Budny 10:00 L03
WHOSE KIDNEY IS IT ANYWAY? : THE BIOPRINTED ORGAN
DEBACLE
Eric Baumann (emb153@pitt.edu)
SCENARIO
As a fine, young doctor, I, Eric Baumann, certainly
back down many arduous tasks. This past week at the
University Of Pittsburgh Medical Center: Presbyterian, I
faced one of the toughest ethical dilemmas I have ever faced,
and I’d like to reflect on my actions and thought processes in
this essay.
On January 2nd 2027, a sixty-five year old
gentleman, herein referred to as Patient #1, came into the ER
complaining of fatigue and nausea. I determined that he had a
developing case of renal failure. While he was not necessarily
at risk for death at the moment, he surely would be by the end
of the month. I predicted that without treatment he would have
a month to live. This man needed a kidney transplant, and he
would surely die waiting on the transplant list because of his
nicotine addiction. His smoking habits label him a higher risk
patient than someone who doesn’t smoke. In other words, he
is looked at as more likely to destroy his organs. I decided to
inform him of a new, risky option: a bioprinted kidney. The
procedure of bioprinting a working organ is relatively new,
but it was a no-brainer because he would die without our
efforts. I informed him of how new the bioprinting process is,
and he agreed to go forward with it. The first step in producing
a bioprinted organ involves taking a sample of “autonomously
self-assembling cellular spheroids” from the patient [1]. Then,
using a computer generated design for a heart, the patient’s
sample is printed layer by layer into the kidney form [2].The
printed sample is given some time to self-assemble and “train
itself” to work as a kidney, and is then ready for the normal
transplant procedure.[2]
The kidney and patient were prepared scheduled for
surgery at 13:00 on January 19th. Two hours prior to the
transplant, we were informed of an incoming patient suffering
a crush injury from a serious motor vehicle accident with
vehicular rollover. The motor vehicle accident patient, a 26
year old mother of two, herein referred to as Patient #2, was
severely injured by the high speed car crash. She was
immediately rushed into the ER where we diagnosed her as
having multiple internal injuries. The most serious of her
injuries was acute renal failure; her kidneys were essentially
destroyed by the crushing blows of the impact. It was a shock
she even made it to the hospital without dying. She needed a
kidney, and she needed it fast.
It is at this point in my day that I was faced with one
of the hardest decisions I’ll ever make in my career: who
University of Pittsburgh, Swanson School of Engineering
should get the kidney? According to my prediction, Patient #1
should survive until we can bioprint him another kidney.
Patient #2 needs a kidney within a few hours or else she is
surely to die.
My immediate next step was to talk to Patient #1
about how his kidney is needed to save Patient #2. As my
background in the National Society for Professional
Engineers taught me, I made sure to be “objective and
truthful” in my comments to him [3]. I told him that I believed
we should be able to make a kidney for him in a timely
manner, but that if anything were to go wrong with that
production, he may die waiting for his kidney. I made sure he
knew that it was completely his decision of whether he would
like to keep his surgery time on January 19th. He said that if it
were up to him, he would like to have the kidney transplant.
In my short amount of time to think before making
my decision, I came upon a case study that referred to a group
project. In said project, one team member seemed to come up
with all the right ideas, and then after a while, the ideas of the
other group members seemed to be disregarded [4]. Even
though as a doctor, I am most bound by the American Medical
Association (AMA) code of ethics, I still must be open to
other ideas and thought processes because there is a good
chance that I will miss some strong ideas if I completely
disregard less obvious sources. More clearly, because of my
engineering background, I should be more open to
engineering codes of ethics and other influential sources
rather than just the AMA code of ethics. The case study
definitely influenced what I used to help make my decision. I
explored an eclectic group of ideas in the pursuit of solving
my quandary.
PATIENT #1 DESERVES THE KIDNEY
From a purely objective standpoint, the kidney was
made for Patient #1, and I told him that. It would be very
unethical to promise something and take it from him against
his will. It is my responsibility as a member of the Biomedical
Engineering Society to “strive by action […] to increase the
[…] prestige, and honor of the biomedical engineering
profession” [5]. I surely wouldn’t increase the prestige and
honor of the biomedical engineering profession by revoking a
debatably life-saving surgery from someone who was
promised said surgery. It would, however, increase the Thus,
I should act with honor and prestige by keeping my word to
Patient #1 and giving him the kidney.
Eric Baumann
As a Christian man, I often times take to the Bible
when I am debating my options in a decision. I feel as if the
Bible can give you an answer to anything if you search hard
enough. In terms of the kidney issue, the Bible, too, says it is
my responsibility to keep my word to Patient #1, “I will not
violate my covenant or alter the word that went forth from my
lips (Psalm 89:34)” [6]. I made a promise to Patient #1 to get
him a surgery for his bioprinted kidney, and I should hold my
word to him. If I go back on that promise, I’ll be going against
the Bible; something I do not find pleasure or happiness in
doing.
