Editorial: Compassion Fatigue

In a recent article in North & South Magazine[i], Donna Chisholm discusses the issue of compassion fatigue amongst doctors and some of the implications of this for patients. It is claimed that around 50 percent of doctors report compassion fatigue, and that there is an exodus of a quarter of young doctors from the country within three years of graduation, many of whom report stress and burnout.

Compassion fatigue has been described in terms of the draining away of what is seen as a finite reservoir of caring. However, recent research from Auckland University’s department of psychological medicine indicates that the ‘leaky reservoir’ model may not be adequate. Its survey of nearly 600 doctors indicates that, in fact, younger doctors report more obstacles to compassion. This work suggests that there are four key factors that need to be looked at and over which a doctor has little control: burnout/fatigue, difficult patients, external distractions and clinical complexity.

Chisholm highlights ‘difficult patients’ as one of the more interesting outcomes of the research. While ‘burnout’ tops the list of influences, “a patient’s attitude and demeanour are almost as important. That means if your doctor actually likes you as a person, you’ll probably get more compassionate care.” (p.61). One of the study authors suggests that “doctors are normal people. If they are confronted with a person who is unpleasant, demanding, non-compliant, ungrateful, malodorous … they won’t like them and they won’t care for them.” (p.61). The report’s author posits that there is an evolutionary aspect to this – it is inefficient to keep caring for people who don’t deserve it. He believes it is basic human functioning to ask ‘Do I like you?’ and that the answer to that question is the first decision that is made; in his opinion “no amount of professional training will ever get us past that fact. Ever.” (p.62).

A more hopeful analysis is offered by an Auckland City Hospital emergency department physician who suggests that while emergency departments are places where patient behaviour is likely to be at its worst, this is no reason for doctors to leave their compassion at the door. He has become considered by his colleagues the person best able to deal with the difficult cases - the angry drunks, the drugged and the homeless regulars who just turn up for a feed – and says: “I’ve learnt to like the people you wouldn’t normally like.” (p.62). Changing the way he thinks about patients has been the key to changing the way he acts, and while fatigue and burnout are factors in compassion failure, he believes that ‘healthy thinking’ can reduce it.

This approach is supported by other research undertaken with doctors that found that those who didn’t feel stressed had one main trait in common, that of being connected to their purpose, or a ‘higher calling’: “The doctors who are absolutely thriving all sound like they’re on a mission.” (p.62). One 60-year-old GP finds he now feels more compassion for his patients than he did 25 years ago. While he has over time become better at the ‘mechanical’ aspects, diagnosis and treatment, he also tries to listen to his patients, to understand what’s happening through ‘their eyes’. A fourth year student suggested that a lot of young doctors do not really listen to patients, “they’re filling out a check box in their head of things they feel they need to ask. I think that detracts from the fact that there’s a patient who’s an individual in front of you. Maybe they have information that’s not on your checklist.” (p.63).

A former primary-care nurse who trains health workers in how to better communicate with patients believes the ‘difficult patient’ problem is exaggerated and that ‘difficult patients’ are created by the way they are spoken to. At the same time, she does not believe every nurse and doctor can be taught to be compassionate and empathetic, and that around a third who attend her workshops “will never get it.”

The factors involved in compassion fatigue include a mix of environmental factors such as workload, the complexity of some illnesses, the behaviour of patients, as well as the evolutionary and personal factors that cause doctors to respond in certain ways to their patients. None of these is easily changed. However, finding ways of preventing compassion fatigue is important, for the doctors themselves but also because empathy and compassion are associated with better patient out-comes, and failure of compassion with poor decisions.

Of course, compassion fatigue is not restricted to the health professions; it also affects teachers, politicians, social workers, chaplains/pastors, prison workers, youth workers, counsellors and parents. With that in mind we have asked seven different practitioners from a variety of caring professions to offer their reactions to, and insights on, the North & South article.

We believe there is something of substantial personal value for every reader in the richness of the authors’ reflections offered in this issue. 

Sue Buckley is a researcher for The Nathaniel Centre and Dr John Kleinsman is the director of The Nathaniel Centre.

[i] ‘Cold Comfort’ by Donna Chisholm. North & South, Issue 59, September 2015. Pp. 59-64.

Guest Editorial: All lives matter … all means ALL

Wendi Wicks

On Tuesday 25 July, at the Kanagawa Kyodokai at Tsukui Yamayuri En, west of Tokyo, 19 disabled people were stabbed to death as they slept. The killer was a former employee at the residential/rehabilitation facility for disabled people. He moved rapidly through the building – in 50 minutes he killed 10 men and 9 women and injured 24 others. He then drove himself to the police station to hand himself in. He said it was better “that disabled people disappear”.

This was not the first time he had made explicit his belief that disabled people should be eliminated. In February he attempted to hand deliver a letter to the speaker of the Japanese parliament.

In it he outlined in stark terms his belief that disabled people should be killed:

I believe there is still no answer about the way of life for individuals with multiple disabiIities. The disabled can only create misery. I think now is the time to carry out a revolution and to make the inevitable but tough decision for the sake of all mankind … I envision a world where people with multiple disabilities can be euthanased with an agreement from the guardian.”

He claimed he could wipe out a total of 470 disabled individuals and offered a “plot”, to be put before the prime minister, whereby he would kill 260 people, be arrested but only imprisoned for 2 years and then receive plastic surgery and a new identity. All of this would be “for the sake of Japan and world peace”, and would be suitably remunerated by the government.

So how did this tragedy play out in the media? Given the prolonged outpourings of grief and solidarity with those killed when it came to similar multiple killings in Paris, Nice, Orlando and Kabul, one might expect something similar. There one saw wall-to-wall coverage, Twitter storms and trending hashtags; altered profile images to indicate solidarity. There were repeated updates, headlining news bulletins on radio and TV – some talkback hosts made wise sayings, other TV hosts left the soothsaying to their guests. Many attended memorial events or vigils.

But in the case of Tsukui Yamayuri En, Japan’s worst mass killing since World War 2, the response was a roaring silence. Hashtags, memorials, public outrage, panels of soothsayers just didn’t happen for the general public, or in international settings. We disabled people know because we looked.

