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First Person Authorization

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First Person Authorization…..Is Objection an Option?
Cindy Sleeper
Ottawa University
December 7, 2015

First Person Authorization….Is Objection an Option?
Midwest Transplant Network (MTN), is a not-for-profit Organ Procurement Organization (OPO), which provides procurement services for the recovery of organs and tissues utilized for transplant purposes. Some individuals choose, while living, to become donors of these tissues upon their death. This is termed a “first-person authorization” and is a legal binding document that cannot be revoked by the family or legal next-of-kin. However, there are occasions where families fiercely object to donation and MTN must reflect on what path is the most ethical to pursue; follow the wishes of the donor or concede to the objection of the family. This paper will examine the three theories of ethics: utilitarian, principle-based, and virtue and discuss which theory applies to this ethical dilemma.
Introduction
Midwest Organ Bank was originally founded in 1973 with the sole purpose of providing organ transplant and procurement services to transplant centers and hospitals throughout Kansas and Western Missouri communities. Organs recovered for transplant included kidneys, liver, heart, lung, pancreas, and intestines. In 1990 Midwest Organ Bank added tissue recovery services to their scope of practice to enable the transplant of life-enhancing tissues. These tissues included heart valves, bone, skin, and blood vessels. In 1998 the addition of eye banking services was added in order to provide the opportunity for corneal transplants. With the expansion of services being provided, Midwest Organ Bank changed its name to Midwest Transplant Network in 1999 and remains in that capacity today (mwtn.org).
Governance
As a not-for-profit OPO, MTN is regulated by the United States Department of Health and Human Services with the Health Resources and Services Administration (HRSA), responsible for overseeing transplantation activity (organdonor.gov). There are fifty-eight OPO’s in the United States to date and all are required by federal law to be members of the Organ Procurement and Transplantation Network (OPTN). In addition, all OPO’s must be certified by the Center for Medicare and Medicaid Services (CMS). According to HRSA, the field of organ and tissue procurement and transplantation is the most highly regulated of all medial entities.
History of First-Person Authorization
In 1968 both the Kansas and Missouri legislatures recognized a signed donor card for organ and tissue recovery as a legally binding document. Put simply, the conscience decision made by a living person to donate their organs and tissues upon death was to be recognized as an authorization by all concerned parties. This was deemed a “first-person authorization.”
Missouri First-Person. On August 28, 2008 Missouri lawmakers passed legislation allowing for the development of a state-wide registry that would serve as a database for all registered donors. The Missouri first-person legal binding document allowed the consent for recovery of all eligible organs and tissues for transplant. However, it did not allow for the recovery of organs and tissues for research purposes. A consent addendum would have to be obtained from the family for this to occur (senate.mo.gov). Currently, 70% of adults are in the Missouri First-Person registry.
Kansas First-Person. On July 1, 2010 Kansas lawmakers passed legislation allowing for the development their state-wide registry to serve as a database for all registered donors. The Kansas first-person legal binding document allowed for the recovery of organs and tissues for both transplant and research purposes (House Bill 2486. Sec 2 KSA 2009 65-3230). Currently 59% of adults are in the Kansas First-Person registry.
Stakeholders
MTN remains the only OPO to date covering all Kansas and Western Missouri communities. MTN”s mission of “saving lives by honoring the gift of donation with dignity and compassion” (mwtn.org), is evident by their dedication to the individuals and entities it serves.
Government. MTN partners with state and local governments to help educate the public about the importance of donation and the power of the gift as they apply or renew their driver’s license. Ongoing connections with state legislators assures that laws are up-to-date for the protection of donors and recipients alike.
Healthcare. MTN partners with healthcare organizations and hospitals to extend legacies, provide hope, and facilitate the giving of the gift of life from one person to another when circumstances present themselves. Education and support of the medical staff is ongoing to help with the often times emotional circumstances they are presented with.
Funeral homes, religious leaders, and medical examiners. Ensuring that funeral home personnel, religious leaders, and medical examiners are supported is vital. Funeral homes and medical examiners receive donors after organ and tissue recovery is complete and are expected by family members to determine the cause of death and to prepare their loved ones for final services. Ensuring they are kept informed of timeframes will assist them in providing for families.
Volunteers. MTN could not provide support for its donor families if it were not for the assistance of volunteers and ambassadors. These are the individuals who give of their time and talent to sit with families and share personal stories of donation and emotional recovery.
Donor families. Donor families are the backbone of the entire donation process. Without their interest in pursuing donation and participation in providing past medical and social history, donation would not be possible.
Recipients. The last obvious stakeholder are the recipients. Currently there are 122,278 individuals who are waiting for an organ; 22 of which will die today without the opportunity to receive one (organdonor.gov). Converting consented donors into actual recovered donors is vital to the lives of so many waiting for a second chance at life (see Appendix A).
The Ethical Question
Currently MTN realizes a 62% conversion rate for those individuals who are not first-person authorizations (mwtn.org). This means that 62% of families approached for organ and/or tissue donation authorize the recovery of said organs and/or tissues. But what happens if an individual is in the first-person authorization registry and the family objects to donation. Can they decline donation of their loved ones tissues and/or organs based on their personal objection? Kansas and Missouri law say no, a first-person authorization is a legal-binding document completed by an individual prior to death.
As an organ procurement organization, MTN has a moral and ethical obligation to honor the wishes of an individual whose desire to become an organ and/or tissue donor is known. However the dilemma remains: Is it worth the potential damage to already fragile families and ultimately MTN’s reputation if MTN rejects a family’s objection to organ and/or tissue recovery? How hard does one fight when a grieving family wants is to be able to effect one outcome or have a little control over a situation that has been out of their control? Currently 20% of families who object to donation have overridden a First-Person Authorization (mwtn.org).
Ethical theories
Individual ethics and corporate behaviors have been studied by philosophers for decades. Socrates, Plato, and Aristotle’s theories on ethics were reflected in their writings and have been expanded on throughout time. The most supported theories of today include utilitarian, principle-based, and virtue ethics.
Utilitarian. Utilitarian is defined as “the ethical tradition that directs us to make decisions based on the overall consequences of our acts” (DesJardins, 2014, pg. 24). Simply put the decision is associated with maximizing the greatest good for the greatest numbers.
Principle-based. Principle-based (Kantian), ethics emphasizes that sometimes the correct path is determined not by its consequences but by certain principles or duties (DesJardins, 2014, pg. 37). Focusing on the importance of general principles such as respect and justice are the backbone of principle-based ethics. Believing that individuals have rights and that these rights should not be surrendered for the sake of an increase in the overall good that cannot be overlooked. Principle-based ethics are believed to be vigorous and flexible because they provide guidance based on the organization’s principles and not the individuals. This makes it easier to cope with the rapid changes that often times occur in business and encourages responsibility to exercise professional judgement.
Virtue-based. Virtue-based ethics emphasize ones moral character and places less value on which principle or rule should be followed. Traced back to the teachings of Plato and Aristotle, virtue-based ethics encourages focusing ones attention on helping people develop good characteristics such as respect, justice, truthfulness and loyalty (DesJardins, 2014). The theory is that as an individual matures, certain virtues will help them be able to make correct decisions later in life or business.
Analysis
Appendix A provides an overview of the positive and negative effects that could occur should MTN pursue donation despite family objection. A quick glance would suggest that by Utilitarian standards, MTN’s pursuit of first-person authorization despite family objections would result in greater good for all. There are many who would benefit from such an aggressive approach, however one should note that two parties fall into both categories suggesting a conflict does exist.
Applying Kantian’s principle-based approach to MTN’s dilemma also seems applicable in this case. Based on principles alone, one could question whether or not MTN should deny the rights of the family who objects to donation. Doing so can send the wrong message to several of the stakeholders and portray MTN as being insensitive. On the other hand complying with a family’s objection seems like a denial to the individual who decided to become a donor in the first place.
Although uncommon, MTN has experienced family objection to donation throughout the years. Each objection is handled individually and the decision is based on what is best for all parties involved. And with each situation, MTN has grown through knowledge obtained and values embraced. This would support the idea that virtue-based ethics does apply in this instance.
MTN philosophy
It has been my experience during years of employment at MTN that family objection is taken very seriously as is a donor’s wishes. As mentioned above, each objection is handled in a very individual and personal way. Families are reeducated on the definition of first-person authorization and what that means. Every option is explored and concern addressed. If after this in-depth communication has occurred and family’s still present objection, it is the practice of MTN to walk away. MTN holds true to their principles that in the end their moral and ethical obligations rest with honoring a family’s objection so as not to create further grief in an already unbearable situation.
Conclusion

