Budny 10:00
L10
ARTIFICIAL LUNG TRANSPLANTATION: DO WE VALUE ETHICS OR
HUMAN LIFE?
Piyusha Sane (pms44@pitt.edu)
TERMINALLY ILL PATIENT’S STRUGGLE
TO LIVE
Gasping for air, a seventy year-old woman finds herself
being rushed out of an ambulance on a stretcher. Her family
members hurry behind. The scene in the Emergency
Department of the city’s largest hospital is rather chaotic:
paramedics, nurses, doctors, and surgeons, running from one
room to another gathering materials, all on a mission to save
another life.
After diagnosis, the professionals determine that the
patient has acquired a rare lung disease that cannot be cured
with the equipment present in the hospital. The physicians
estimate that the woman will have only four weeks to live,
unless a miracle should occur. The aged woman would be
added to the list for lung transplant.
Meanwhile, the news upsets the entire family of the
patient. The doctors advise the family that it should not count
on the transplant since the waiting list for organ donors is
extensive. A physician adds that “an average of 18 people die
each day waiting for transplants that can’t take place because
of the shortage of donated organs” [1]. Hearing this alarming
statistic, the son firmly rises and poses a request to the
surgeon: he would like to offer $100,000 to the engineers who
could construct an artificial lung for his mother. The surgeon
contacts me, a bioengineer at the University of Chila
Pulmonary Research Institute, with the request.
I approach the head of our lab team and, we set up a lab
meeting with my team members to discuss the situation. This
was the first time the world would hear of a long-term
artificial lung transplant. First we consider the possible
processes we could employ to design and build the organ.
Then, the lab team deliberates over the techniques used in the
past to manufacture artificial organs including the trachea,
bladder, and heart.
Following the reflection, the members realize that
although the lung could be made in the four weeks, there most
likely would not be enough time to perform the required
testing certifying the lung for transplantation. After a few
minutes of thought, the head of the lab team decides that the
testing is not necessary; he suggests we should regard the
monetary award with utmost importance. Moreover, the
woman is terminally ill. Even if the transplanted lung had
defects, would it not be better to try to save a life with the time
and resources we have? The head remarks that he can get the
certification made by a friend who is part of the
Bioengineering Board of Certification. The team would
simply have to pay $1000 to obtain certification that approves
the untested lung for transplantation. We must vow to secrecy,
University of Pittsburgh, Swanson School of Engineering 1
2013-10-01
because the physicians, patient, and family members will be
told that the certification is official. I sit there puzzled. How
could we misinform the patient, misinform the physicians,
misinform the world? At the same time, was it not better to
try to save a life than leave the woman to her terminal illness?
Mystified, I start planning the construction of this organ,
reconsidering the procedure and past successes of organ
transplantation. Would there any way to build and test the
lung in four weeks and obtain official certification for the
transplant? Would it acceptable to transplant the lung without
official certification? Would the artificial lung transplant even
help rectify her terminal illness?
THE PROCESS OF ORGAN
TRANSPLANTATION
To answer the questions running through my mind, I
explore the practice of organ transplantation. Through
experimentation, bioengineers have been able to consider
three main techniques to acquire organs for transplantation.
The oldest method involves direct replacement by a donor
organ. Unfortunately, this system carries a major drawback:
“the foreign tissue can be rejected by the recipient” [2]. To
challenge this issue, researchers discovered the practice of
reseeding, in which a donor’s organ is reseeded with the
patient’s own cells [2]. In this case, although there is no
foreign tissue which can be rejected, several other problems
persist. According to the New York Times, “A donated organ
may not be the right size; it has to be stripped of its cells and
reseeded while the recipient waits; and the procedure still
requires donor organs, which are in short supply” [2]. Even if
a donor organ is available, this time-consuming process could
prove to be too lengthy for the patient’s survival. Attacking
the difficulty of obtaining donor organs, today’s engineers are
discovering a third formula to procure organs for
transplantation: construction of artificial organs using stem
cells. This technique uses a synthetic scaffold made with
templates of the patient’s own organ. This not only ensures
that the organ will be accepted by the patient’s body, but also
that it will be of the perfect size for the patient [2]. And best
of all, the patient will not have to wait for a donor organ.
In the case of our task, the woman would not be able to
attain a donor organ in the four weeks considering the
overwhelming discrepancy between patients and donors:
“There are currently 118,617 people waiting for lifesaving
organ transplants in the U.S.” compared to the 14,630 donors
[2] [3]. Consequently, we cannot approach the situation with
direct donor organ transplantation or use the technique of
reseeding donor organs. Ultimately, building an artificial
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organ using the patient’s own stem cells remains our only
option. It is important to review prior achievements in the
bioengineering division of artificial organs. These would
guide us in our project.
