ETHICAL ASPECTS OF HEART TRANSPLANTATIONS
On February 29, 1968, on the initiative of the Chair of Ethics of Warsaw University and the Department of Medicine of the Polish Academy of Sciences, a conference on the ethical problems raised by heart transplantations was held in Warsaw. In the discussion took part representatives of philosophy, ethics, the sociology of law, and medicine. The debates were opened and, afterwards concluded by Professor Tadeusz Kotarbiński. The following participated in the discussion:
Professor Marek Fritzhand, head of the Chair of Ethics of the Warsaw University Institute of Philosophy, Editor of „Etyka”
Professor Kornel Gibiński, head of the 3rd Internal Diseases Clinic of the Medical Academy of Katowice
Assistant Professor Henryk Jankowski, Deputy Director of the Warsaw University Institute of Philosophy, research worker at the Chair of Ethics
Professor Józef Keller, head of the Department of the Study of Religions of the Polish Academy of Sciences Institute of Philosophy and Sociology
Professor Tadeusz Koszarawski, Chairman of the Polish Medical Society, head of the Department of Surgery of the Institute of Oncology in Warsaw
Professor Leon Manteuffel, head of the Clinic of Chest Surgery of the Institute of Tuberculosis in Warsaw
Assistant Professor Mieczysław Michalik, research worker at the Depertment of Philosophy of the Military Political Academy in Warsaw
Professor Jan Moll, head of the 2nd Surgery Clinic of the Medical Academy in Łódź
Professor Jan Nielubowicz, head of the Department of Experimental and Clinical Surgery of the Polish Academy of Sciences, and of the 1st Surgery Clinic of the Medical Academy in Warsaw
Professor Tadeusz Orłowski, Deputy Secretary of the Medical Department of the Polish Academy of Sciences, head of the 1st Clinic of lnternal Diseases in Warsaw
Assistant Professor Adam Podgórecki, head of the Chair of the Theory and History of Morals of the Warsaw University Institute of Philosophy
Professor Ksawery Rowiński, Scientific Secretary of the Medical Department of the Polish Academy of Sciences
Assistant Professor Magdalena Sokołowska, head of the Department of the Sociology of Medicine of the Institute of Philosophy and Sociology of the Polish Academy of Sciences.
A definite majority of the participants in the discussion did not find heart transplantations objectionable on moral grounds. This was pointed out by Professor T. Kotarbiński who in his concluding speech said: „I think that the answer to the paramount question of whether the ethics we represent here, after the most thorough study of all available information, can find any serious fault with practising heart transplantations, is definitely negative”. The only person to speak against heart transplants was Professor L. Manteuffel, who said: „The mere thought of heart transplants is disgusting to me. Still, I do not know whether disgust fits into the framework of ethics. I simply find this method to be a degradation of human dignity. Do we really have to live at all costs?”.
The participants in the discussion differed in their opinions on the future of transplantation as a medical method. Professors L. Manteuffel, T. Orłowski and J. Nielubowicz, for instance, regard it as a sign of weakness of medicine, to be jettisoned some time in the future. Also Professor M. Fritzhand spoke against overestimating the importance of transplantation in the future, presenting a handful of ethical reasons. On the other hand, Professor J. Moll, who later carried out Poland’s first transplant operation, said that the future of surgery is with transplantology.
A number of details discussed can be grouped around the following topics:
- Whether or not the transplantation runs counter to the medical ethics?
On this point the participants emphasised the necessity of differentiation between kidney and heart transplants. In the first instance it is really debatable whether taking a kidney out of a living and healthy organism is not tantamount to breaking Hippocratic oath, which, first and foremost, imposes on a doctor the duty of protecting human health. However, both the doctors and the ethicists were unanimous in their view that it is noble, and even heroic, for a mother to donate her own kidney to save her child. What is more – they continued – the moral wound she would inflict on herself if she did not sacrifice her kidney would certainly outweigh all implications resulting from the fact of donating it’.