The most compelling argument for Patient #1 lies in
the fact that the artificial kidney was produced from a sample
of his “autonomously self-assembling cellular spheroids” [1].
Therefore, I look at it as him being a donor of the artificial
organ. By Opinion 2.16 of the AMA Code of Ethics, a living
donor is allowed to designate who gets his or her organ [7].
By that logic, Patient #1 should get the final say in where his
“donated” organ goes. Since he stated that he’d like to go
through with the surgery, he is acknowledging that his
donation should be directed toward himself, and I think that it
is my duty to respect that. As a doctor in the American
Medical Association, there really isn’t a much more
influential code of ethics for me to follow. I am bound by the
contents of the code, and I should uphold their standards to
the best of my ability by giving the kidney to Patient #1.
As I scanned the internet looking for resources to
help me decide, I came across a case study that surely
contributed toward my final decision. In the case study, a
BioDesign student was observing a surgery, and the assisting
surgeon had to step out for a second [8]. The leading surgeon
asked the BioDesign student to hold the assisting surgeon’s
clamp while he dealt with his business [8]. The student did
not have expressed consent to assist in the surgery, so it is
unethical for him to help [8]. It is considered battery of the
patient if he were to assist [8]. Similarly, since Patient #1 did
not give me expressed consent to use his donated cells to help
Patient #2, it is unethical for me to do so.
When I was just a young lad, I was a little bit of a
“momma’s boy” if you will. Obviously, I love my mother
with all my heart, and she is always there for me. Honestly,
my mom’s opinion of my decisions means more to me than
anyone else’s opinion. I hate when she is disappointed in me,
so I tend to discuss things with her a lot. Plus, when I’m
talking to my mom, I tend to develop some of my clearest,
most coherent thoughts. In my discussion with my mom, she
told me:
“Eric, think about it. The second patient has been
through the ringer. The old man was supposed to get
the kidney, and he is the most reliable to benefit from
it. You don’t know what else is wrong inside that
poor, young woman. If you give her the organ, she
could die anyway. Why risk two lives when you can
likely save one?” [9].
As terrible as it would be to lose one of the patients, it would
be significantly worse to lose both by playing God. I should
to focus my efforts on saving one patient, and I should,
therefore, give the kidney to Patient #1.
In my research, I looked at a very relevant case study
on patient recruitment for a clinical trial [10]. In this case
study, a second-year fellow was responsible for seeking out
patients fit for the trial [10]. After a very long and
unsuccessful screening process, his boss claimed he found
two potential candidates [10]. The fellow interviewed the
candidates, and he believes that they are, in fact, not fit for the
trial [10]. There is an ethical dilemma for the fellow to deal
with: does he allow the candidates to go forth with a
potentially harmful trial, or does he inform the boss of his true
opinion of the patients? The decision the fellow needs to make
really helped me with the decision I was debating when I put
myself in his shoes. I would go with the safe option and tell
my boss that I think he is wrong. It made me lean a little bit
more toward what I consider the safer option in my scenario:
give the kidney to Patient #1 and focus on saving at least one
life. Patient #2 is not sure to live, even with the kidney, and
there is no sense in risking two lives just to have a chance to
save two lives.
PATIENT #2 DESERVES THE KIDNEY
One of the most important things to consult in a
decision-making process is one’s personal thoughts and
reactions to the situation [11]. I think it is much more of a
tragedy to see a twenty-six year old mother of two die than a
seventy year old man [11]. Patient #1 has a heavy nicotine
addiction, and according to Huffington Post, “Average life
expectancy from age 70 was […] only about 14 years in men
still smoking at 70” [12]. Therefore, Patient #1 will likely
only have about fourteen years to benefit from his kidney.
Patient #2 is a twenty-six year old female with two kids. Not
only will Patient #2 have more time to benefit from the
transplant, but she also has two dependents that would surely
benefit from her survival. My intuition surely points me
toward fighting for Patient #2’s life. She hasn’t lived a full
life, and it’s not like I’m signing Patient #1’s death wish by
giving her the kidney [11]. There is still ample time to get him
a kidney provided the process goes smoothly on the first try.
My objective opinion (however cynical) would undoubtedly
give the kidney to Patient #2. Unfortunately, the decision isn’t
that easy, and I need to continue to deliberate.
The American Medical Association’s code of ethics
is very clear about the allocation of limited medical resources
in Opinion 2.03 [7]. The patients with an increased need for
the medical resources are generally given priority over those
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Eric Baumann
the kidney to Patient #1, which is surely going to “hold
paramount the […] health, and welfare of the public” like the
National Society of Professional Engineers commands [3]. In
short, the decision to give the kidney to Patient #1 upholds the
values of the majority of the discussed codes, case studies,
and other sources, and I, therefore, feel confident that it is the
correct decision.
with less need [7]. Ergo, Patient #2 has a more demonstrated
need to get the kidney, so she should be given priority over
Patient #1. Another tenet of AMA code states that another
factor in distribution of limited medical resources is the span
of benefit [7]. In other words, since Patient #1 is a seventy
year old smoker, he likely will not have nearly as much time
to benefit from the kidney as the twenty-six year old healthy
mother. The AMA code agrees with my intuition without
necessarily calling it less traumatic for an older gentleman to
die.
