Prof. A. H. Sheriffdeen on:

Ethics of transplantation

THE science of ethics covers a wide range of definitions ranging from a principle or rule of right conduct, study or moral standards, a system or rules or principles for behaviour to rightness or moral quality of an action.

The common denominator is the adherence to accepted principles concerning right and wrong. The problem here is that these principles could change from country to country and within a country from different cultures, religions and regions and even from time to time.

Awareness a key instrument

Professor Danstan has defined Medical Ethics as obligations of a moral nature, which govern the practice of medicine. Obligations are what we ought to and ought not to do; and moral is the divide between right and wrong/good and bad.

These morals should govern medical practice but unfortunately this is not always the case and organisations such as the Sri Lanka Medical Council, Parliament, Oaths such as the almost obsolete Hippocratic Oaths, medical defense societies, employers, lawyers and the media have become the instruments that set the pace and standards which govern medical practice.

Awareness is one of the key instruments which are responsible for the establishment of good ethical conduct, especially in medicine where the issues involved may not be all that obvious.

To create this awareness on the issue of ethics governing transplantation Central to this discussion are that we should not transgress the four basic principles of ethics viz. beneficence, autonomy, justice and non malfeasance.

Autotransplantation and Homotransplantation

Transplantation is the transfer of tissues or organs. Autotransplantation is the transfer in the same individual such as skin and bone grafts and does not present any ethical problems of significance.

Homotransplantations (within the same species) and heterotransplantation or xenotransplantation (across species e.g. from animals to man) on the other hand could raise many issues.

Rejection and side effects

The first of these is that a protein, which includes all tissues and organs, cannot be transferred from one individual to another without it being rejected. Unless there is 100 per cent compatibility as in identical twins, such a transplantation procedure must be followed by lifelong anti rejection therapy.

Such therapy is with powerful drugs which are not only expensive but also have serious side effects, the chief of these being susceptibility to serious infections and even to cancers.

Ethical issues and dialysis

A discussion on the ethical issues concerning transplantation must therefore begin with the problem of resource allocation for a transplantation program. A renal transplantation program commences with dialysis for chronic renal failure which costs Rs. three to five thousand per dialysis session.

A patient needs three sessions a week of dialysis for the rest of his life or until he receives a transplant.

Following a successful transplant the patient needs anti rejection therapy for the rest of his life, in addition to regular blood tests to monitor renal function and any complications that could develop.

Transport to the hospital and maybe overnight stay nearby for the patient and an accompanying person could add up to Rs. 20,000 a month.

There are approximately 30 to 50 per million population of new patients with chronic renal failure per year. If the State has to fund this it could take off a considerable slice of the health budget, leave alone the Gross National Product.

However when one considers the quality of life, employability, family life and productivity of at least 50 to 60 per cent of these patients there is indeed a strong case for this program.

Liver transplantation costs Rs. 10 to 20 m

Liver transplants cots a considerable sum more, estimated to cost Rs. 10 to 20 million for the operation alone.

An additional ethical dilemma is whether such an operation should be carried out on a person who refuses to change his lifestyle of alcohol consumption which probably originally contributed to his cirrhosis that needed a liver transplant in the first instance.

Organs a scarce resource

Organs are a scarce resource and the demand outweighs the supply worldwide. Such organs could be regenerative such as blood and bone marrow and non regenerative such as kidney, liver and heart. A kidney and a part of the liver are the only organs that can be donated by a living person.

Beating Heart cadavers

Heart, kidneys, livers and other organs could on the other hand be obtained form brain dead persons. They are also called beating heart cadavers. Using strictly laid down criteria which have been accepted internationally, organs could be harvested from such donors.

It is ethically and morally important that physicians and surgeons involved in treating the potential donor and those involved in the transplantation operation should not be the ones confirming brain death. A conflict of interest should be declared.

Consent for such procurement differs in different countries: the opting in system where people could consent to donate using a donor card system seems fair.

However certain countries such as Belgium and Singapore adopt the opting out system where, unless the person has specifically laid down that his organs should not be removed, the state has the right to use them. Facilities for such refusal should therefore be easily available.

