempo em que se procura promover a doação de órgãos para aumentar o número de transplantes, também se vão delineando estratégias para salvaguardar a integridade corporal do dador e a eminente dignidade que o constitui como pessoa. As estratégias consistem fundamentalmente num diálogo entre o princípio de autonomia, que determina a singularidade da pessoa, e o princípio de solidariedade, que é desencadeado pela relação com o outro. Estes princípios éticos, articulados e uma vez cumpridos, são os alicerces da doação voluntária e altruísThe western anthropological and philosophical notion of person' emerges as a corporal and spiritual entity, which determines his singularity at the level of community. From this perspective, the notion of person' holds an important place in ethical considerations concerning the scientific applications of artificial manipulation of human life. More precisely, the notion of person' must contribute towards the ethical basis of transplant therapeutics. The transplantation of human organs and tissues is one of the most notable advances in twentieth century medicine, and, as such, has had an unquestionable impact on health care practice. Transplants are now seen as the best treatment for chronic diseases that impair the function of some vital organs, improving the patient health and/or quality of life. The success of organs transplantation depends entirely upon the altruism of people giving their bodies for the well-being of others. Organ donation, performed during life or after death, raises not only technical, but also mainly ethical challenges. This work focuses on the ethical considerations associated with human organs and tissue donation for transplantation and on the impact that a donation of an organ has on the notion of person'. At the same time that one recognizes the need to increase the number of organs for transplanting, there is also the need to preserve the donor's corporal integrity and his eminent dignity. Strategies to preserve the donor's corporal integrity and dignity must take into consideration the dialogue between the principle of autonomy, which is characterized by the singular entity, and the principle of solidarity, born out of one's relationship with those around you. These ethical principles, once engaged and fulfilled, are the bases of a voluntary and altruistic donation, and prevent the donor from becoming a mere instrument and being exploited as such

Considerações a Propósito do Testamento Vital

UID/HIS/04666/2013publishersversionpublishe

Mortality from gastrointestinal congenital anomalies at 264 hospitals in 74 low-income, middle-income, and high-income countries: a multicentre, international, prospective cohort study

Background: Congenital anomalies are the fifth leading cause of mortality in children younger than 5 years globally. Many gastrointestinal congenital anomalies are fatal without timely access to neonatal surgical care, but few studies have been done on these conditions in low-income and middle-income countries (LMICs). We compared outcomes of the seven most common gastrointestinal congenital anomalies in low-income, middle-income, and high-income countries globally, and identified factors associated with mortality. // Methods: We did a multicentre, international prospective cohort study of patients younger than 16 years, presenting to hospital for the first time with oesophageal atresia, congenital diaphragmatic hernia, intestinal atresia, gastroschisis, exomphalos, anorectal malformation, and Hirschsprung's disease. Recruitment was of consecutive patients for a minimum of 1 month between October, 2018, and April, 2019. We collected data on patient demographics, clinical status, interventions, and outcomes using the REDCap platform. Patients were followed up for 30 days after primary intervention, or 30 days after admission if they did not receive an intervention. The primary outcome was all-cause, in-hospital mortality for all conditions combined and each condition individually, stratified by country income status. We did a complete case analysis. // Findings: We included 3849 patients with 3975 study conditions (560 with oesophageal atresia, 448 with congenital diaphragmatic hernia, 681 with intestinal atresia, 453 with gastroschisis, 325 with exomphalos, 991 with anorectal malformation, and 517 with Hirschsprung's disease) from 264 hospitals (89 in high-income countries, 166 in middle-income countries, and nine in low-income countries) in 74 countries. Of the 3849 patients, 2231 (58·0%) were male. Median gestational age at birth was 38 weeks (IQR 36–39) and median bodyweight at presentation was 2·8 kg (2·3–3·3). Mortality among all patients was 37 (39·8%) of 93 in low-income countries, 583 (20·4%) of 2860 in middle-income countries, and 50 (5·6%) of 896 in high-income countries (p<0·0001 between all country income groups). Gastroschisis had the greatest difference in mortality between country income strata (nine [90·0%] of ten in low-income countries, 97 [31·9%] of 304 in middle-income countries, and two [1·4%] of 139 in high-income countries; p≤0·0001 between all country income groups). Factors significantly associated with higher mortality for all patients combined included country income status (low-income vs high-income countries, risk ratio 2·78 [95% CI 1·88–4·11], p<0·0001; middle-income vs high-income countries, 2·11 [1·59–2·79], p<0·0001), sepsis at presentation (1·20 [1·04–1·40], p=0·016), higher American Society of Anesthesiologists (ASA) score at primary intervention (ASA 4–5 vs ASA 1–2, 1·82 [1·40–2·35], p<0·0001; ASA 3 vs ASA 1–2, 1·58, [1·30–1·92], p<0·0001]), surgical safety checklist not used (1·39 [1·02–1·90], p=0·035), and ventilation or parenteral nutrition unavailable when needed (ventilation 1·96, [1·41–2·71], p=0·0001; parenteral nutrition 1·35, [1·05–1·74], p=0·018). Administration of parenteral nutrition (0·61, [0·47–0·79], p=0·0002) and use of a peripherally inserted central catheter (0·65 [0·50–0·86], p=0·0024) or percutaneous central line (0·69 [0·48–1·00], p=0·049) were associated with lower mortality. // Interpretation: Unacceptable differences in mortality exist for gastrointestinal congenital anomalies between low-income, middle-income, and high-income countries. Improving access to quality neonatal surgical care in LMICs will be vital to achieve Sustainable Development Goal 3.2 of ending preventable deaths in neonates and children younger than 5 years by 2030

