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肝脏移植中的伦理问题

Authors
Lisa Anderson-Shaw, DrPH, MA, MSN, ANP-BC
Scott J Cotler, MD
Section Editor
Robert S Brown, Jr, MD, MPH
Deputy Editor
Anne C Travis, MD, MSc, FACG, AGAF
Translators
宋世兵, 主任医师，副教授

引言

对于终末期肝病患者而言，肝脏移植已从实验性操作快速进展为标准治疗。因为外科技术、免疫抑制及器官保存技术的进展，死者供肝肝脏移植患者的1年和5年生存率已分别达到86%和72%，而活体供肝肝移植(living donor liver transplantation, LDLT)患者的1年和5年生存率分别达90%和78%[1]。虽然美国每年完成的肝脏移植已达到大约6000例，但对供者器官的需求远远超过了供给。因此，在肝脏移植等待名单中每年有1800多例死亡[2]，供者器官相对短缺是很多肝脏移植相关伦理问题的基础。

器官捐献

美国目前的器官捐献体系的基础是1968年的统一遗体捐赠法案(Uniform Anatomical Gift Act)，该体系被称为“选择式加入(opting in)”或“表明志愿(expressed volunteerism)”[3]。该法案规定有行为能力的成人可指定其器官捐献意愿。即使死者签署过捐献卡或在器官捐献注册网上登记过，器官获取机构一般会在法案的规定之外而征得捐献者最近血亲的同意，从而确认死者家属支持器官捐献。更常见的情况是，死者没有签署过捐献卡或没有关于器官捐献事先声明的证据。在这种情况下，家属会被要求对死者的意愿进行判断。如果死者最近血亲同意，无捐献卡时也可捐献。但让悲痛欲绝的家属在这样的艰难时期做出这样困难的决定，这给捐献造成了重大障碍。目前正在继续努力加强获取器官捐献事先声明的过程。

美国的很多州都采纳了统一遗体捐赠法案1987年修订版，该法案规定，如果死者生前以书面形式告知了医生其意愿，则无需死者的最近血亲同意器官捐献。美国医学会(American Medical Association, AMA)的伦理与司法事务委员会的观点与此法案一致。该委员会指出：“从伦理角度来说，由捐赠者个人而非其家人来决定其器官捐赠事宜更合适”[4]。统一遗体捐赠法案2006年修订版中包括了“器官捐赠优先于其他临终关怀”的条款，以增加捐赠器官的可用性。此法案引发了一些伦理学问题，即器官捐赠不应优先于其他临终关怀处理决策，如拒绝心肺复苏(cardiopulmonary resuscitation, CPR)和插管[5]。后来提出的修订版本为临终关怀与器官捐献之间的冲突提供了解决途径。

增加供者器官可用性的努力 — 很多原因造成器官捐献程序效率相对较低。如果医生对脑死亡的标准认识不足，则会造成器官不能捐献。针对医疗保健人员的教育项目可有助于阐明关于宣布脑死亡的法律。捐献请求通常由经验不够丰富的人员处理，此为捐献同意率降低的一个相关因素。美国“医疗照顾”保险与医疗补助服务中心(Centers for Medicare and Medicaid Services, CMS)的条例要求医院向当地器官获取机构报告即将死亡的病例和死亡病例。目前，只有获得器官获取机构认可的人才有权向死者最近血亲请求捐献死者器官。最后，家属拒绝同意捐献死者器官的原因包括，对器官捐献缺乏认识及在情绪混乱时难以迅速做出决定。

现已提出了其他一些器官捐赠体系：

强制性选择 — “强制性选择(mandated choice)”是另一种器官捐赠体系，要求有行为能力的成年人记录其器官捐献意愿。根据此方案，所有人都会被要求完成一份标准记录，可能在申请驾照或填写纳税申报单时完成。该决定不会因捐赠者家属而改变。强制性选择的优点包括：消除死者家属就是否捐献器官做出决定的负担，同时尊重个人自主权，还减轻了可能从非同意个体获取器官的担忧。

               

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Literature review current through: 2017-06 . | This topic last updated: 2015-09-23.
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