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Case studies: c-section for organ donation.

This case forces us to question the Kanfian principle that human beings Must never be treated solely as a means for the good of others. It also further complicates the already difficult questions surrounding the treatment of infants with anencephaly. Ms. F's request puts herself at risk not to benefit her fetus, who will die regardless of any intervention, but for the potential benefit to another child of her own child's organs. Not only is this fetus to be used to benefit another, but now the mother's own life may be put in danger to benefit a third person. For a variety of reasons, this cesarean section should not be performed. The rationale for refusing the woman's request emerges clearly when we analyze critically the most plausible arguments that might be put forward in favor of a cesarean section under these circumstances.

The first, and perhaps most forceful, argument rests on the principle of autonomy. Some, including Ms. F herself, the transplant surgeon, and the potential recipient's family, might argue that the decision whether to have a cesarean section to "save" her fetus is hers, and hers alone. This, in fact, is the very argument that has been made against forcing a woman to undergo a cesarean section against her will to save the life of a (presumably healthy) fetus. By the same token, the United States Supreme Court has upheld the freedom of a woman to have an abortion (within certain limitations) precisely because she has a right to privacy and to make decisions affecting her own body. How, then, can the principle of autonomous decision making by a competent adult be set aside in this case?

Autonomy, important as it is, should not be the overriding moral principle in all cases. Indeed, the fact that a person requests a medical therapy is not in itself sufficient reason for the physician to comply. The Physician's decision must be based, first and foremost, on a professional judgment about what course Of action is medically indicated in the particular situation. In this case, there are no compelling medical reasons for Ms. F to have a cesarean section insofar as neither she nor her fetus stand to benefit from the procedure. Ideally, this issue should have been raised and discussed by the physician at the time the initial diagnosis of anencephaly was made. Ms. F would then have known in advance that a cesarean section would be performed only if her life were in jeopardy as, for example, in the case of placenta abruptio.

In response, it might be argued that the benefit being sought here is not primarily medical, but emotional. Ms. F wishes to undergo surgery in this case for the psychological benefit she believes will result from finding some good in this tragic situation. Moreover, there are medical benefits (at least potentially) for the organ recipient and his or her family, and these may warrant performing the cesarean.

The potential benefits to Ms. F depend on several contingencies, not the least of which is having a liveborn child, which occurs only in approximately 50 percent of cases of anencephaly. Even if a cesarean section were performed and the child delivered alive and not suffering from asphyxia, there is still a high probability that its organs would not be acceptable for transplantation. Not only is there an increased incidence of low birth weight among infants born with anencephaly between 5080% of these infants have a birth weight less than 2500 gm), but also an increased incidence of other congenital malformations of major organs (between 25 and 30% of these infants have gross malformations of at least one other organ). Either one of these factors might render the child's organs unacceptable for transplantation, and thus negate the potential psychological benefit to the mother and the possible medical benefit to the recipient. Finally, even if the child were born alive, of adequate weight and with viable, normal organs, a suitable recipient would have to be found and a successful transplantation performed before the mother could hope to gain any measure of emotional comfort.

The odds of all this occurring are not great. In such a case, where the possibility of producing real, lasting benefits is so limited, the principle of nonmaleficence takes medical and moral priority. The potential morbidity to Ms. F is not insignificant, with complications occuring in 25 to 50 percent of cesarean section deliveries. Even if the probability of success were significantly higher, potential benefit to an organ recipient should not be considered in determining appropriate treatment for a patient. We must not compromise the medical care of patients simply to secure one or more of their vital organs, however much these might benefit others, especially if there is a risk to the patient in donating the organ. In fact if Ms. F's reason for requesting a cesarean section were simply to give her child the greatest chance for some sort of life, however short, it would seem easier to justify ethically although still not medically).

In summary, a cesarean section should not be performed in this case to save the fetus. It is not medically indicated for the mother or fetus. In addition, there is a real risk to the mother from a cesarean section, with only limited potential benefits.