In contrast, disabled people worldwide reacted with a storm of comment, horror and action. New Zealand disabled people led off with a vigil – most attenders were disabled people and there was no media attention. Protests, memorial services and marches of solidarity followed worldwide. Many excellent blogs with sound analysis were written. But only disabled people mourned in public.

A particularly challenging part of our public mourning and memory was when we found that the men and women killed at Kanagawa Kyodokai would not be named, because, it was said, their relatives were too ashamed to acknowledge having a disabled family member: in effect erasing disabled people from the public record and perpetuating our invisibility. It is an obscenity, felt strongly by us and still stinging. All the disabled people who have learned of this lack of names recoil in either body or spirit.

Sadly, what happened in Japan is symptomatic of the everyday invisibility of disability we experience.  Society sees disabled people as not really needing human rights, because we aren’t fully human. It seems that our names or identities don’t matter. We are pegged as ‘takers’ of society’s precious resources. As reflected in court judgements, it is understandable if disabled people are abused because caring can be difficult and stressful. And if this is understandable, well it may be OK to euthanase them.

The message here, (as in Hitler’s Germany where over half a million disabled people were gassed, starved, neglected, or sent to the death camps), is the opposite of “all lives matter”. To the general public, and in the media, our lives don’t seem to matter, and the realities of how we live are seen to be a good reason for our deaths. There is an invisibility of the humanity of disability.

So Tsukui Yamayuri En is not our first and nor is it an unusual encounter with such attitudes and their consequences. It is most troubling that we encounter similar attitudes as common currency: when disability is seen in negative un-affirming terms; where people believe ‘better dead than disabled’, notably if one needs assistance with bathing, toileting, or getting in and out of bed (loosing dignity in such processes); when we are seen to suffer, have unendurable pain, feel hopeless and a burden. In these ways disabled lives are daily discounted.

While these inimical attitudes exist about disabled people, we will remain at risk of the extermination the Japanese knifeman advocated for – whether in New Zealand or elsewhere.

In this context, any attempt to put up assisted suicide legislation with so-called eligibility criteria will also have deadly consequences. As various select committee reports make clear (Scotland, UK, Victoria, Bulgaria), legal safeguards and criteria cannot make such legislation sufficiently robust. Disabled people deserve much better - it is our world too.

Wendi Wicks is a celebrant, writer and strong advocate for disability rights. She convenes “Not Dead Yet Aotearoa”.

 

People Who Use Wheelchairs Don’t Actually Want to Kill Themselves

David Bekhour challenges the underlying and unquestioned assumption in the film ‘Me Before You’, that someone with a spinal injury and using a wheelchair will unquestionably find life too difficult and want to end it all. “People in wheelchairs don’t actually want to kill themselves”, but films such as this perpetuate the antiquated and dangerous idea that the lives of disabled people “are somehow less worth living”.

Available online at: http://medium.com/@OptimisticGrin/people-who-use-wheelchairs-dont-actually-want-to-kill-themselves-d76493596eb6#.z276ob8mt

Stem cell research

Celina Capistrano

In 2004, a Nathaniel Report article outlined ethical issues surrounding the use of human stems cells in research and medicine. The following is an update on that article, providing a description of the different types of stem cells and the ethical issues associated with these. It also reports on the recent discovery of a new gene-editing technique, CRISPR/Cas9, and some of the ethical issues that are involved with its use.

Human Stem Cells

Human stem cells, characterised by their ability to develop into a range of different cell types, were first discovered in the mid-20th century and isolated in embryos in 1998. They may be found in embryos or derived from non-embryonic sources.  

Human embryonic stem cells (hESC) can be derived in two ways: (i) using early stage embryos (blastocysts) created from eggs fertilised with sperm in vitro, embryonic stem cells (ESCs) can be isolated from the inner cell mass of the blastocyst and exposed to factors that allow these ESCs to continue growing; (ii) by a process called Stem Cell Nuclear Transfer (SCNT) where genetic material from an adult cell (e.g.  skin or connective tissue) is injected into an egg that has had its genetic material removed (enucleated egg). The egg is then stimulated to develop until it reaches the blastocyst stage, thus becoming a ‘cloned’ embryo, at which point the inner cell mass is removed and grown in a petri dish (in vitro).  One of the key scientific advantages of producing pluripotent cells (cells that can give rise to all cell types)by SCNT is that it enables a patient’s own cells to be used, thus avoiding the problems of immunological rejection that occur when using stem cells originating from another person. Both of these procedures, however, involve the destruction of the embryo and consequently give rise to significant moral and ethical issues concerning the value of, and respect for human life. Additionally, with SCNT there is the extremely controversial issue of creating human clones. There have been research developments resulting in isolation of ESCs without destruction of the embryo thus bypassing concerns regarding embryo destruction. However, the further healthy development of such embryos remains uncertain.

Induced Pluripotent Stem Cells

Largely as a result of the ethical issues related to human cloning and embryo destruction, but also because of various research controversies, progress on human stem cell research from about 2001was somewhat stalled. However, in 2006, Japanese Scientists Dr Takahashi and Dr Yamanaka1 (Nobel prize winners in 2012) discovered how to re-programme ‘somatic’ cells (‘non-embryonic’ or ‘adult’ cells) to reverse their state back into pluripotent form through the re-expression of key embryonic genes (suppressed in the somatic state), thereby enabling these already differentiated adult cells to behave as embryonic stem cells2. These new cell forms, Induced Pluripotent Stem Cells (iPSCs), appeared to the have same essential characteristics as embryonic stem cells. With the ethical barriers to the development of stem cells now removed, these new methods have sped up the discoveries regarding stem cell research to a “near-exponential rate”3.

Since the Takahashi and Yamanaka discovery, developments in iPSC methods have provided the best opportunity to avoid the ethical objections associated with destroying human embryos as well as the problems of immunological rejection.

iPSC in therapy

With this new ability to differentiate pluripotent cells into any cell through iPSC technology, researchers are now developing new model systems to investigate the biology of early mammalian and human development as well as new approaches for regenerative medicine. These systems offer improvements in the ability to study disease at a patient specific level and to increase the potential for more efficient methods for drug discovery and screening for genetic disorders. Specific strategies to tackle a range of diseases and disorders including Parkinson’s disease, spinal cord injuries, heart disease, inflammatory diseases, joint injuries, and Age Related Macular degeneration are also being developed, and there is the potential to use iPSC in transplantation medicine.