Allocation and ethical issues

Allocation of such organs cold raise ethical issues. Can relatives of donors demand payment for such organs? Can donors or their relatives specify to what category of patient the organs should go to based on ethnicity, colour, social status etc? All human beings should be treated equally.

Living donations also raise many issues. If related, to what degree of coercion was this person subjected to by other family members? Children, minors and the incompetent are another group that often needs ethical committees or even the law courts to resolve contentious ethical issues with regard to consent.

Pandora's Box in renal transplantation

Commercialism in renal transplantation is another Pandora's box. The scarcity of organs has committed many countries to relax the rules on non related transplantation to allow altruistic donations from spouses, friends etc.

An extension to this concession is that the expenses borne by the donor for investigations, travelling, hospitalization etc. could be paid by the donor. The question is often asked "in this world of consumerism, why cannot a poor man sell if he has a marketable commodity?"

The world has learnt lessons from experiences in India, Philippines and South America where middle men and mafia style operators have collected a major portion of the fee paid to the donor.

Animal sources for organs

The shortage of organs has led to researchers to look at animal sources for organs. These animals should be easily bred in sufficiently large quantities, should be genetically compatible, and free of transmissible disease.

Monkeys and apes have not been followed up due to pressure from animal rights groups but transgenic pigs are being experimented with as being possible sources in the future.

Foetal tissues and umbilical cord cells

The use of foetal tissues and stem cells from the umbilical cord too raise serious ethical issues. Foetal brain cell transplants are used to treat Parkinson's disease.

The issue of deliberate abortion to provide the source of these cells has raised questions of autonomy for both the recipient and the donor.

Similarly blood from the umbilical cord is a source of stem cells. The problem is that the timing of clamping of the cord has to be precise and could be harmful in premature infants.

Many issues need to be freely discussed

In conclusion, these are issues that are being discussed in the world literature. Many more issues such as competence of the medical and technical staff, resources to handle complications, research and funding are issues that need to be freely discussed. There should be committees to handle delicate problems and to advise those seeking it.

To leave or not to leave

THE migration of Physicians from poor to rich countries is not a new phenomenon. This migration which is commonly referred to as brain drain has both positive and negative aspects. The benefits include substantial financial remittances from expatriates and long term professional networks and collaboration in health research.

However, the disadvantages such as loss of public educational investment, reduced range of available services and chronic understaffing of health facilities outweigh the benefits (Ahmad, 2005)

Can brain drain be stopped?

In the modern world there is no place for enforcing legislations that forbid migration (Patel, 2003). A decision to do away with the overseas component of the postgraduate training will be an equally negative measure as the opportunity to work in a different country is an enriching professional experience.

There are suggestions to introduce legislations to delay and discourage the migration, such as increasing the amount of bond to be signed before commencing the overseas training.

However, if these measures are perceived as too punitive, it may be self-defeating by causing a lack of co-operation from physicians. There need to be more sustainable solutions addressing the fundamental causes.

What, then, are the possible causes of the brain drain?

One of the key reasons is professional dissatisfaction due to causes such as poor working facilities and lack of intellectual stimulation. Personal and financial reasons play a major role when a physician contemplates the decision to leave.

Deteriorating political and financial situation of a country is another reason that might intensify brain drain (Ahmad, 2005; Pang et al., 2002)

When considering the above factors, there should be strategies to provide an attractive environment for returning doctors to work by ensuring financial stability, providing adequate facilities and opportunities for professional development (Pang et al, 2002, Patel, 2003).

The negative effects of the brain drain can be reduced by developing a brain gain network to attract the medical professionals back to the country.

The promotion of joint research and the use of medical specialists in periodic return visits can harness the expatriate of expertise physicians. What is required is to develop and implement strategies to get the maximum benefit out of a disadvantages situation.

(Courtesy: SLMA News August 2005)

Breast cancer

BY DR. PANDUKA Jayasekera (Consultant Surgeon)

THE breast is a gland made up of milk sacs where milk is made and ducts, which take milk to the nipple along with supporting fibrous and fatty tissue that contains arteries, veins, nerves and lymph vessels.

In your armpits are lymph nodes or glands, which are connected by a system of lymph ducts. This system of lymph glands and ducts which are dispersed in your entire body are part of your defense system - helping to fight infection.