Heart Beats to Life
As seen above, engineers have been fruitful in producing
hollow organs, “a visceral organ that is a hollow tube or pouch
or that includes a cavity which serves a vital function,” such
as the trachea and the bladder [6]. But now, the focus lies in
creating more complex organs, which could change the scene
of transplants forever. Currently, many research teams around
the world are working to construct an artificial heart. The
French company Carmat recently developed an artificial heart
devised from cow tissue (animal stem cells) [7]. According to
the New York Times, “the device, soon to be tested in patients
with heart failure, is regulated by sensors, software, and
microelectronics. And its power will come from two external,
wearable, lithium-ion batteries” [7]. The next step in this
project is to eliminate the batteries and sensors to have a heart
pumping on its own. Then, the heart will be tested again
before widespread use [7]. Such discoveries are on their way
to guiding engineers into shaping more efficient and practical
solutions to organ dysfunction. A critical point in this case is
that this heart is taken through gradual stages of development
and is tested multiple times before its integration into the
human body. In the four weeks, we would not have time to
perform repeated tests to achieve precision and accuracy in
the making of the lung.
ACCOMPLISHMENTS: YESTERDAY,
TODAY, AND TOMORROW
An Extra Breath of Air
As of now, engineers have been able to build a few organs
from patient stem cells, the most prevalent method of artificial
organ construction. One of the first artificial organ transplants
was that of a trachea: “Surgeon Paolo Macchiarini has made
his name by successfully transplanting bioengineered stem
cell-based trachea, composed of both artificial and biological
material” [4]. In 2011, Andemariam Beyene, a patient in
Sweden, found a tumor growing in his windpipe that could
not be contained through surgery. He was on his death bed,
when Dr. Macchiarini considered the idea of building a
windpipe for Beyene [2]. Dr. Macchiarini, a doctor at the
Karolinska Institute, was determined “to harness the body’s
repair mechanisms so that it [could] make a damaged organ
on its own” [2]. In June 2011, he showed the world that he
could design, construct, and transplant a windpipe through
Beyene’s own stem cells. The doctor emphasizes the
significance of using the features of the human body to treat
itself: “The human body is so beautiful, I’m convinced we
must use it in the proper way,” as he aims on building more
complex tissues and organs, such as the esophagus,
diaphragm, heart and lungs, for transplants [2] [4]. As we
attempt to construct the lung, we must apply a similar
technology, using the patient’s own stem cells as our building
blocks. This way, we can be sure that her body will not reject
the tissue.
ETHICAL CONCERNS
The main issue with our project is time. Designing and
constructing the lung would take four weeks based on
previous experience. So, obtaining a valid, genuine
certification would not be possible in the given time. But my
boss’s solution of faking the certification would not be
tolerated as per the National Society of Professional
Engineers (NSPE) Code of Ethics and the Biomedical
Engineering Society’s (BMES) Code of Ethics! As engineers,
we are expected and required to follow these guidelines in our
research, design, and implementation.
The Bladder’s Rebirth
Along with the trachea, bioengineers have successfully
constructed and transplanted bladders also fabricated from the
patients’ own cells. At Wake Forest University School of
Medicine, the Institute for Regenerative Medicine conducted
a study to build new bladders for “patients four to nineteen
years old who had poor bladder function because of a
congenital birth defect that causes incomplete closure of the
spine” [5]. This process involved conducting a biopsy of the
children to obtain cells that were then grown and placed into
a biodegradable scaffold in the shape of a bladder. Smooth
transplantation of the bladder has shown successful results in
several patients [5]. Here, we see that the scaffold is one of
the most important parts of design. Learning from this case, it
is vital that we manufacture a scaffold that perfectly supports
the woman’s internal network of tissues and vessels,
eliminating any possible sources of rejection.
Considering the NSPE Code of Ethics
The NSPE Code of Ethics is established as a part of the
engineering profession, in which integrity and honesty are
two of the respected principals of conduct. If we would have
a counterfeit certification made, this would clearly violate the
fifth canon of the Code of Ethics: “Engineers shall avoid
deceptive acts” [8]. The code explicitly states that engineers
should not “falsify their qualifications” [8]. The lab team
cannot accept credit for the production of the lung if it has not
passed official regulations.
Considering the BMES Code of Ethics
The BMES Code of Ethics highlights the responsibilities
of professionals in the department of biomedical engineering,
incorporating “engineering, science, technology, and
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medicine” [9]. It divides its code into four sections,
“professional practice, research, patient care, and training,”
each designated to a particular subsection of the biomedical
engineering field [9]. As a biomedical engineering lab team,
we strive to use our “knowledge, skills, and abilities to
enhance the safety, health, and welfare of the public” [9].
Additionally, we must regard the greater consequences of our
work, and how they affect our health care delivery [9]. In our
attempt to design the lung, we would surely be attempting to
encourage the health and wellbeing of the patient, but we
cannot guarantee our success without testing the lung,
ultimately risking the safety of the individual. And even
though on a larger scale we are attempting to save a life, it
remains unethical to risk the welfare of the patient, thus
negatively affecting our health care delivery.
everything possible to construct the lung and certify it for
transplantation. But several questions remain unanswered.