REFERENCES
[1] S. Murphy. (12 June 2014). “3D bioprinting of tissues
and organs.” Nature Biotechnology. (Online
article).http://www.nature.com/nbt/journal/v32/n8/full/nbt.2
958.html
[2] G. Filardo. (January 2011). “Vascular Bioprinting.” The
American Journal of Cardiology. (Online article).
http://www.researchgate.net/publication/49672629_Vascular
_bioprinting
[3] (July 2007). “NSPE Code of Ethics for Engineers.”
National Society for Professional Engineers. (Website).
http://www.nspe.org/resources/ethics/code-ethics
[4] “Case 16- A Bright Team Member.” Stanford Biodesign.
(Website).http://biodesign.stanford.edu/bdn/ethicscases/16br
ightteammember.jsp
[5] (February 2004). “Biomedical Engineering Society Code
of Ethics.” Biomedical Engineering Society. (Online PDF).
http://bmes.org/files/2004%20Approved%20%20Code%20o
f%20Ethics(2).pdf
[6] “New International Version.” BibleGateway.com.
(Website).https://www.biblegateway.com/passage/?search=P
salm+89%3A34&version=NIV
[7] “AMA Code of Medical Ethics.” American Medical
Association. (Website). http://www.amaassn.org/ama/pub/physician-resources/medical-ethics/codemedical-ethics.page?
[8] “Case 3- Conscientious Student.” Stanford Biodesign.
(Website).http://biodesign.stanford.edu/bdn/ethicscases/3con
scientioustudent.jsp
[9] Jan Baumann (2014, October 25). Phone Interview.
[10] “Case 13- Patient Recruitment.” Stanford Biodesign.
(Website).http://biodesign.stanford.edu/bdn/ethicscases/13pa
tientrecruitment.jsp
[11] My Intuition. (2014, October 27).
[12] S. Emling. (1 September 20130. “Smokers Who
Survive to 70 Still lose HOW Many Years of Life?”
Huffington Post. (Web Article).
http://www.huffingtonpost.com/2013/09/01/smokinghealth_n_3852209.html
CONCLUSION
In the analysis of the decision at hand, I encountered
many forcible arguments for both sides. My decision is
undoubtedly well-researched; as I referred to three separate
codes of ethics, three separate case studies, and three outside
sources. I wanted to be very methodical in coming to a
conclusion, so I made sure to spend equal amounts of time
pondering each side.
On one hand, I could give the kidney to Patient #1,
the seventy year old smoker who has had a long-term renal
failure. I would be able to keep my word if I gave him the
kidney. Technically, it was his donation, so he should get to
decide where it goes [7]. If I give Patient #1 the kidney, there
is a much higher chance of saving at least one life because I
won’t be risking the lives of both patients. Unfortunately, it
would likely result in the death of Patient #2. He is surely the
safer option, and I can basically ensure his survival if he gets
the transplant. I can’t say the same if I were to give the kidney
to Patient #2. For a variety of reasons, Patient #1 seems to be
a very safe and reliable choice for the organ recipient.
On the other hand, I could give the organ to Patient
#2, the twenty-six year old mother of two who is suffering
from a crush injury from a car accident. The crush injury is
causing acute renal failure due to trauma. She needs the
kidney within a few hours or she will surely die. By giving
Patient #2 the kidney, I can possibly save both of the patients’
lives. Although this is a riskier option than giving the kidney
to Patient #1, it could enable me to save both patients if all
goes well. Patient #2 has a larger span of benefit and has a
higher need for the kidney, so according to AMA transplant
rules, she should get priority over Patient #1 [7]. In addition,
Patient #2 is not a smoker, so she isn’t considered as much of
an at risk patient.
In my final decision, I ended up giving the kidney to
Patient #1. It is much too difficult to overcome the fact that
Patient #1 should be given the right to decide where his
sample goes because it belongs to him [7]. He is the one
responsible for choosing the recipient of his donation, and he
chose himself as the recipient of the artificial kidney. I feel as
though I am surely capable of saving at least one life if I give
ADDITIONAL SOURCES
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Eric Baumann
H. Bergenmeister. (1 August 2013). “Tissue Engineering of
Vascular Grafts.” European Surgery. (Online article)
http://link.springer.com/article/10.1007/s10353-013-0224x/fulltext.html
D. Seifu. (July 2013). “Small-diameter vascular tissue
engineering.” Nature Reviews Cardiology. (Online article).
http://www.nature.com/nrcardio/journal/v10/n7/full/nrcardio
.2013.77.html
ACKNOWLEDGEMENTS
I would like to formally thank my roommates for turning
down the Sunday Night football game in order to let me
focus. Special thanks to my mom for partaking in a 5 minute
phone interview. Thanks to Emelyn for meeting with me on
such short notice at 7:30 AM!
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