There are still some significant safety issues that need to be overcome. For example, one of the early ways of creating iPSCs was by transfecting or inserting the desired genetic material into the adult cells through use of a virus to shuttle the transcription genes. The procedure, however, could have the potential for the virus to be integrated into the cell’s DNA and cause undesired mutations.

Though iPSC’s are the most ethical way to experiment with pluripotent stem cells, other ethical issues are likely to arise depending on where the research is heading. For example, scientists have now succeeded in creating human primordial germ cells (sperm and egg precursor cells). Some scientists will continue to advocate for the use of embryonic stem cells in research that aims to better understand embryonic development, and to find ways to treat infertility and improve in vitro fertilisation (IVF). The shift away from embryonic research due to the new technology may even lessen the rigidity of regulations in terms of these studies, which may be a problem in the future.

CRISP/Cas9

CRISPR-Cas9 is a molecular tool that is being used in laboratories to edit genes. It was noticed that in some bacteria the DNA sequence in cells was repeated many times, interspersed with unique sequences between the repeats, and this configuration was called ‘clustered regularly interspaced short palindromic repeats’ or CRISPR. It was later found that these unique sequences matched the DNA sequences of invading viruses, and that the bacteria made RNA copies of these unique sequences. This RNA would link up with an enzyme named Cas (CRISPR Associated Protein, a nuclease that can cut DNA) and guide the CRISPR/Cas complex to a matching DNA sequence, enabling the Cas enzyme to cut and disable the invading gene.

This discovery became a genome engineering tool when it was found that this technique could be used to cut not only viral DNA but any DNA sequence by altering the guide RNA to match a targeted gene sequence. Scientists can synthesise RNA sequences to match the DNA sequence they wish to target and use CRISPR/Cas9 to repair or inhibit the gene. There are a number of Cas enzymes but Cas9 is the best known.

In 2015, researchers in China used CRISPR technology to edit the genes of human embryos in their research into a cure for the blood disease, beta-thalassaemia4, and again in 2016 in an attempt to introduce a mutation that would make people immune to HIV. UK researchers were recently successful in obtaining permission from the Human Fertilization and Embryology Authority to edit human embryos using CRISPR/Cas9 genome editing technology5. Their research was aimed at developing a better understanding of successful human embryo development and the causes of miscarriage and infertility.

With CRISPR/Cas9 genome editing technology it is possible to cut out and replace defective genes, which also means that primordial germline cells can be altered. The removal of ‘defective’ traits and the possibility of creating enhanced human beings would usher in a new era of eugenics thinking and practice. A number of scientists, including Jennifer Doudna, one of the scientists who discovered the CRISPR/Cas9 technique, have noted that there are significant ethical issues associated with the development of germline editing, and that CRISPR should not be used on reproductive DNA, or germline cells, while allowing laboratory research to continue6.  They are concerned that, unless there is education and discussion amongst both scientists and the public about the risks and benefits of scientific developments such as CRISPR, then (i) there a greater likelihood of unethical use of such technologies and (ii) research into the therapeutic use of genetic changes that cannot be inherited, will be put at risk. 

The potential for a ‘new eugenics’ is a concern with CRISPR/Cas9 technology, and as described above, the destruction of embryos is a key ethical issue associated with stem cell research. However, there are other ethical issues associated with stem cell research and germline modification. These include the commodification of human reproductive materials; the potential for exploitation of donors (e.g. women donating eggs for the derivation of hESC lines); the possibility for human reproductive cloning; and, finally, uncertainties relating to the creation and use of human–animal hybrids and chimeras for research7.

Endnotes

1.Takahashi, K., and Yamanaka, S. (2006). “Induction of pluripotent stem cells from mouse embryonic and adult fibroblast cultures by defined factors.” Cell 126, 663–676. DOI:http://dx.doi.org/10.1016/j.cell.2006.07.024

2. Brunt K.R, Weisel R.D, Ren-Ke L. (2012) "Stem Cells and regenerative medicine- future perspectives" Can. J. Physiol. Pharmacol., 90(3), pp.327-335. doi: 10.1139/y2012-007 

3. Ibid.

4. Cyranoski, D., and Reardon, S. (2015). “Chinese scientists genetically modify human embryos.”  Nature News, 22 April 2015. doi:10.1038/nature.2015.17378 (Original Article of the Research from China, Liang, P., Xu, Y., Zhang, X. et al. (2015) Protein Cell, 6: 363. doi:10.1007/s13238-015-0153-5)

5. Callaway, E. (2016) UK scientists gain licence to edit genes in human embryos. Nature News, 530(1),18.doi:10.1038/nature.2016.19270

6. Doudna, J. (2015). “Genome-editing revolution: My whirlwind year with CRISPR.” Nature, 528(1), 469–471. doi:10.1038/528469a and Doudna, J. (2015). “Perspective: Embryo editing needs scrutiny.” Nature, 528 (S6). doi:10.1038/528S6a

7. Caulfield T, Kamenova K, Ogbogu U., Zarzeczny A, Baltz J, Benjaminy S, Cassar PA, Clark M., Isasi R., Knoppers B., Knowles L., Korbutt G., Lavery JV, Lomax GP, Master Z, McDonald M, Preto N, Toews M (2015) "Research ethics and stem cells" EMBO reports, 2015, Vol.16(1), pp.2-6 doi:10.15252/embr.201439819

Celina Capistrano graduated with a Bachelor in Biomedical Sciences (BBmedSc) specialising in Molecular Pathology and Genetics in 2015. She is currently undertaking a practicum with the Malaghan Institute of Medical Research as part of her Masters in Clinical Immunology course with Victoria University, Wellington.

