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UA / Philosophy / PHL 223 / Adult to adult liver transplants began in the u.s. in what year?

Adult to adult liver transplants began in the u.s. in what year?

Adult to adult liver transplants began in the u.s. in what year?


School: University of Alabama - Tuscaloosa
Department: Philosophy
Course: Medical Ethics
Professor: Stuart rachels
Term: Summer 2015
Tags: medical ethics
Cost: 50
Name: PHL 223: Final
Description: These notes only contain the lectures from class for the final.
Uploaded: 04/28/2016
11 Pages 149 Views 13 Unlocks

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Adult to adult liver transplants began in the u.s. in what year?

● Friend got a heart transplant in college at the age of 19

○ He saw the doctor friday, and got the heart monday.

○ Isn’t expected to live until 30 years old

○ He is now 45

● Liver Transplant: a case study

○ Drindee: 50­ish year old woman in Atlanta

○ PhD; hospital administrator, eating disorders

○ 1994, diagnosed with primary sclerosing cholangitis (PSC), which destroys the bile ducts in liver

○ Walter Payton had this disease

○ Cause of the disease, unknown

■ In her case, NOT due to alcohol

○ Only hope for cure: liver transplant

○ She ignored her doctor

○ In 2000, Drindee started having bad symptoms:

How many birds and mammals are used for research in the u.s.?

■ Weakness

■ Nausea

■ Pruritis (itching)

■ Bleeding esophageal varices (large varicose veins)

■ Mental lapses (couldn’t figure out how to start a car)

○ She cut back her hours at work, until she had to quit.

○ She wants a transplant, looks sick, but not too sick

○ In 2002, she got on “the list” at Emory Transplant List.

○ She had about 1 year to live

■ 3 times she had shunt operation. (esophagus) Shunt artificial tube, reroutes blood around needed area.

■ Experienced tremendous pain after shunt If you want to learn more check out English ships sunk by the germans.

○ Pain: doctors and nurses underestimated it

○ Good looking, but now ugly.

○ Her chances of getting a cadaveric liver: 50/50 maybe

Why is it bad for animals to feel pain?

○ Head of health in government, Shalala, changed the rules for getting an organ. ■ Now based entirely on 3 numbers

■ Took away all physician judgement

■ It meant that recipients will be close to death, and less likely to survive. ○ Bad for 2 reasons:

■ Those numbers are poor indicators of how sick someone with PSC is. ■ Alcoholics are more likely to get transplants Don't forget about the age old question of What is supply schedule?

○ Drindee’s doctor, Thomas Heffran, advised her to seek living donors. ○ Adult to adult liver transplants began in the U.S. in 1997.

○ In 2002, 1 in 12 liver transplants were from living donors.

■ Must have same blood type, or your body will reject it.

○ Who donates their liver?

■ 75% blood relative family

■ 13% friend

■ 11% spouse

■ 1% altruist (stranger)

○ Drindee send a group email in March 2002.

■ Determination.

■ I was afraid. 20+ people called the surgeon.

■ They looked at 1 person at a time. Why? (expense to insurance company. Protecting the surgeon’s time.)

● Grim determination. Aware of situation. Why not me (Dr. Rachels)? ○ I (Dr. Rachels) was afraid

● 20 people called the surgeon

● The hospital looked at one person at a time. Why?

○ Expense to the insurance company

○ Protecting the surgeon’s time

○ Hospital had no method for prioritizing potential donor, because events like this didn’t happen frequently.

● Potential Donor #1: Bob

○ Eliminated, because he had a blood vessel out of place

○ Too big of a risk to operate on

● Potential Donor #2: Friend (college roommate) If you want to learn more check out What is dipole ­induced dipole?

○ Eliminated, because he was on a minor medication (prozac)

● Potential Donor #3: Friend

○ Eliminated, because she drank too much red wine.

○ Drinking alcohol in moderation is good for you. Drinking TOO MUCH is deadly, and destroys your liver.

○ Surgeon wasn’t sure if she was drinking more than the medically recommended ■ Doctors are cautious!! (If something goes wrong, whole operation shut down)

● May 2002:

○ I’ve got to do this soon (Dr. Rachels)

○ Had to begin exercising

● Potential Donor #4: Friend

○ Eliminated, because he changed his mind at the last minute.

○ Confidentiality broken, because the hospital told Dr. Rachels about the potential donor dropping out.

● Potential Donor #5: Friend (Dr. Rachels)

○ Got an appointment with Dr. Heffron & Emory Hospital in Atlanta, GA ○ What are the risks?

■ 1% chance of donor death If you want to learn more check out What is connectome?

■ Really it’s more like 1/10th of 1%, or 1 in 1000.

