Anything but the eyes: culture, identity and the selective refusal of corneal donation

At the time that a patient is diagnosed as brain dead, a substantial proportion of families who give consent to heart and kidney donation specifically refuse eye donation. This in part may relate to the failure of those involved in transplantation medicine and public education to fully appreciate the different meanings attached to the body of a recently deceased person. Medicine and science have long understood the body as a “machine.” This view has fitted with medical notions of transplantation, with donors being a source of biologic “goods.” However, even a cursory glance at the rituals surrounding death makes it apparent that there is more to a dead body than simply its biologic parts; in death, bodies continue as the physical substrate of relationships. Of all the organs, it is the eyes that are identified as the site of sentience, and there is a long tradition of visual primacy and visual symbolism in virtually all aspects of culture. It therefore seems likely that of all the body parts, it is the eyes that are most central to social relationships. A request to donate the eyes therefore is unlikely to be heard simply in medical terms as a request to donate a “superfluous” body part for the benefit of another. That the eyes are not simply biologic provides one explanation for both the lower rates of corneal donation, compared with that of other organs, and the lack of adequate corneal donation to meet demand

Anything but the eyes: culture, identity and the selective refusal of corneal donation

At the time that a patient is diagnosed as brain dead, a substantial proportion of families who give consent to heart and kidney donation specifically refuse eye donation. This in part may relate to the failure of those involved in transplantation medicine and public education to fully appreciate the different meanings attached to the body of a recently deceased person. Medicine and science have long understood the body as a “machine.” This view has fitted with medical notions of transplantation, with donors being a source of biologic “goods.” However, even a cursory glance at the rituals surrounding death makes it apparent that there is more to a dead body than simply its biologic parts; in death, bodies continue as the physical substrate of relationships. Of all the organs, it is the eyes that are identified as the site of sentience, and there is a long tradition of visual primacy and visual symbolism in virtually all aspects of culture. It therefore seems likely that of all the body parts, it is the eyes that are most central to social relationships. A request to donate the eyes therefore is unlikely to be heard simply in medical terms as a request to donate a “superfluous” body part for the benefit of another. That the eyes are not simply biologic provides one explanation for both the lower rates of corneal donation, compared with that of other organs, and the lack of adequate corneal donation to meet demand

Organ donation in Australia: Reply

Like McCaughan1, we are both in the unfortunate position of owning and driving a car in NSW, and have therefore faced the frustration associated with licence renewal. We consequently agree that any system that attempts to provide an opportunity for discussion of organ donation would need to be carefully thought through, systematically organized and appropriately funded. We accept that our paper did not provide the costing and administrative detail that would be necessary for our proposal to be turned into policy. Nonetheless, it is feasible that a model of a 5-min discussion with only those licence holders who refused donation would come in well under the $13.4 million allocated for public awareness and education in the Australian ‘World's Best Practice (WBP) Reform Plan’2. While in general terms we are supportive of the WBP approach, it is worth pointing out that none of the countries with leading organ donor rates uses the model described by McCaughan; that there are important differences between the ‘Spanish Model’ and what is referred to as WBP (differences that may ultimately compromise the success of reforms of organ donation in Australia); that WBP is modelled after countries who are all, with the exception of the USA, opt-out countries – thereby negating the necessity for registration of donor intention; and that regardless of the approach they have taken very few countries have achieved donor rates of 25–35 p.p.m. (only Spain, Belgium, Portugal and occasionally the USA)

Registering wishes about organ and tissue donation: personal discussion during licence renewal may be superior to online registration.

