National recommendations for donation after cardiocirculatory death in Canada: Donation after cardiocirculatory death in Canada.

These recommendations are the result of a national, multidisciplinary, year-long process to discuss whether and how to proceed with organ donation after cardiocirculatory death (DCD) in Canada. A national forum was held in February 2005 to discuss and develop recommendations on the principles, procedures and practice related to DCD, including ethical and legal considerations. At the forum's conclusion, a strong majority of participants supported proceeding with DCD programs in Canada. The forum also recognized the need to formulate and emphasize core values to guide the development of programs and protocols based on the medical, ethical and legal framework established at this meeting. Although end-of-life care should routinely include the opportunity to donate organs and tissues, the duty of care toward dying patients and their families remains the dominant priority of health care teams. The complexity and profound implications of death are recognized and should be respected, along with differing personal, ethnocultural and religious perspectives on death and donation. Decisions around withdrawal of life-sustaining therapies, management of the dying process and the determination of death by cardiocirculatory criteria should be separate from and independent of donation and transplant processes. The recommendations in this report are intended to guide individual programs, regional health authorities and jurisdictions in the development of DCD protocols. Programs will develop based on local leadership and advance planning that includes education and engagement of stakeholders, mechanisms to assure safety and quality and public information. We recommend that programs begin with controlled DCD within the intensive care unit where (after a consensual decision to withdraw life-sustaining therapy) death is anticipated, but has not yet occurred, and unhurried consent discussions can be held. Uncontrolled donation (where death has occurred after unanticipated cardiac arrest) should only be considered after a controlled DCD program is well established. Although we recommend that programs commence with kidney donation, regional transplant expertise may guide the inclusion of other organs. The impact of DCD, including pre-and post-mortem interventions, on donor family experiences, organ availability, graft function and recipient survival should be carefully documented and studied.

Ethical perspectives for public and environmental health: fostering autonomy and the right to know.

In this paper we develop an ethical perspective for public and environmental health practice in consideration of the "right to know" by contrasting consequential and deontological perspectives with relational ethics grounded in the concept of fostering autonomy. From the consequential perspective, disclosure of public and environmental health risks to the public depends on the expected or possible consequences. We discuss three major concerns with this perspective: respect for persons, justice, and ignorance. From a deontological perspective, the "right to know" means that there is a "duty" to communicate about all public health risks and consideration of the principles of prevention, precaution, and environmental justice. Relational ethics develops from consideration of a mutual limitation of the traditional perspectives. Relational ethics is grounded in the relationship between the public and public/environmental health providers. In this paper we develop a model for this relationship, which we call "fostering autonomy through mutually respectful relationships." Fostering autonomy is both an end in public health practice and a means to promote the principles of prevention, precaution, and environmental justice. We discuss these principles as they relate to practical issues of major disasters and contaminants in food, such as DDT, toxaphene, chlordane, and mercury.