One donor has the potential to save eight lives through organ donation and one-hundred plus lives through tissue donation (americantransplantfoundation.org). With a nation-wide shortage of organs and tissues available for transplant it should be obvious as to why a first-person authorization is important to society. And since it is a legal-binding document irrevocable by law, an individual would think that objecting would not be an option. But it does occur. There are many opportunities in life and in business to act either with integrity and honesty or with greed and deceitfulness. MTN’s decision to walk away from donation after a strong objection from family has occurred supports their mission and speaks to the fact that sometimes one must forgo following the rules and focus on what is morally and ethically right. Allowing families to make decisions at a time when they feel most vulnerable shows great character and respect for the communities they serve.

References
DesJardins, J. (2014). An introduction to business ethics (5th ed.). New York, NY: McGraw- Hill.
Facts and Myths - American Transplant Foundation. (n.d.). Retrieved November 14, 2015, from http://www.americantransplantfoundation.org/about-transplant/facts-and-myths/. http://senate.mo.gov/08info/BTS_Web/Bill.aspx http://www.kansas.gov/government/legislative/bills/2010/
Midwest Transplant Network. (n.d.). Retrieved November 14, 2015, from http://www.mwtn.org.
Why Organ, Eye, and Tissue Donation? (n.d.). Retrieved November 14, 2015, from http://organdonor.gov/index.html

Appendix A
Stakeholders
Positive Affects | Negative Affects | * Government 1) Driver’s License Bureau 2) Legislature * Healthcare 1) Hospitals 2) Hospice * Funeral homes * Religious leaders * Medical examiners * Volunteers * Recipients * MTN | * Donor families * Recipients * MTN |

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