Mortality from gastrointestinal congenital anomalies at 264 hospitals in 74 low-income, middle-income, and high-income countries: a multicentre, international, prospective cohort study

Summary Background Congenital anomalies are the fifth leading cause of mortality in children younger than 5 years globally. Many gastrointestinal congenital anomalies are fatal without timely access to neonatal surgical care, but few studies have been done on these conditions in low-income and middle-income countries (LMICs). We compared outcomes of the seven most common gastrointestinal congenital anomalies in low-income, middle-income, and high-income countries globally, and identified factors associated with mortality. Methods We did a multicentre, international prospective cohort study of patients younger than 16 years, presenting to hospital for the first time with oesophageal atresia, congenital diaphragmatic hernia, intestinal atresia, gastroschisis, exomphalos, anorectal malformation, and Hirschsprung’s disease. Recruitment was of consecutive patients for a minimum of 1 month between October, 2018, and April, 2019. We collected data on patient demographics, clinical status, interventions, and outcomes using the REDCap platform. Patients were followed up for 30 days after primary intervention, or 30 days after admission if they did not receive an intervention. The primary outcome was all-cause, in-hospital mortality for all conditions combined and each condition individually, stratified by country income status. We did a complete case analysis. Findings We included 3849 patients with 3975 study conditions (560 with oesophageal atresia, 448 with congenital diaphragmatic hernia, 681 with intestinal atresia, 453 with gastroschisis, 325 with exomphalos, 991 with anorectal malformation, and 517 with Hirschsprung’s disease) from 264 hospitals (89 in high-income countries, 166 in middleincome countries, and nine in low-income countries) in 74 countries. Of the 3849 patients, 2231 (58·0%) were male. Median gestational age at birth was 38 weeks (IQR 36–39) and median bodyweight at presentation was 2·8 kg (2·3–3·3). Mortality among all patients was 37 (39·8%) of 93 in low-income countries, 583 (20·4%) of 2860 in middle-income countries, and 50 (5·6%) of 896 in high-income countries (p<0·0001 between all country income groups). Gastroschisis had the greatest difference in mortality between country income strata (nine [90·0%] of ten in lowincome countries, 97 [31·9%] of 304 in middle-income countries, and two [1·4%] of 139 in high-income countries; p≤0·0001 between all country income groups). Factors significantly associated with higher mortality for all patients combined included country income status (low-income vs high-income countries, risk ratio 2·78 [95% CI 1·88–4·11], p<0·0001; middle-income vs high-income countries, 2·11 [1·59–2·79], p<0·0001), sepsis at presentation (1·20 [1·04–1·40], p=0·016), higher American Society of Anesthesiologists (ASA) score at primary intervention (ASA 4–5 vs ASA 1–2, 1·82 [1·40–2·35], p<0·0001; ASA 3 vs ASA 1–2, 1·58, [1·30–1·92], p<0·0001]), surgical safety checklist not used (1·39 [1·02–1·90], p=0·035), and ventilation or parenteral nutrition unavailable when needed (ventilation 1·96, [1·41–2·71], p=0·0001; parenteral nutrition 1·35, [1·05–1·74], p=0·018). Administration of parenteral nutrition (0·61, [0·47–0·79], p=0·0002) and use of a peripherally inserted central catheter (0·65 [0·50–0·86], p=0·0024) or percutaneous central line (0·69 [0·48–1·00], p=0·049) were associated with lower mortality. Interpretation Unacceptable differences in mortality exist for gastrointestinal congenital anomalies between lowincome, middle-income, and high-income countries. Improving access to quality neonatal surgical care in LMICs will be vital to achieve Sustainable Development Goal 3.2 of ending preventable deaths in neonates and children younger than 5 years by 2030