The future of global health:The future of global health:Navigating a complex ethical terrainNavigating a complex ethical terrain

Mary Simmerling, PhD

Assistant Professor of Research Integrity in Medicine

Office of Research Integrity & Assurance (ORIA)

Office of Research Integrity

Service, training, and research to address health problems that transcend national boundaries, disproportionately affect the resource poor, and are best addressed by multidisciplinary solutions. 

Goal is to create a sustainable and innovative research and training program that engage students and faculty at all levels and from multiple disciplines to solve problems of global health.

Global Health at Weill Cornell Medical College

Australia: University of Sydney Medical School Brazil: UFBa and FIOCRUZ India: Christian Medical College India: Narayana Hrudayalaya and Mazumdar-Shaw

Cancer Center Peru: San Marcos Medical College Qatar: Weill Cornell in Qatar Tanzania: Weill Bugando Haiti: GHESKIO Centers

Major Global Health Initiatives at WCMC

GHESKIO (Groupe Haitien d’Etude du Sarcome de Kaposi et des Infection Opportunistes) Centers

* 'Managing Conflicts of Interest in Clinical Care: The 'Race to the Middle' at US Medical Schools' appeared in the October 2013 edition of Academic Medicine, Vol. 88, No. 10 – data based on September 2011 Policies

* 'Managing Conflicts of Interest in Clinical Care: The 'Race to the Middle' at US Medical Schools' appeared in the October 2013 edition of Academic Medicine, Vol. 88, No. 10 – data based on September 2011 Policies

* 'Managing Conflicts of Interest in Clinical Care: The 'Race to the Middle' at US Medical Schools' appeared in the October 2013 edition of Academic Medicine, Vol. 88, No. 10 – data based on September 2011 Policies

1982

2014

How do we respond when things don’t go that well?

What happens at the intersection of longstanding cultural norms and moral disagreements/disharmonies?

What happens when we are faced with conflicting demands (internal or external)?

Philosophical considerations

Principles based framework for establishing: What is morally permissible/justifiable What is morally required (eg, as a duty or

obligation) What is morally unjustifiable

Guiding/foundational moral principles

BeneficenceDo good, don’t harm

Respect for persons Treat people as autonomous agents (with limitations)Allow them to make their own decisionsPut them in a good position to make those decisions in a well-informed way (power differential, knowledge differential)

JusticeFairness (not necessarily equality, but consistency)

Do we need to respect everyone and everything?

What does it mean to do good? Towards what end?

How do we resolve competing moral – and practical - demands?

With hard questions…..

Beneficence

What maximizes benefits?

Whose benefits?

Who gets to decide?

Respect for Persons

Who gets to choose (be a chooser)?

Under what circumstances?

Justice

Fairly sharing benefits and burdens – should geographic lines matter? Are they morally relevant?

Defining the standard of care: is it where one stands at the time, or is it defined by the best (available) options? Does this mean the poor should get less, because they have less? (and if so, how could THAT be fair?)

Organ transplantation in China

January 2007 – Vice Minister of Health publicly admits that China uses organs from executed prisoners for transplantation

Case for consideration/discussion

How should we respond?

Supply & Demand – US & PRCSupply & Demand – US & PRC

US:– SUPPLY:

• ~30,000 transplants in 2005

• 12,958 donors in 2011 (7,502 deceased)

– DEMAND:• > 112,905 currently wait

listed for transplant

PRC:– SUPPLY:

• ~10,000 transplants/year

– DEMAND:• ~1.5 million in need

of transplant

HBV and HCV Prevalence

Worldwide Incidence of HCC

• China

– 120,000 deaths per year

– Highest incidence in the world

– Second leading cancer related cause of death

Sources of OrgansSources of OrgansUS

– Living donors (~50%) • Biologically & emotionally

related• Stranger/”Good Samaritan”

– Deceased donors (~50%)• Donation after cardiac death • Donation after brain death

(1968)

PRC

– Living donors (~5%)• Currently all living donors

are genetically related to recipient – e.g., parents, children, siblings

– Deceased donors (~95%)• Donation after cardiac

death – Small percentage

(~2-3%) from traffic accident victims

– Majority of deceased donor organs from executed prisoners (Huang, 2007)

Use of Organs from PrisonersUse of Organs from Prisoners

US• Prisoners are allowed to

donate organs (while alive and at death), though deceased prisoner organs are rarely used – no use of organs from executed prisoners