Breasts do not stay the same throughout your adult life. Your monthly period, age, pregnancy and weight changes can all alter its shape. Some women find their breasts more tender and lumpy before their periods. This tenderness or 'lumpiness' disappears after a period. This is quite normal.

Breast cancer is the most common type of cancer in women. There are several types of breast cancers. Most begin in the milk ducts. Some begin in the milk lobes and sacs. Some breast cancers are found when they are 'in situ'.

This means they have not spreads beyond the tissue in which they began. However most breast cancers are found when they are invasive. This means they have grown beyond the tissue in which it goes in to other areas of the breast or out of the breast.

Breast cancer first grows out of the breast in to the lymph nodes in the armpit nearest to the affected breast. If untreated breast cancer can then spread to other parts of the body such as the bones and liver.

Although unusual men too can develop breast cancer. In women breast cancer is rare before the age of thirty. It starts in the forty - fifty age group and then gets more common with increasing age.

By and large breast cancer is found to be more common in countries that have a western lifestyle than in developing countries. Though we do not know the exact causes of breast cancer, we do know several risk factors.

The causes of breast cancer - The exact cause is not known, however the risk of getting cancer increases with the following:

Age - The older a woman gets the risk is more. Most breast cancers occurs in women over the age of fifty.

If you have a strong family history of breast cancer.

If you have had breast cancer before.

If you have not certain breast conditions such as a typical ductal hyperplacia, or ductal carcinoma 'in situ'.

Not having children or having children after the age of thirty.

Early onset of menstruation, later age of menopauses (Fifty five years or older).

An increased alcohol intake.

Obesity or a substantial increase in body size after menopauses.

Using hormone replacement therapy - the risk increases the longer you take it but disappears within about two years of stopping use.

However several of these risk factors does not mean that you will get breast cancer. Most women with breast cancer have no known risk factors.

People should also be aware that there are a number of myths or false beliefs around about breast cancer. Here's the truth:

1. A bump or blow to your breast will not cause breast cancer although it may make you aware of an underlying lump.

2. Breast cancer cannot be 'caught' from someone who already has it

3. Breast feeding does not cause breast cancer.

Probably the most common way in which a lady finds a cancer in her breast is through feeling a lump in her breast. In a lot of cases the lump has not caused any problems but seems to appear quite suddenly. Lumps in the breast are very common and most lumps in the breast are not cancer.

However, because of the risk of cancer any woman finding a lump in her breast should see her doctor promptly meaning a few days. (It need not be a middle of the night medical emergency) Most cancers of the breast do not cause any symptoms at all. Hence self examination has been advocated as an effective screening method.

Old age or disease? Recognising dementia

YOU may think that becoming more forgetful or repeating yourself in conversation is just a natural part of getting older.

Sometimes though, increasing memory loss may be an early sign of dementia. Old age does not cause memory loss but when memory loss starts to disrupt everyday life, it could be time to get help.

Other common symptoms of dementia include difficulty performing familiar tasks such as preparing food, problems in naming everyday objects such as a watch, getting lost easily even in familiar places, and changes in mood, personality and behaviour.

Sometimes people fail to recognise that these symptoms indicate that something is wrong, especially as they may develop gradually and go unnoticed for a long time.

If you or someone you care about is experiencing some of these symptoms it is important to see your doctor.

If the diagnosis is dementia there is help available. An early diagnosis can provide access to resources and treatment and an opportunity to talk and plan for the future.

Subtle early signs.....

MY husband was diagnosed with Alzheimer's disease in 1996. Although signs of his illness manifested two years earlier, we never suspected anything as he looked physically fit and normal.

The golf course was where signs of the disease first showed up. These early signs were rather subtle and included 'small things' like being impatient when standing in queues at the golf club and being short-tempered with his golfing mates.

These may look like a normal reaction to others but to me - and even my husband himself - they were not.

When his golfing friends complained to me of his impatience with them, I felt they were being unkind. But, over time, these little incidents became more frequent and more 'bizarre'.

He started to break the rules of the game. Friends started to avoid playing with him. My husband would come home after every game, looking very upset.

(Courtesy: World Alzheimer's Day Bulletin)