A Short Précis of Transplantation Dogged by problems surrounding rejection;

Law and Ethical Issues in Harvesting Solid Organs for Transplantation from Deceased Infants and Children by William J Keough, BA, LLB, Dip.Crim, M.Hlth & Med.Law Barrister & Solicitor, Melbourne Australia Paper presented to the 6th World Congress on Family Law & Children’s Rights, Sydney, Australia, March 2013

“New technologies like transplantation force society to continually re-examine the values and boundaries of life and death” A Caplan & D Coelho, eds, The Ethics of Organ Transplantation, Prometheus Books, NY, 1998 @ p.13.

A Short Précis of Transplantation • Dogged by problems surrounding rejection; • First successful Kidney Tx in 1954 – twins with same antigens; • First Heart Tx in South Africa in December 1967 – died 18 days; • American Heart Tx in 1968 – lived >8 years.

Live Organ Donation: an organ taken from a living person and given to another, eg: a kidney; • Cadaver Organ Donation: an organ taken from a person shortly after death and transplanted into another; • Xenotransplantation: an organ taken from an animal and used in humans; • Genetically Created Organs: arising from advances in undifferentiated stem cell research; and • Artificial Organs.

Staunton identifies the wide range of tissue currently being transplanted as follows: Regenerative Tissue Blood; Bone Marrow; Skin. Non-Regenerative Tissue Blood Vessels; Bone; Corneas; Heart; Intestines; Kidneys; Liver; Lung; and Pancreatic Tissue. P Staunton, Law For Nurses & Midwives, 7th Edition, Elsevier, Sydney, 2013, @ p.303.

The Paediatric Context . This is Canadian Dylan Stork who weighed 5.5 lbs, or 2.5 kilos at the time of transplant.

Donation Statistics for Paediatric Population For the period 2003-2005 there were only 9 deceased donors in the age group of 0-4 years, and 25 donors in the age group of 5-14 years; For the period 2006-2008 there were 5 donors in the 0-4 year age group and 21 donors in the 5-14 year age group; and For the period 2009-2011 there were 8 donors in the 0-4 age group and 20 donors in the 5-14 age group. ANZOD 2012 Report @ p.7

Parental Willingness to Donate • Prior Exposure to Organ Donation information; • Their own beliefs; and • Who First Mentions Donation.

Emotional Issues Dominate Refusal to Consent The process of ”decoupling” (ie: separating the death declaration from the donation request) has been shown to increase consent rates. E Tsia, et al, “Organ Donation in Children: The Role of the Pediatric Intensive Care Unit”, 2000, Vol 1, No 2, Pediatric Critical Care Medicine, 156.

Definitions of Death There are essentially three definitions of death from a theoretical perspective: • Traditional heart-lung [cardiac] definition; • Whole-Brain Death; and • Higher Brain Death. B Ott, “Defining & Redefining Death” in A Caplan, ed, The Ethics of Organ Transplants, Prometheus Books, NY, 1998, p.16 @ p.17

Cardiac Death • Cessation of Heart and/or Lung Functioning • “Clinically Recognisably Dead” • Not Pink, Warm and No Reflexes

Brain Death “Coma Dépassé”, literally a state beyond coma, just before death. P Mollaret and M Goulon, “Le Coma Dépassé (Mémoire Préliminaire)”, 1959, 101, Review of Neurology, 3. See also D Lamb, Death, Brain Death & Ethics, 1985, Croomhelm, London, p.4. “Harvard Criteria” (i) Unreceptive & Unresponsive – patient shows total unawareness to externally applied stimuli, even painful stimuli; (ii) No Movement or Breathing – all spontaneous muscular movement is absent; and (iii) No Reflexes – no response to external stimuli and no tendon reflex.

Higher Brain Death “Loss of higher brain functions robs us of all that makes us human in any sense beyond that defined by our genetic endowment” J Botkin, “Anencephalis Infants as Organ Donors”, 1988, Vol 82, No 2, Pediatrics 250, @ p.252.

Anencephalic Infants • Cerebrum and Cerebellum (“Higher Brain”) is absent • Brain Stem (“Lower Brain”) is present • Never Experiences Consciousness • Very Short Life Span – less than half survive >1 day • Remainder of Organs fully functioning • Neither “Cardiac Dead”, nor “Whole Brain Dead” • Violation of “Dead Donor Rule” • “brain absence” be given the same medico-legal significance as brain death. M Harrison, “Organ Procurement for Children: The Anencephalic Fetus as Donor”, 1986, 2 Lancet, 1383-1385.

The Law Australian Law favours “Whole Brain Death” in the alternative to Cardiac Death” Section 41 Human Tissue Act 1982 (Vic) Section 33 Human Tissue Act 1983 (NSW) Law Sitting on the Fence

So What Does This All Mean in Practice? The Moral Imperative: The Utmost Adherence to Sensitivity and Respect

Caregivers of deceased infants/children be approached about organ donation • Decoupling • Best Practice • The Moral Imperative: The Utmost Adherence to Sensitivity and Respect

A Short Précis of Transplantation Dogged by problems surrounding rejection;