■ 15% chance of significant surgical complications

■ 100% chance of pain and a big scar

● You won’t be writhing in pain

■ I could change my mind at any time, even the morning of the surgery ■ Hospital booted his car after surgery

■ On another day, they took my blood, and did an MRI.

■ Psychiatric Interview:

● Psychiatrist wanted to know if he was going to take the procedure seriously, and if he was a sound & normal adult. We also discuss several other topics like What was the purpose of sputnik 1?

● Psychiatrist tried to find out if Drindee was paying Dr. Rachels for

his liver.

● “Everyone says they underestimated the pain.”

■ Liver biopsy, next step.

● Look at liver, see if cells are healthy in liver. If you want to learn more check out What is the musical style of arnold schoenberg?

● Dr. Rachels was eliminated, because his liver was “too thick”.

● Potential Donor #6: Altruist (stranger)

○ Knew Drindee, because the daughter went to school with one of Drindee’s children.

○ Potential Donor backed out after 6 weeks.

● Drindee got a transplant on 8/20/2002, but not from anyone she knew. ○ The liver came from a 9 year old boy who died in a car accident.

○ Successful surgery, hard recovery.

○ While she was sick, Drindee became religious but she lost it when she healed and became atheist again.

■ A minister had befriended her, but her husband felt like he was

brainwashing Drindee.

● Bureaucracy

○ Dr. Rachels hospital bills were being paid by Drindee’s hospital bills, but he would get calls from Emory Hospital about whether or not he was going to pay his bills. ○ Drindee wrote a letter about how her body transformed after the surgery, ■ She hates her scar and says it looks like a “Mercedes Benz” logo. ■ Her midsection looks like a “war zone”

■ Her body was “butchered” and she feels “numb” around the scar

○ 2002→ Drindee had the transplant

○ 2004→the disease came back

○ 2009→she needed a second transplant and went into septic shock at one point ○ Adult to adult liver transplants are no longer done, because 1 donor out of 1,000 died.

○ January 2010→she got the transplant

○ By then medicine has advanced, so the 2nd transplant was better than the 1st. ○ August 2010→Drindee met the family of her first donor.

○ Living very well right now, still has a couple problems.

● Organ transplants

○ Everyday people in Drindee’s situation die waiting, 22 specifically

○ UNOS (united network for organ sharing) created in 1987

○ To get a transplant you must live near a transport center

○ There are 250 centers. In AL, basically birmingham

○ Multiple listing: getting on the list at more than one center

○ Some people will live, others die because they have better insurance ○ Some people live because they know the system and can afford to be away from work

● Organ On Waiting List 

● Kidney 100,419

● Liver 14,753

● Heart 4,158

● Kidney & Pancreas 1,924

● Lung 1,475

● Pancreas 1,034

● Intestines 271

● heart/lung 43

● Total #: 121,227 people waiting for a transplant ● Waiting in Alabama, 3269 waiting for a transplant

● In 2015, transplants performed = 30,969

● Roughly half of those waiting will die waiting

● Donors are 60% cadaveric

● 40% are living

● Over 10x 9/11 people die

● 80% transplants are from dead people.

○ Roughly half of those waiting will die

○ Each year, 5­7000 people die who could donate but don’t.

○ Why? Under 20% of american adults sign organ donor forms

● Checking the box on your driver’s license is not enough

● Doctors are cautious about harvesting

● It is hard to approach grieving families

● Families are hoping for a miracle

● Uncertainty about when death occurs.

● Ethical Perspective 

○ Many people are needlessly dying.

○ How can we increase the supply

● Possibilities 

○ 1. Forced donation

■ Freedom to bury organs after death vs. human life

○ 2. Presumed consent

■ You’re a donor unless you indicate otherwise

○ Organ Donor 

■ Denmark 4%

■ Germany 12%

■ U.K 17%

■ The Netherlands 28%

■ Sweden 86%

■ Belgium 98%

■ Austria, Poland, France, Portugal 100%

○ Why? Not cultural

■ People go for the default option

■ “Check the box if you want to be an organ donor”

■ “Check the box if you DON’T want to be an organ donor”

○ 3. Commercial Market for Organs

■ “Some things should not be bought or sold” Why not?

■ Exploitation of poor? (danger with living donors only)

■ Even if you think I shouldn’t sell my organs don’t I have the right to? ■ Is selling one’s organs so stupid that we shouldn’t allow it, as with slavery? Of course not.

○ Drawback of 1­3:

■ Increased distrust in doctors

■ Which leads to more death

○ 4. Stem Cell Research may allow us to clone organs

■ The God Committee: 

● About first dialysis machines

● Dialysis­ cleans the blood and return it to the body; a kidney


■ Purpose of sleep is to clean the brain.

■ Dialysis machine: invented in 1943. Willem Kolff (Dutch)

■ 1960, Belding Scribner invented the “Scribner Shunt”

■ 1962, Scribner’s hospital could serve 17 dialysis patients

■ 1961, the “God Committee” was set up to decide who to accept.