Provided we do not have the time to test the artificial lung,
should we obtain a fake certification to follow through with
the transplant? Should we hide the uncertainty of the
transplantation results from the patient, the family members,
and the physicians? Should we value ethics or human life?
I consider it my responsibility to abide by the ethical codes
of conduct and avoid deception. Only with approval from the
Bioengineering Board of Certification shall we proceed with
the lung transplantation.
REFERENCES
[1] “The Need is Real: Data.” U.S. Department of Health and
Human
Services.
(2013).
(Website).
organdonor.gov/about/data.html
[2] H. Fountain. (2012, November 15). “A First: Organs
Tailor-Made With Body’s Own Cells.” New York Times.
(Online
article).
www.nytimes.com/2012/09/16/health/research/scientistsmake-progress-in-tailor-madeorgans.html?pagewanted=all&_r=0
[3]“Organ Donation and Transplantation Statistics.” National
Kidney
Foundation,
Inc.
(2013).
(Website).
www.kidney.org/news/newsroom/factsheets/OrganDonation-and-Transplantation-Stats.cfm
[4] “Stem Cell-Based Bioartificial Tissues and Organs.”
Science Daily. (2013, February 18). (Online article).
www.sciencedaily.com/releases/2013/02/130218103026.htm
[5] “Wake Forest Physician Reports First Human Recipients
of Laboratory-Grown Organs.” Wake Forest Baptist Medical
Center.
(2013,
April
18).
(Online
article).
www.wakehealth.edu/NewsReleases/2006/Wake_Forest_Physician_Reports_First_Hum
an_Recipients_of_Laboratory-Grown_Organs.htm
[6] “Hollow Organ.” Merriam Webster (2013). (Website).
http://www.merriam-webster.com/medical/hollow%20organ
[7] A. Eisenberg. (2013, July 13). “The Artificial Heart is
Getting a Bovine Boost.” New York Times. (Online article).
www.nytimes.com/2013/07/14/business/the-artificial-heartis-getting-a-bovine-boost.html?_r=0
[8] “NSPE Code of Ethics for Engineers.” NSPE (2013).
(Online
article).
http://www.nspe.org/Ethics/CodeofEthics/index.html
[9] “Biomedical Engineering Society Code of Ethics.”
Biomedical Engineering Society (February 2004). (Online
article).http://bmes.org/files/2004%20Approved%20%20Co
de%20of%20Ethics(2).pdf
[10] A. Steinberg. (2012) “The Terminally Ill Patient” The
First
International
Colloquium.
(Online
article).
http://www.hods.org/pdf/Steinberg%20Terminally%20ILL
%20Patient2.pdf
[11]The IAHPC Manual of Palliative Care. (2013). (Online
article).
Ethics in Terminally Ill Patients
Since we are confronted with a terminally ill patient, it is
necessary for the lab team to consider the ethics pertaining to
that dispute in addition to the Engineering Codes of Ethics.
According to Professor Avraham Steinberg, a pediatric
neurologist at the Shaare Zedek Medical Center, we find
terminally ill patients to be “people whose quality of life
seems greatly reduced, and whose survival is expected to be
short” [10]. But what does that mean? The professor discusses
the ethical concerns of terminally ill patients emphasizing that
the term possesses a very vague definition. He states: “in
effect, we are all terminal. The most serious and dangerous
disease that a person can contract is called life, because it is
the one thing that we know for certain will lead to our death”
[10]. This argument poses the idea that the case cannot simply
be considered as a “terminal illness”: just because this woman
has a fatal illness does not mean it is acceptable to “try and
see” if the organ functions in her body.
The truth is, we are not even sure of whether this lung
transplant would save the woman’s life. The IAHPC Manual
of Palliative Care stresses that “terminally ill patients should
not be subjected to futile therapies” [11]. In our case, the team
members cannot not predict whether this transplant would be
futile or successful! How could we proceed to building and
transplanting an organ without knowing its potential effects
and consequences on the human body?
CHALLENGE TO RESPONSIBILITY
As a bioengineer, I feel that it is my duty to support the
growth of the engineering discipline. I should accept the
challenge as a responsibility and construct the first artificial
lung. Engineers now have the capabilities of designing and
producing artificial organs, and I must take advantage of the
emerging technology.
Meanwhile, the lab team must reflect upon the ethical
concerns of the situation. I will meet with the head of the lab
team to decide what would be in the best interest of both the
lady and the engineers. In the four weeks given, we would do
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http://hospicecare.com/uploads/2013/9/The%20IAHPC%20
Manual%20of%20Palliative%20Care%203e.pdf
ACKNOWLEDGEMENTS
I would like to thank Dr. Budny for giving me a chance to
explore the bioengineering world in action. Also, I appreciate
Ms. Katy Rank Lev’s guidance in explaining the project with
clarity. Additionally, I sincerely thank my writing instructor,
Ms. Janine Carlock, who directed me in the process of writing
a coherent and focused paper.
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