Dignity Wrapped in a Scarf of Gold: A Physician’s Reflection

By Sinéad Donnelly

In medicine and palliative medicine much is written about dying with dignity, about treating someone with dignity, but what do we mean? Harvey Chochinov, who has studied this concept in relation to people who are dying, writes:

“One of the most confounding challenges faced by end-of-life care providers is helping patients achieve or maintain a sense of dignity. Our prior studies of dignity and end-of-life care have shown a strong association between an undermining of dignity and depression, anxiety, desire for death, hopelessness, feeling of being a burden on others, and overall poorer quality of life.

…. patients deem a sense of spiritual peace, relieving burden, and strengthening relationships with loved ones among the most important facets of end-of-life care..  Several studies have linked these issues, including a loss of sense of dignity, loss of meaning, and a sense of being a burden on others, with heightened requests for a hastened death. Clearly, palliative interventions must reach beyond the realm of pain and symptom management to be fully responsive to a broad and complex range of expressed needs.”1

I recognize dignity when I see it, yet I struggle to articulate what dignity might be.

Is it a decision one makes? Is it what others do to you? Is it how you respond to others? How do you die without dignity? Is vomiting as you die an undignified death?

Is being alone when you die an undignified death? Having been invited to write about dignity, I have become very conscious of looking more closely for those occurrences in the hospital. Will I hear it? Will I smell it? Will I contribute to it? Will I detract from it? Does it exist in the hospital? 

It is said that “rather than viewing death with dignity as a separate construct, it might be viewed as an interactive process between the dying and their caretakers. Terms such as pride, self respect, quality of life, well being, hope and self esteem all overlap conceptually with the term dignity. While most of these terms refer to internal states of mind, dignity is distinctive in that it also has an external component based on the perception of one’s worthiness of honour and esteem from others”2 

Gold is the colour that comes to mind. Her little face without teeth was wrapped in a scarf of deep blue and gold. As we entered the hospital room we saw the hands that tucked the scarf around her face. She smiled with her eyes and her whole face. Her two daughters by her side, watchful, were totally engaged. The photograph of a handsome soldier leaning against an Italian stone building in sunshine, many years ago, rested on the shelf to her right. The photographed face of her great grandchild, a baby, on the hospital wall opposite her bed. There were three vases of lilies - maroon, orange and white. The whole space embodied dignity. I just wanted to linger here, to be a part of this inspiring space. How was it created? 

Two days earlier, the night doctors handed over that this ninety one year old lady was dying. She had collapsed at home the previous night and was unconscious. Given her age and the way she presented clinically, it was deemed highly likely that she had had a brain stem stroke. In view of the poor prognosis, nurses had thoughtfully placed the patient in a side room rather than a ward space. The lighting was low. There were three generations of family in the room. The daughter, a nurse, stood closest, leaning in attentively. The air was heavy, full of concern in anticipation of her dying. 

When I first saw this frail unconscious woman, felt her hand, and asked for more detail from the family, I wondered whether her situation was irreversible. So, in the dim light, trying not to counter all that had been said by the ED doctors which had alerted three generations to arrive in the early hours, I introduced the new idea that we would wait and see and … that maybe she will wake up. 

By the following evening she was arousable. By the next day she could say a few words and smile, though a bit confused. We treated her kidney infection. She gradually sipped water and smiled more. There I witnessed the resurrection of a lady attended with the infinite patience of a caring family. They loved their mother. They loved their grandmother. 

I hoped that the young doctors who accompanied me on our rounds each day understood the mystery and power of what was going on in that room – not the fact that she became physically better but the honor and dignity that was in the air. As we entered that space of dignity we breathed that same air. It did not belong to one person. It was co-created. 

Dr Sinéad Donnelly, an Irish doctor, is a Palliative Medicine specialist and General Medicine physician at Wellington Hospital.

 

Endnotes:

1. Chochinov HM, Hack T, Hassard T, Linda J. Kristjanson LJ, McClement S, Harlos M. “Dignity Therapy: A Novel Psychotherapeutic Intervention for Patients Near the End of Life.” Journal of Clinical Oncology 23;24 (2005) 5520-5525

2. Chochinov HM, Hack T, McClement S, Kristjanson L, Harlos M. “Dignity in the terminally ill: a developing empirical model.” Social Science and Medicine 54 (2002) 433-443.

Re-imagining Our Mortal Stuff: Finding Dignity Amongst the Matter of You (And Me)

By Bernard Leuthart

Wise man lookin’ in a blade of grass

Young man lookin’ in the shadows that pass

Poor man lookin’ through painted glass

For dignity.

 

Sick man lookin’ for the doctor’s cure

Lookin’ at his hands for the lines that were,

And into every masterpiece of literature

For dignity.

                        ~Bob Dylan

“Don’t go all timid on me, now! We’re only just getting to know where we are both going here and we ain’t there yet. Look, take my pulse. I know you are gonna work me out.” (Juanita J.) 

When I met Juanita early in my medical novitiate, I was terrified. Juanita was a Texan with Texan self-assurance and a state-sized understanding of her own diagnoses and the appropriate ways to keep her well. This had me on the back foot: she would tell me so kindly what was going on and what was to be done to hand her back to herself. But the gift with which she dignified my learning, ostensibly allowing me to do the doctoring, was her coming often to consult me and her ability to invite me into the personal space of her relapsing, remitting, interminable suffering. She got me amongst her stuff. When she died, I felt broken at the loss of that element of love that revealed more in me than I could reveal or heal in her. 

Generalists spend a great deal of time building their catalogue - episode after episode of care and delving into problems forming the skeleton of learning that informs the next consultation and the next. But Juanita had assisted me to something different, unfolding a map of possibility between us which pointed more to encounter than perfect solutions. 

Hungarian poet Miroslav Holub writes eloquently of a detachment of personnel sent into the Alps by an officer. Heavy snow falls and the landscape is obliterated. The group does not return. Seemingly, they have been sent to their deaths and their officer feels deep remorse. As if by some miracle, the group emerges unscathed three days later. How was it possible, they are asked. Admitting their initial despair, one of the number explains how he reached into his pocket and produced a map. Using this map, after the worst of the storm, they found their way out. On inspection of the remarkable map, it is discovered that it is not a map of the Alps, but of the Pyrenees

Taking this illustration, religious educator Maria Harris, whose work has had a profound influence on my role in general practice, makes the point that imagination brought to bear on our engagements has a power similar to the map of the Pyrenees. It has a prospective and explorative quality which can open possibility1 and delve down into the dignity dwelling at the heart of our encounters. And at this core is mortal matter - our frail human stuff that seeks the kind of transformation that can point us, we can imagine, towards the divine. 