● They limited candidates to those under 45 that could pay

● Considered if they were employed

● Educated

● Had dependent children

● Had achievements

● Could potentially help others

■ Were they “playing God?”

■ Well some choice had to be made.

● The End­Stage Renal Disease Act (1972):

○ The government funds all dialysis

○ Lives were saved, but it was too much money.

● Animal Research 

● How many birds and mammals are used for research in the U.S.? ○ Roughly 25 million per year

○ Most are rodents, with very similar genomes

● Animal care and use committees (required since 1986)

○ Must be a committee that researchers have to go through

○ Because of monkeys

● 3 approaches to assessing animal research:

○ 1) Any research on animals is ok.

■ It’s just an animal

○ 2) No research on animals is ok.

■ They’re not ours to use/animal rights must be protected

○ 3) Research is judged in terms of harms and benefits

■ How many animals?

■ How much pain?

■ To what end is the research?

■ Likelihood of success?

■ Are there alternatives?

● Position is too extreme.

● Immoral research done on animals:

○ LD 50 Test

○ “Lethal Dosage” 50%

○ Products are force fed to animals until 50% die

■ Ex. paint thinner, floor wax, motor oil.

● Shopping is like voting.

● Company can do harm:

○ Mistreatment of own workers

○ Treatment of animals

○ Treatment of environment

● Another Immoral research:

○ Draize Test:

■ Mostly done on shampoo

■ Chemicals are applied to rabbits eyes

■ Rabbit’s arms are restrained and eyelids slit (rabbits don’t have tears) ● Why are these tests wrong?

○ Because animals feel pain

● Why is it bad for animals to feel pain?

○ Pain is bad because it hurts.

● Animal pain, if it hurts as much as human pain, is just as bad. So these tests are very wrong.

● What is human equality?

○ Humans are not equal in intelligence, beauty, moral virtue, wit, grace, speed, memory, age, height, the ability to hold one’s breath, etc.

○ Human equality is a moral idea. It is about equal consideration of interests ○ The Equality Principle: Everyone’s interests should count equally ■ Exception! Maybe your interests should count more if they are good, not bad.

○ Ways to violate the Equality Principle (forms of discrimination)

● A Group The belief that their interests matter less ● African Americans Racism

● Jews Antisemitism

● Women Sexism

● The Elderly Ageism

● Everyone but you Seflism (selfishness)

● Foreigners Nationalism

● Nonhumans Speciesism

● Most people are speciests: they favor human interests over similar non human interests. ● Factory Farms (CAFO)

○ concentrated animal feeding operations

○ 10 billion animals suffer horribly each year in US

○ Cramped, unsanitary conditions, disease, stress, mutilation.

● Overuse of antibiotics­ disease evolved and becomes resistant

○ Most antibodies use on animals in feed

● Pigs: gestation grates, castration, and tail docking with anesthesia. ● Cows: hot iron branded, castrated, tail docked, dehorned, ears cut, all without pain relief ● Chickens and turkeys: 9 billion; de­beaking, forced molting, ammonia ● Meat industry does more global warming than transportation.

● The reason for all this suffering:

○ Cheap, tasty food

● Why does this happen?

○ Green revolution

○ We buy meat

○ It’s legal, tax supported

○ It’s profitable

○ Animals can’t fight back

○ Long history of speciesism

○ Influence of money in american politics.

● The Tuskegee Syphilis Study: 

○ Syphilis is acquired through bacterium and transmitted sexually

○ The three stages of acquired syphilis:

■ 1. Primary Syphilis:

● Starts up about 2 weeks after having sex

● Lasts about 4­6 weeks

● Painless lesion appears (chancres, visible spots on the skin)

● Highly infectious period

■ 2. Secondary Syphilis:

● Last 1­30 years

● Very vague

● Chancres on skin subside/fade, but often internal lesions will rise

(medically dangerous)

● Various symptoms

■ 3. Tertiary Syphilis:

● Can go in different directions medically

● Some people may heal, asymptomatic

● But lesions can cause major damage to cardiac and/or

neurological system which can result in paralysis, blindness,


● Tuskegee Timeline:

○ 1909→Erich (German) and Hata (Japanese) invented salvarsan (arsphenamine) heavy metals to treat syphilis.

○ 1912→Neosalvarsan (new­salvarsan) newly absorbed into the skin, “less toxic” but really more toxic

○ 1929→Boeck & Bruusgaard (Norwegian) questioned whether it’s better than no treatment.

○ 1931­1937→The Scottsboro trials happened in northern AL

■ Supreme Court Decisions that came out of these trials:

● A) Defendants have a right to a lawyer (representation). Don’t

assume that they’re always guilty. Is it OK for you to be put on trial

if you aren’t guilty and can’t afford it? (Giddeon v Wainwright)

● B) Right to a fair trial with jury by peers. African Americans were

never allowed to sit on jury. During the Scottsboro trials it was an

all white jury.