Consent to organ and tissue donation is higher when the deceased has indicated a wish to donate. The Australian Organ Donor Register (AODR) is the national register of preferences regarding donation. The AODR has a number of limitations; it has no mechanism for requiring individuals to register their wishes, while the online format both raises concerns about the validity of the consent obtained and precludes personal discussion of fears and concerns about donation. A solution to these limitations is to utilize state-based agencies that administer driving licences. This strategy ties the donation decision to an existing task (renewal of driving licences), and provides an opportunity for a personalized intervention at the time the decision is being made

Vaccines – but not as we know them: An ethical evaluation of HPV vaccination policy in Australia

Objective: To show how systematic ethical evaluation of public health policy may reveal issues of moral significance for critical examination. Method: Using Australia's human papillomavirus (HPV) vaccination program as an exemplar and adopting an approach outlined elsewhere, we determine whether conditions of effectiveness, proportionality, necessity and least infringement, and public justification, are met such that any breach of autonomy or justice principles associated with this intervention can be defended. Conclusions: While the HPV vaccine itself may be efficacious, some aspects of the program lack sufficient moral justification and raise concerns around procedural and social justice and gender equity. Implications: Public health interventions deploying new technologies against new targets – such as vaccines against cancer and chronic illness – require approaches crafted to their specific risk-benefit profiles that have carefully considered the ethical issues involved. Systematic ethical reflection is a useful tool for this

Doctors behaving badly?

It is in doctors’ and the drug industry’s best interests that their interactions be openly declared. There is no such thing as a free lunch. Pharmaceutical companies lavish meals, five-star travel, cash and gifts on doctors for one reason: to encourage them to prescribe their drugs. The standard retort from the medical profession is that doctors have sufficient clinical objectivity — and personal integrity — not to be so crudely swayed. Perhaps s

Return of the Memento Mori: imaging death in public health.

Death has always held a morbid fascination for humans. Indeed, awareness of one’s own mortality may well be one of the defining features of the ‘human condition’ – symbols of death appearing in most civilizations since artefacts have been made. The Latin phrase memento mori, meaning literally ‘remember to die’, encapsulates a rich and varied artistic tradition, dating back to the Middle Ages, of figuring death by symbolizing its literal processes and remainders. From the decomposed effigies of 15th-century ‘cadaver tombs’, to the humorous medieval iconography of the skeletal danse macabre, the works of this genre draw on the destructive physical changes that are a part of our understanding of death. Prolific within its morbid imagery are the use of skull, skeleton and verminous or rotting flesh as ‘trope’ or symbol of the processes that eventually take away the person who lived, and who was once like us. At the height of its popularity between the 16th and 18th centuries, Church walls, tombs, jewellery, paintings, and so on frequently depicted death and decay. The entreaty to ‘remember’ death in memento mori was more than simply a call for ‘therapeutic contemplation’1 or the banal acceptance of the imminence of death; it was a call to piety, to conformity. Damnation would be added to death if the individual transgressed the rules of Catholic doctrine, such that scholars often trace a continuity between the motives of memento mori, and the biblical injunction: ‘Whatsoever thou takest in hand, remember the end, and thou shalt never do amiss’ (Ecclesiasticus 7:36).2 Even within the iconophobic Protestantism of the post-Reformation era, the memento mori trope persisted as a privileged mode of pious warning. In the visually secular effigy monuments of the Elizabethan gentry, inscriptions urging the reader to ‘(r)emember the last things and…not sin again’ signified that death would come to everyone – but only spiritual public health would reduce the risk of eternal punishment and separation from God.3 The memento mori trope survives into the present day, albeit in differing locations. Loosely discernible in the ‘corpse chic’ of contemporary haute couture, and entrenched within the aesthetics of punk and gothic subcultures, the skull and skeleton loom large as Western symbols of cultural rebellion.4 Similarly, the fully enfleshed ‘corpse’ continues to haunt the zone of 2 | P a g e contemporary representation – saturating the realm of Hollywood film and ‘hard news’ reportage alike, and asserting its dominance in forensics-inspired television programmes such as CSI. Representing death, it would seem, has never been more popular. Indeed, depictions of death have emerged as ‘mainstream advertising strategy’4 – their gore and horror satisfying a perverse voyeurism that many would attribute to the alienating effects of mass media saturation. While the ‘pornography’ of suffering5 in contemporary culture appears to have little in common with classical memento mori, if one looks closely, certain elements particular to this once-spiritual genre of death depiction can be unearthed, most notably in the secular arena of public health