Engagement that sets out on this footing, that cleaves to a disposition for encounter, can’t help but engender dignity. It invites quite naturally an emptying of the subjective ego and an imaginative opening of ourselves to the person present there. It recognises something between subjects (the subjects you and me and the subject matter) that perhaps approaches reverence; what Martin Buber refers to as perceiving ‘a thou’ there. It establishes, re-imagines and re-forms the covenant potentiated between each other there, through which trust comes and grace is allowed to work. 

I am reminded of a recent audience with 102 year-old Ken, in the locked dementia unit, who, across a corridor, beams his appreciation to the nurse who has just kissed his head and told him he is amazing. Grinning, he draws a harmonica from his pocket and plays for her and me a jaunty hornpipe. His dignity is renewed there. And, irrefutably, ours is too. 

Dignity emerges when, despite differentials of power, knowledge, mobility or well-being between us, we are both disposed to accompanying the other and making space for the other, especially when the matter is unwieldy and the outcomes elusive. The doctor and the patient, in a very real way, are tasked with making the stuff between them ‘something other’. We are, I believe, in our medical or ordinary encounters that matter, to become witnesses together to something being made holy: our frail human stuff dignified by a redemptive transaction that, as bioethicist Dr Michael McCabe has put it, “joins the dots on grace.” 

Attending to engagement, grounding ourselves, as Juanita did, in a disposition for encounter and rooting out the deep dignity made mutual there, can unfold the map on us. It can bring us to the transcendent value of human heartedness that helps us into gratitude and a eucharistic kind of openness to real presence in each other. It’s the matter of you and me. Bigger than Texas

Dr Bernard Leuthart is Clinical Director at Waiwhetu Medical Group in Lower Hutt. 

Endnotes: 

1. Harris. M. Teaching and Religious Imagination. 1987. Harper and Row, San Francisco.

 

What ‘Artificial Intelligence’ can teach us about humanity

Lynne Bowyer and Deborah Stevens

The term ‘Artificial Intelligence’ (AI) was coined by the computer scientist John McCarthy in 1956. It is an area of computer science involved with the development of computer systems capable of performing tasks normally requiring aspects of human intellect. We are currently seeing exponential growth in AI, and this is due to a number of factors: the availability of faster hardware; the ability of computers to run more complex algorithms; the development of massive data sets; and the enormous monetary incentives involved with this technology.

Our lives are already permeated by a range of what has been called ‘Narrow AI’ applications. ‘Narrow AI’ is incorporated into many of the products and procedures that impact on our daily lives: automatic heat pumps; smart-phones; web-based searches; self-driving cars; complex assembly work in industrial processes; Facebook automatically labelling your friends in photos; Amazon and Netflix making personalised product and film recommendations. Already these ‘Narrow AI’ applications do calculative tasks faster than humans can, and are altering our world in significant ways. The increase in speed and capability of ‘Narrow AI’ has enabled increased flexibility within AI systems so that in many cases those systems are able to transfer what they ‘learn’ in one domain to another. For those working in the field, this is fuelling the idea that we can create what has been termed ‘Artificial General Intelligence’(AGI).

AGI technologies have been built that incorporate algorithms that mimic aspects and degrees of human cognitive function, including visual perception, speech recognition and means-ends decision-making. This field of research draws on experiments with ‘machine learning’ that utilise neural network technology. This technology creates simplified models of brain networks that can self-organise and solve problems. With such things as voice and image recognition, and faster computational power, it is envisaged that AGI will be as capable as any human across any ‘intellectual task’. This is said to include things like complex reasoning, thinking abstractly and learning from experience.

 

These claims and the impetus behind these developments give us pause for thought. They give us the opportunity to ask the questions: What is human intelligence? How is human intelligence developed? Can human intellect ever be simulated by a computer programme?

 

We argue that human intellect cannot be simulated by a computer programme, however complex that programme may become. This is because human intelligence is more than being able to access and process information in an abstract way and calculate means-ends decisions. Genuine human intelligence is embodied and embedded in a particular shared world and is concerned with making sense of our earthly existence in a way that enables us to enact the moves that enable all to flourish. Consequently, our human life-world will be dangerously eroded if the push for AI is allowed to continue unchecked.

 

We begin by discussing how a dominant paradigm of thought perpetuates the idea that human intelligence is all about abstract calculation and means-ends decision making. This framing supports the notion that more complex forms of ‘super-computation’ will enable the development of AGI. We argue that such a paradigm offers an attenuated understanding of human cognition that veils genuine human intelligence. We then attend to the way in which genuine human intellect is embodied and discursively formed within a community of others who are embedded in sustainable ways of life and who are responsive to the “slings and arrows of outrageous fortune”1 that can derail us from time to time. At such times, our human intellect can hold us and others in being, in moments of existential uncertainly, enabling people to live well together.2

 

The dominant framing of human intellect

The philosopher Rene Descartes has exerted an enduring and pervasive influence on dominant western conceptions of human beings and their relation to the world.3 Descartes based his arguments on a metaphysical position that takes a reductive approach to seeking knowledge of things. This reductive approach isolates entities from their environmental context, strips them of all significance and pares them down into ‘component parts’. Descartes claimed that this process was thought to give us a sure and certain knowledge of things.

 

In relation to human beings, Descartes’ reductive approach opened up a chasm between the mind, the body and the world, and located the ‘human’ aspect of our Being in the mind. The mind, somehow associated with the brain, is said to be the locus of rational thought. On the Cartesian model, the ‘human’ is a fragmented and divided form of existence - human beings are a compound of a mind substance (res cogitans) and a body substance (res extensa), which somehow come together but need no other thing in order to exist. The mind, as the place of rational thought and language, is said to be an ontologically different substance from the body, and as the mind does not require the body, thought is essentially a disembodied process.4 To be human is to be a ‘thinking non-extended thing’ conscious of an ‘extended, non-thinking thing’, so that we are both subject and object.