■ Atime of enormous racism in AL.

■ But the role of racism in the study is unclear.

○ 1932:

■ Tuskegee experiment begins

■ Economic Depression

■ WWI, Great War

■ Tuskegee experiment→ “An experiment in nature” of 399 men in Macon County, AL

■ Experiment to take a look at how the disease acts over time if it’s


■ Macon County: 82% black; today: 85% black, 40% live below the poverty line

■ At the time, Macon County had a syphilis rate of 20%

■ Subjects had early secondary syphilis, not contagious.

■ Research by United States Public Health Services in cooperation with the Tuskegee Institue.

○ 1941­1943:

■ Penicillin mass produced for soldiers in WWII (for bacterial infection) ■ Discovered by Fleming in 1928

○ 1941­1945→Scientists ensured that drafted subjects (from experiment) won’t get penicillin.

○ 1946→ penicillin becomes widely available, but tuskegee subjects aren’t given it. ○ 1969:

■ Neil Armstrong walks on the moon

■ CDC committee votes to continue the syphilis study

■ Tuskegee physicians, almost all black, agree to never give antibiotics to the subjects.

○ 1972:

■ America wins chess championship (Bobby xyz)

■ Nixon is president and Watergate scandal is coming up

■ Popular Press reports on the study, and it was ended

■ Tuskegee Study went on for 40 years using public’s money

■ 28 of 399 subjects had died

■ Publicity creates mistrust of doctors among blacks

● Institutions that experiment on humans are required to have IRBs (Institutional Review Boards)

○ 1974:

■ Alegal settlement, subjects sued the government.

■ the government paid 10 million dollars which mainly covered medical costs

○ 1988:

■ President Clinton apologizes to 4 of the 8 living subject

■ the youngest Survivor was 97 years old and the oldest Survivor was about 104 years old

● Bad Science:

○ No central supervision and no written protocols

○ years would pass between visits with researchers from Washington DC and Tuskegee subjects

○ There was a period where they didn’t see subjects and went 9 years without knowing anything

○ There was poor record­keeping and subjects got mixed up with controls who didn't have syphilis

○ some subjects got neosalvarsan or penicillin outside of Macon County ○ the upshot was basically that it was useless and nothing was learned ● Ethics: the “no one was harmed” defense

○ Kampmeier: The subjects were not worse off for being in the study ■ A) Neosalvarsan was probably worse than no treatment

■ B) Penicillin was the most effective for primary syphilis

■ C) Many poor African Americans in Alabama would not have gotten penicillin anyways

● Responses:

○ As Aand B were true the researchers didn't know it

■ They should have been given penicillin

○ 12.5% of subjects could have been held by penicillin

○ Doctors agreed to never treat subjects with antibiotics

○ They were lied to and told it was “treatment” for “bad blood”

○ No informed consent until after 1960s.

● Genetic Disease

○ The Human Genome Project: 1990­2003 AGCT

■ Located most of the 25,000 genes

○ 15 million Americans have genetic diseases

○ 2009: the Genetic Information Nondiscrimination Act became law ● Huntington’s Disease

○ Afatal neurological disorder

○ Huntington discovered it, used to be called corea

○ Purely genetic

○ Onset: 35­44

○ There’s no treatment or cure

○ About 25,000 Americans have it

○ Many more are at risk

○ 1983→ genetic marker was found

○ 1993→ gene was found; 60%­80% of people at risk said they would take test ○ Only 1% took it

● Involuntary Psychiatric Commitment:

○ In 1970s, over half of the mental patients in the US were released ■ Many became homeless

○ 1953: 75% in mental institutions; 25% in prisons

○ 2007: 3% in mental institutions; 97% in prisons

○ Why were so many people released?

■ O’Connor vs. Donaldson (1975): the Supreme Court ruled that to be involuntarily confined, you must: 1) Have a mental illness. 2) Be

dangerous to yourself or others

■ This now applies to sex offenders

○ Most states also say:

■ 3) facilities must be as unrestrictive as possible

○ More reasons for release:

■ New antipsychotic drug made people better, thorazine

■ But these are only temporary treatments.

● Schizophrenia:

○ Aform of psychosis; varying degrees of severity

○ 1%­2% of the population has it

○ NOT Dissociative Identity Disorder

○ Onset: late 20s

○ $65 billion to treat it per year

○ Symptoms of Schizophrenia:

■ Auditory (and other) hallucinations

■ Delusions

■ 10% suicide rate

○ John Nash “ABeautiful Mind”

● Prudy→against reproducing if you have the disease

● McMahan→bad to have disabled child instead of healthy, genetic testing is good.

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