The ethical obligation of the dead donor rule.

The dead donor rule (DDR) originally stated that organ donors must not be killed by and for organ donation. Scholars later added the requirement that vital organs should not be procured before death. Some now argue that the DDR is breached in donation after circulatory determination of death (DCDD) programs. DCDD programs do not breach the original version of the DDR because vital organs are procured only after circulation has ceased permanently as a consequence of withdrawal of life-sustaining therapy. We hold that the original rendition of the DDR banning killing by and for organ donation is the fundamental norm that should be maintained in transplantation ethics. We propose separating the DDR from two other fundamental normative rules: the duties to prevent harm and to obtain informed consent

The attitudes of Chinese family caregivers of older people with dementia towards life sustaining treatments

Aim. This paper is a report of a study to examine attitudes towards life-sustaining treatment in family caregivers of older Chinese people with dementia. Background. Deferring decisions about life-sustaining treatments to surrogate decision-makers is common among older people with dementia. However, surrogate decision-makers frequently lack knowledge about disadvantages and benefits of treatments and do not understand the principles of surrogate decision-making. Method. A total of 51 Chinese family caregivers were interviewed during 2003 and 2004. The interview included an assessment of their knowledge about cardiopulmonary resuscitation and tube feeding, a questionnaire to assess their anticipated decisions for four treatments (cardiopulmonary resuscitation, artificial ventilation, tube feeding and antibiotic administration) if the older relative suffered critical illness or irreversible coma, and their comfort and certainty in making such decisions. Findings. Family caregivers displayed poor knowledge about life-sustaining treatments, with 30 (59%) and 13 (26%) unable to name any feature of cardiopulmonary resuscitation and tube feeding, respectively. Most relied on their own views in decision-making rather than on what they thought their relative would have wanted. Most family caregivers were reluctant to forgo treatments. Nursing home residence predicted family caregivers' willingness to forgo artificial ventilation for critical illness. Financial burden predicted inclination to forgo antibiotics for critical illness and irreversible coma, as well as tube feeding in irreversible coma. Conclusion. More dialogue and education are needed about end of life issues in the early phase of dementia. Nurses should be aware of the cultural implications of surrogate decision-making for Chinese family caregivers. © 2007 Blackwell Publishing Ltd.link_to_subscribed_fulltex

Turning failures into successes: a methodological shortcoming in empirical research on surrogate accuracy

Decision making for incompetent patients is a much-discussed topic in bioethics. According to one influential decision making standard, the substituted judgment standard, a surrogate decision maker ought to make the decision that the incompetent patient would have made, had he or she been competent. Empirical research has been conducted in order to find out whether surrogate decision makers are sufficiently good at doing their job, as this is defined by the substituted judgment standard. This research investigates to what extent surrogates are able to predict what the patient would have preferred in the relevant circumstances. In this paper we address a methodological shortcoming evident in a significant number of studies. The mistake consists in categorizing responses that only express uncertainty as predictions that the patient would be positive to treatment, on the grounds that the clinical default is to provide treatment unless it is refused. We argue that this practice is based on confusion and that it risks damaging the research on surrogate accuracy