 

The Cartesian framework sets each of us up in a private world of our own in which we establish “sure and certain knowledge” through the machinations of the rational mind. The mind, associated with the brain (and in subsequent theories that retain a Cartesian dualism, equated with the brain), is said to contain internal representations that correspond to an external reality. ‘Thinking’ is considered to be an isolated, inner process done in the mind/brain in terms of these representations and the way that they are manipulated. The ability to manipulate mental representations according to formal rules is said to be the ability to reason, and Descartes considered logic, especially mathematics, to be the quintessential form of human reasoning.5 As reasoning is considered to be a formal process, it is said to be universal: correct reasoning builds complex ideas out of simple ones in a way that anyone capable of applying the process can grasp. As rational beings – the archetypal animal rationale - Descartes’ epistemology claims that we are capable of expedient calculation through rigorous reflection on our ideas and mental operations. It is through this process that we can ‘know’ with absolute certainty that when we think, we exist…cogito sum.

 

This particular approach to the framing of ‘humanity’ and ‘rationality’ forms the basis of many western practices and institutions, and it underpins the initial forays into AI and AGI.

Initial ventures into Artificial Intelligence

When human thinking is equated with the ability to calculate ‘rationally’, understood as the abstract manipulation of representations according to formal rules, one can see how those working in computer science developing ‘artificial intelligence’ envisage that we can create machines capable of surpassing humans in “all areas of reasoning”. However, when reasoning has been pared down to ‘instrumental reasoning’ or ‘calculative reasoning’, concerned with the most efficient means to a given end, meaning and significance are drained from the world.7 Friedrich Nietzsche was one of the first people to articulate this existential situation.8 He noticed that a reductive, instrumental rationality had come to dominate our approach to science, and this ‘scientific thinking’ was permeating all aspects of life. At the same time, other ways of thinking and the values and ideals they embrace, began to be seen as increasingly less ‘rational’. Over time, instrumental rationality has been increasingly adopted and normalised to the point where it has been unquestioningly and uncritically accepted. It has come to arrange and dominate all aspects of our lives, permeating our social institutions and creating bureaucratic spaces devoid of humane understanding. As a corollary, it shapes who we are and what we can do.

 

With ‘rationality’ unhinged from human meaning and significance, the need for ‘moral theories’ came to the fore, in order to work out the ‘right’ thing to do. Such theories, for example utilitarianism, emanate from the same impoverished mode of thinking that reduces intelligence to a calculation formula, whilst presenting it as a universal logic which it (falsely) claims is the same for everyone. In other words, instrumental reasoning has produced a way of inhabiting the world and relating to others that is hideously flawed, losing sight of the mystery and richness of what it means to be truly human.

 

We therefore need to pause and consider our human way of being and what has been effaced by the dominance of instrumental thinking. In so doing, we have cause to question both the approach and the outcomes of Cartesian claims, and the practices, including the development of AI and AGI, that push forward in their wake.

 

Our human way of being – embodied, embedded and discursively informed

When Descartes made his famous conclusion - cogito sum – he failed to ask about, or take into account, the I that thinks. For in order for any abstract, instrumental, reflective thinking to occur at all, there must be someone, somewhere, doing something that is pre-reflective; that is, there first of all has to be a self, engaged in a world of activity, who can then come to reflect upon that activity.

When we attend to the way in which human beings engage with the world, we see that human activity is first and foremost embodied activity, that is, discursively embedded in a world of human endeavours. The things we come to know are the things we come to do, and they are learnt over time through our interaction with significant others.

Our knowledge of things is through our involvement with them, and this knowledge is inscribed into our very being and it has an inexpressible aspect. For example, one can write down the rules involved with a game of football, along with explanations of player positions, the physics involved with every play of the ball, and the biomechanics of the player’s moves. But none of this grasps the way in which we learn to play football, the dispositions and qualities of character inculcated through training and participation, the reading of the nuanced bodily moves done by one’s own team and the opposition, the self-discipline required to be able to play one’s role well, and the shared aspirations and unity of purpose that makes participation meaningful.

As we learn to play the game we become attuned to the thoughts and actions of one another. We come to feel and think as others do, because “our flesh is inseparable from the flesh of the world”.9 In the immediacy of a unique situation we anticipate where other players are going to move next and what they are likely to do when they get there. Our understanding of what to do in each moment is shaped by cues that we are not explicitly aware of: the ‘thwack’ of the ball; the feel of the grass and soil under our feet; the movement of the wind around us. Informed by the dynamic existential feel of the situation, players come to move as one, in seamless and complex ways that embody the game and defy any linear or algorithmic programming, or calculating of ‘probability’.

Like any other human activity we are engaged in, be it making friendships to making a cup of tea, we become accomplished in that activity through being immersed in it, practicing our moves, making mistakes, being guided, corrected and encouraged by others who have been there before us, and who have our well-being in mind. At the same time we come to embody the language that frames aspects of our world, along with the dispositions and qualities of character needed to live in that world together. In the situation of coming to play football, we will be told “take it slowly, look up…. towards where you are going” and “steady….full strength now….pass to Stevie on the wing”. Such words are accompanied by the appropriate gestures and facial expressions of those who are nurturing us into this practice. In this way, through our engaged, practical involvement with things, we come to embody a range of dispositions towards the world, as we learn the meaning of a language. In this embodied, interactive way we come to be “in the world and the world is in us”.10

The complex, rich, dynamic and ineffable character of human life means that it is not possible to create a list of rules, or a programme, for all eventualities; we cannot learn a fixed set of structured dispositional responses to events in the world. Instead we must learn the art of responsively negotiating the contingencies of the world, flexibly drawing on past situations to inform our present moment in light of future considerations.11 Consequently, human intelligence is a temporally integrated, hermeneutic achievement of an embodied, dispositionally informed individual embedded in a lived, meaningful environment.