The first question this case raises is why the parents were given the option of donating their infant's organs. Anencephalic infants are not now, and probably never will be a significant source for transplantable organs: Most women choose to abort rather than carry to term a child who has no chance of survival; about half of the anencephalic infants carried to term are stillborn, and often the organs of those who survive birth are damaged during the dying process of the child. The number of organs available for transplantation is reduced even further when we consider the difficulty of matching the organs with potential recipients, since the diseases for which the organs are needed are relatively rare.

And before continuing a pregnancy with the hope of giving birth to a child whose organs could be removed for transplantation into other children would be a realistic option, many technological advances are necessary: procedures to keep anencephalic infants alive (or their organs in functioning order) while suitable recipients are located, consensus on standards for determining the death of donor infants, and successful transplantation procedures at several medical centers across the country. Currently, then, we need to recognize that at a societal level, using the organs of anencephalic infants will not significantly reduce the shortage of small transplantable organs, and on an individual level, the chances of using organs from a particular infant with anencephaly are slim.

While in principle I believe that it is ethically appropriate to harvest organs from anencephalic infants, I worry about the way in which the option is presented to grieving parents. Parents like Ms. and Mr. F want to donate the organs of their anencephalic child to soften their tragedy; they believe that at least some good can come out of their pain. To do this, they continue a pregnancy which otherwise they might have aborted-and so they donate not only their child's organs but themselves as well. Yet the organs are not likely to be usable, despite all efforts. This failure is apt to increase the parents' suffering and sense of loss: Not only have they lost their own child, but they have lost someone else's as well. Ironically then, one of the reasons for wanting to take the organs of an anencephalic infant-the well-being of the parents-also stands as a reason against doing so. The only bulwark against this compounded sense of loss is knowledge: If parents are ever given the option of donating their anencephlic infant's organs for transplantation into other children, then it must be with a clear understanding of the facts. False hope is no hope.

In the case at hand, a couple has been struggling for six weeks with the realization that their child cannot survive, and they have dealt with it by deciding to donate the child's organs so that some other child (or even children) can live. Now their fetus is in distress, is probably dying, and Ms. F wants to undergo a cesarean section to save its life. This type of fetal distress is common in these cases, so a decision should have been made beforehand about what would be done should this occur. There is no reason for this decision to be a sudden one; there is no reason for the physician to be taken by surprise. I am, of course, assuming that the physician recognizes the importance of communicating with her patients and takes seriously the doctrine of informed consent. In other words, I am assuming that the physician has fulfilled her responsibilities by informing the couple of all of the relevant facts (including the very real possibility that their child could die in utero) and by discussing the alternatives available (including the option of having a cesarean section should the fetus experience distress). It also means that the physician would have made plain any qualms she might have about performing a cesarean section to save the life of the fetus-indeed, she would have tried to convince the parents to forgo the operation because of the increased risks to the mother it presents-and she would have made provisions with the couple to transfer their care to another physician in the event that she was unable to persuade them to accept her recommendation.

Should die physician accede to Ms. F's request for an operation? Under the conditions presented above, and assuming the fetus is in real distress, yes. It is Ms. F's body, her sense of worth, her values that are at stake. She has decided to carry her fetus to term and donate its organs to benefit some other child (not a small sacrifice on her part), and she has decided to undergo a cesarean section for the same reason (an even larger sacrifice, but not an unreasonable one, given the relative safety of the procedure). She would make this decision, I presume, over the course of several weeks' time and in consultation with her physician and her husband. Although her decision may exhibit a degree of altruism or even self-sacrifice with which we are uncomfortable, there is no reason to believe that it is self-destructive, or delusional, or in any way incompetent or nonvoluntary. Hence the physician has no justification for overriding it.
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Title Annotation:includes commentaries
Author:Berkowitz, Sheldon T.; Newman, Louis E.; Mathieu, Deborah R.
Publication:The Hastings Center Report
Date:Mar 1, 1990
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