The situation looks different as regards heart transplants, because in this particular case the donor can be only a dead man. „But even in this case – argued Professor T. Koszarowski – the decision to swap organs is neither against the law nor the medical deontology binding in this country”.
- The definition of death
The question of how to define death was given priority by all those present, and the statement by Professor T. Orłowski seems to have been representative of the views voiced during the discussion. He said: „Working out a legal formula for the death of a potential donor is out of question now, since the present methods of classifying the man as dead are far from perfect and there is as yet no official rule to follow. Hypostatic spots appear many hours after the actual death, and at present only after cutting a man’s head off can one be perfectly sure that he is dead”. In Professor M. Fritzhand’s opinion the present definition of death is not a purely theoretical one, but persuasive (appreciative), attributing explicit values to life. This definition, in fact, carries an element of approval of performing operations such as transplants, and so accepting it involves not only a theoretical but also a moral decision.
- The possibility of abuse
The very fact of existence of contesting definitions of death may raise fears about the possibility of abuse of transplantation. However, the medical scientists who attended the discussion presented some ways of ascertaining that a man is dead, used both in Poland and abroad which, in their opinion, eliminate the possibility of committing malversations. Among the latter were named the selling of bodies, the use of violence, the transplantation of hormonopoietic glands, and, in the future, even of the brain. Incidentally, the present-day medicine is not yet so advanced as to make brain transplants possible now.
- The respect for and the utilisation of the corpse
Explaining the existence of certain social prejudices against transplantation, some of the speakers pointed to moral norms which order respect for the corpse. And so, on the one hand, there were voices calling for the maximum respect for the bodies, on purely ethical grounds (Professors T. Koszarawski and M. Fritzhand), and, on the other, emphasis was laid on their full utilisation for transplants. Professor K. Rowiński, who spoke for the latter, put it very strongly indeed. He said: „The cremation of corpses now that their organs can be used for transplants is sheer wastefulness. In fact, I am not against cremation as such. I think bodies can and should be cremated, but only after taking out of them all those organs that can help save the living”.
- Health protection and heart transplantation
Professor K. Gibiński and Assistant Professor M. Sokołowska strongly emphasized the existence of economic limits, disadvantageous for heart transplants, as well as moral and legal problems connected with the choice of a donor. Present economic circumstances eliminate the possibility of carrying out transplants on all those in need. On the other hand, everybody here has the right to benefit from the latest achievements of medicine. „Therefore, have we the moral right to refuse to cure a man if there is a positive chance of success?” – asked Professor K. Gibiński.
- Can hear t transplants cause changes in personality
Views of those gathered differed on the extent of changes in personality brought about by a heart transplant. Some even said that there were no changes whatsoever, others maintained the very fact of regaining health was tantamount to a change of some sort. These conflicting opinions resulted largely from different interpretations of the, term „change in personality”.
- Religion versus transplantation
Professor J . Keller remarked that the source of the existing prejudice against heart transplantation is the cult, prevalent in our culture, of the human heart as the abode of all feelings, mostly positive ones. There is a religious background to it.
- Transplantation and the confidence in doctors
The absence of legal formulas and definitions regulating the conditions for transplantation, and the rapid expansion of medicine constantly increase the doctor’s responsibility for his decisions. Therefore, all those gathered appealed for more confidence in doctor, which does not mean a total abandonment by the society of all precautions against possible abuse of transplantation .
- Transplantation and the tasks confronting ethicists
The participants in the seminar were unanimous in their view that lively discussions on heart transplantation are proof of great moral sensitivity of the society. Still, the ethicists, distant as they are from presenting ultimate solutions, must point out, to both society and the physicians alike, the complexity of circumstances under which their decisions are made. It was further decided that close co-operation between physicians and ethicists may lead to elaborating a modern medical ethics, among whose tasks would be not only compiling a doctor’s moral code, but which would, first and foremost, teach them to think in rational terms once they are confronted with ethical issues, brought to the surface in profusion by the development of modern medicine.