As we learn to navigate the world appropriately through the guidance of others, we develop a sense of who we are, as well as what we can do and how we should do it. For example, we may make a fortnightly commitment to mow the lawns and weed the garden for an elderly neighbour, as we know that he struggles to do this job and that his family do not live close enough to help out on a regular basis. We also know how much pleasure he gets from sitting in his garden and admiring it. Our action is based on the insights we have developed over time, which orient us in light of the significance of things in this particular situation, and which illuminate what is a fitting response.12 The motivations that inform our thinking are the values that circumscribe our shared understanding of the world. As well as being an expression of what is good in this particular situation, we also come to understand ourselves as someone who can be relied upon to uphold the values of our community. Others also come to see us in this light. Aristotle has argued that the human intellect is determined by upbringing, and not abstract calculative thought. The shaping of an individual’s reasons for acting and ways of acting are discursively constituted in community, so that her upbringing is responsible for instilling the excellences of character required to respond appropriately to the situations she encounters. That is, she perceives the situation in its entirety and responds with practical wisdom.13

Although we are first and foremost embodied creatures immersed in a world of pre-reflective activity, we can of course re-present and reflect on an aspect of our life and consider ways we can improve what we are doing and hence, who we become. For example, we make an inappropriate comment to a friend and see that we have upset her. We do our best to apologise, but realise that we have hurt her deeply. Reflecting on this gives us the opportunity to ask ourself such questions as: “How did I lose sight of what matters, and how can I avoid doing that again?” How can I now make amends when my verbal apology is certainly not enough? Such reflection gives us the opportunity to sharpen our insights and refine our understanding of the situation, enriching what we have to draw on as we move forward. At the same time we shape who we will become, as we consider what has happened and what we will enact next, in light of the values that we - in our community - hold to be salient and want to uphold.

What is significant to note however, is that this reflective process is a derivative mode of thinking, dependent upon having a pre-reflective understanding of things. It does not have the foundational status that the dominant Cartesian-based framework of things has given it; nor is it merely means-ends instrumental thinking, as the ends themselves are evaluated and shape our very way of being.

The move to embodied AGI

Some AI researchers have recognised the significance of our human body for thinking. Rodney Brooks is an Australian roboticist and a leading proponent of embodied cognition. Noting that experiencing the world like a human is essential to developing human-like intelligence, he argues that a machine needs to have a body — it needs to perceive, move, survive and deal with the world. Brooks also notes that abstract computation is the least important human skill, and that embodied, sensorimotor skills are essential for higher level skills like common-sense reasoning.14 Proponents of embodied cognition have also recognised the importance of engaged human interaction for enabling someone to become ‘human’. They argue that a humanoid robot makes people more comfortable in their interactions with it, and this will make it easier for the robot to learn.

However, one wonders what is fuelling the drive to create such a machine, and whether those involved with AI research fully comprehend what is entailed in our human way of being.

What narrative will an AGI machine come to inhabit, and why? Do AI researchers grasp that flesh and blood creatures such as ourselves are intimately connected to the cosmos that sustains us, and this connection must inform the narrative that we live, as our very survival depends upon it? Do they understand the way in which a unique character is informed and shaped within a discursive community, embedded within a form of life that structures a liveable narrative, framing the significance of things, and thereby the values that we enact? Do they comprehend the significance of the relationships that encourage, comfort, uphold and affirm us, so that we hold one another well?

 

Do they understand how our interpretation and understanding of the world, and hence, what we do, is shaped by language? For example, if we take any concept – let’s say the concept ‘bear’ - and we consider how we have come to grasp this concept through a myriad of contextual interactions which have secured its multiple roles in our conceptual system, what are we to say about this concept in a machine? Can an ‘artificial intelligence’ ever really think, as opposed to calculate? Can it know what it ‘thinks’? Do those who talk about embodied machines and push this notion of AGI really know what they are saying when they make their claims?

Conclusion

We have argued that human beings are so much more than just creatures of instrumental rationality. Although instrumental reasoning is responsible for the development of the tools, techniques and technologies that have made life easier and more comfortable for us, its dominance has come at a cost. It has arguably thinned out and devitalized the richness of our humanity, along with the world we inhabit. It has allowed the calculation of the most efficient means to a given end to replace the evaluation of those ends themselves. It has left many people bereft of understanding the significance of their life, as in a world requiring mere calculation, the self recedes; for it is when enacting practical wisdom that the self is chosen. If we continue to allow the narrow and impoverished concept of instrumental thinking and the practices that it underpins to define our world for us in an un-checked way, our humanity will suffer and our world will become less liveable.

If we uncritically allow the push for the creation of AGI to go unchallenged, we may find that the entities we meet in government departments, healthcare situations, education, lawyer’s offices etc., lack the human touch.

 

Dr Lynne Bowyer is an educator with a background in philosophy and mental health. Lynne has a PhD in philosophy and bioethics and has taught in primary, secondary and tertiary settings. ​Dr Deborah Stevens is a science communicator and educator. Her PhD in bioethics education is informed by her interdisciplinary background in science, psychology, public medicine and education.

 

They are founding Trustees of the Centre for Science and Citizenship (www.nzcsc.org), a charitable trust that works with students and communities throughout New Zealand promoting thoughtful engagement with the ideas and actualities that contemporary science and its accompanying technologies bring, in order to consider whether and how we can live well with them.

 

 

Endnotes

 

  1. William Shakespeare, Hamlet, Act III, Scene 1.
  2. The idea of ‘holding one another in being’ is developed in the philosophy of Martin Heidegger; see Being and Time, translated by John Macquarrie & Edward Robinson. Oxford: Basil Blackwell, 1962. It has been used beautifully by Hilde Lindemann Nelson in “What Child is This?” The Hasting’s Centre Report, 32: 6 (2002): 29-38.
  3. René Descartes, Meditations on First Philosophy, Cambridge: Cambridge University Press, 1996, I, V.
  4. Descartes, Meditations on First Philosophy, I, VI.
  5. Ibid., V
  6. Ibid., II
  7. Max Weber, The Sociology of Religion London: Methuen, 1971, 270. Heidegger, “What calls for Thinking”, Basic Writings, from Being and Time (1927) to The Task of Thinking (1964), ed. David Farrell Krell, New York: HarperCollins, 1993,, 369-391; Theodor Adorno and Max Horkheimer, Dialectic of Enlightenment, trans. John Cumming, London: Verso, 1997, 37.
  8. Friedrich Nietzsche, “Thus Spoke Zarathustra: A Book For All And None”, The Portable Nietzsche, ed. and trans. Walter Kaufman, New York: Penguin, 1976.
  9. Heidegger, Being and Time, 98-99.
  10. Heidegger, Being and Time, 376-377, 387-388.
  11. John McDowell. Mind, Value, and Reality. Cambridge Massachusetts: Harvard University Press, 2002, 30-32.
  12. Rodney A. Brooks & Lynn Andrea Stein. ‘Building Brains for Bodies’. Autonomous Robotics 1 (1): 7-25 (1994).
  13. John McDowell. Mind, Value, and Reality. Cambridge Massachusetts: Harvard University Press, 2002, 30-32.
  14. Rodney A. Brooks & Lynn Andrea Stein. ‘Building Brains for Bodies’. Autonomous Robotics 1 (1): 7-25 (1994).