• South Carolina passed legislation allowing the creation of a network for organ & tissue donation in prisons

• In 2007 legislation was under consideration in South Carolina that would have given prisoners the option to donate organs in exchange for 180 days off their sentence

PRC

• Prisoners (and their families) are asked to give consent to allow their organs to be used for transplantation after execution

Executions in the US 1930-Executions in the US 1930-20062006

U.S. Dept of Justice Office of Justice Programs Bureau of Justice Statistics

US - 2006• Population in US

~298,444,215

• US DOJ states that 53 prisoners were executed in 2006

PRC - 2006• Population in PRC

~1,313,973,713 (~4x that of US)

• Amnesty International has estimated that ~1,700 prisoners were executed in PRC in 2006 (per capita ~32x that of US)

Number of Number of Executions/Population Executions/Population

• Separability between medical organ transplantation and the criminal justice system• Although the practice of organ transplantation is

standardized globally, the systems and mechanisms for criminalization and punishment of citizens varies widely

• Use of organs from executed prisoners in PRC has been widely criticized by international transplant community

• US’s decision not to use organs from executed prisoners has been criticized as unethical by some who argue it is wasteful

Use of Organs from Prisoners

Access to TransplantationAccess to Transplantation

US– National recipient waiting

list– National allocation system

- deceased donor organs “public” goods

– No national heath insurance

– Average cost of liver transplant in 2011 $557,100 US

PRC– No national recipient

waiting list– No national allocation

system– No national health

insurance– Average cost of liver

transplant ~$30,000 US

Ethical ChallengesEthical Challenges

• Historical Challenges• Feasibility• Risks & Benefits • Scarcity, Supply &

Demand• Access & Allocation • Informed Consent• Use of prisoner organs• Organ sales

• Continuing/Emerging Challenges

• Risks & Benefits • Scarcity, Supply &

Demand• Access & Allocation • Informed Consent• Use of prisoner organs• Organ sales• Transplant tourism

Continuing & Emerging Ethical Continuing & Emerging Ethical ChallengesChallenges

• US• Promote deceased donation• Ensure validity of informed

consent for donors & recipients (living & deceased donors)

• Ensure protection of vulnerable individuals

• Prevent organ trafficking & transplant tourism

• Standardization of evaluation & consent criteria for living donors

• Move towards greater equality of access to transplantation – address issue of poverty as a de facto contraindication for tx

• Address issue of compensation/organ sales

• PRC• Promote deceased donation• Ensure validity of informed

consent for donors & recipients (living & deceased donors)

• Ensure protection of vulnerable individuals

• Prevent organ trafficking & transplant tourism

Legislation of TransplantationLegislation of Transplantation

US• 1968 - Uniform Anatomical gift

Act (UAGA)– Establishes comprehensive &

uniform laws regarding organ and tissue donations

• 1984 – National Organ Transplant Act (NOTA)– Prohibits commercial dealings

in organs for transplantation

PRC• 1995 – Ministry of Health

enacts “The Human Organ Transplant Ordinance” – Prohibits commercial dealings

in organs for transplantation– Regulates living donor

transplantation

• November 2006 – Guangzhou meeting – established “entrance criteria” for programs – reducing the number from 600 to 125/150

• 2007 – Regulation of Human Organ Transplantation

Challenges Challenges

• Abolishing & criminalizing transplant tourism• China has already taken a clear and strong position against

this human rights abuse, however there is still a need to enforce it

• Utilizing living organ donors without contributing to the organ trafficking problem

• Establishing an ethical framework for transplantation that reflects China’s history, culture, and beliefs

OpportunitiesOpportunities

• Use of brain dead donors in PRC

• Establishment of a national system for access and allocation of organs

• Further improvement of procedures for informed consent for living & deceased donation

• The global transplant community has supported China’s efforts to establish an ethical framework for transplantation that reflects China’s history culture, beliefs, and values - simply imposing a distinctively Western ethic on China would be disrespectful & may be damaging to China’s efforts.

• At the same time, initiated sanctions by barring publication of articles utilizing organs from executed prisoners

Support, and sanctions

Moral engagement

Be humble, curious, and creative

Approach issues with humility, gravitas, and honesty

Recognize these are complex and serious issues that can’t be solved alone, and often are not completely solvable

Don’t be a moral bystander – take the opportunity to tune your moral compass