Kidney Transplantation: A New Zealand Perspective

Tony Stephens

This article has come about in response to a request to The Nathaniel Centre for information about the processes and ethical issues surrounding kidney transplantation. When we approached the Donor Liaison Coordinator in the Renal Department at Capital and Coast DHB for updated information about kidney donation, he agreed to provide the following piece which describes the practices involved. There are currently about 700 people in New Zealand on waiting lists for a kidney transplant.

Organ transplantation is a life-saving and life-enhancing therapy for many people. In New Zealand the heart, heart valves, lungs, liver, pancreas, kidneys, corneas and skin can all be transplanted.1

While most donated organs come from deceased people, live donors can give one of their kidneys or part of their liver to someone in need.

A transplant kidney allows the recipient to lead a relatively normal life. While they must take anti-rejection medications for the rest of their life, this is easier to fit into normal life than dialysis.

In New Zealand over 91 percent of kidney transplants are working after one year with over 82 percent still working five years after surgery.2 Some transplants have lasted for over 30 years.

Deceased Organ Donation

In some countries - including New Zealand - a person or family must make a conscious decision to be an organ donor after death. This can be done by stating ‘donor’ on our driver’s license but, most importantly, by informing our families of our wishes. This approach is known as ‘opt-in’.

If you are in a non-survivable condition in an Intensive Care Unit (ICU) your family will be asked to consider giving permission for organ donation after death. If you want to be an organ donor, your family is much more likely to agree if they know in advance. Therefore, it is essential that you inform your family of your wishes to be an organ donor or not.

An ‘opt-out’ system is the opposite; a person and family must make a conscious decision not to be an organ donor. In the absence of a decision to opt-out it is assumed they have given consent to be an organ donor. In such cases, family members are also assumed to have given consent for organs to be removed from their loved one. An individual or family may not feel completely comfortable about being a donor but may feel that the pressure of society to donate compels them to be a donor.

Intensive Care

Over recent years, in an attempt to improve donation rates in New Zealand, there has been a focus on training ICU doctors and nurses to better identify potential donors and then sensitively raise the question with family members.

Unfortunately, some people mistakenly believe a patient may be treated less well in ICU because of the focus on their organs rather than their recovery. This is not true.

One of the most important issues addressed by ICU staff during family discussions is that the care of the patient will not be compromised, whether organ donation has been agreed or not.

The ICU and transplant teams are separate entities. The ICU team focuses on treating the patient, and someone who is going to donate organs after death is treated the same as anyone else with all possible steps taken to improve their condition.

While the transplant team is informed when there may be a potential donor dying in the near future, this team is not involved with the patient’s care while they are still alive. The transplant team performs its roles with deep respect, sensitivity and gratitude to the person and their family.

The doctors of potential recipients are also not involved in the care of someone dying in ICU, and are only informed of a potential organ donation late in the process. They do not go to the ICU to talk with family members or to influence the care and treatment the patient is receiving.

Sometimes families decline organ donation and often face criticism from the media. While it’s easy to criticize, we must remember that the family is in shock with their loved one dying in front of them. To then be faced with the decision to have organs removed can be overwhelming.

However, if the family knows that their loved one wishes to be a donor, it may be easier for them to agree to the organ donation. Conversely, if the family knows the person does not want to be an organ donor, they can express this clearly to the ICU staff who will respect and honour this wish.

Live Donation

A healthy person can donate a kidney to someone in need. Live donors are usually members of the recipient’s family, although friends are also often donors. Donors can also offer a kidney in an anonymous (non-directed) manner. In this case the best matching recipient from the waiting list is allocated the kidney from the non-directed donor.

Live donors go through an extremely vigorous testing process to help ensure they will be fit and healthy for the operation and for the rest of their lives. This testing process takes place over many months and involves many appointments with nurses, doctors, surgeons and psychologists. A live donor can withdraw from the process at any stage with the support of the renal team. Equally, at any stage they may be found unsuitable due to a health condition or concern about their future with one kidney.

There are risks involved in being a live kidney donor – risks associated with the surgery as well as a slightly higher chance of developing renal failure (due to having only one kidney). There is also a higher chance of developing high blood pressure later in life and the consequences this can have on the donor’s health and life expectancy. A younger donor will have a longer life ahead of them for possible complications to develop.3

In New Zealand, the minimum age to be an organ donor is 18. While all potential donors are asked why they want to donate, extra care is taken with young donors - an 18 year-old would be asked at each stage if this is what they really want to do and would undergo a psychological assessment to help determine their motivations and their mental state.

Due to the long-term risks of kidney donation, anyone with diabetes or hypertension is ruled out of being a donor. Other factors ruling out live kidney donation are obesity and major psychiatric issues.

Kidney donors are monitored by the renal service or their GP for the rest of their life to help ensure they stay healthy.

At times a live anonymous donor will specify that they would like to donate their kidney to a child, or a particular person (a celebrity for example) or to someone ‘who has looked after themselves.’ This is not an option as non-directed kidneys are allocated purely on a tissue-typing test. This test identifies the person on the waiting list who best matches the donor. This person is offered the kidney and, if they agree, a surgery date is arranged. If the recipient does not agree, the next person on the waiting list with the closest tissue match is offered the kidney.

Ranking by tissue-typing gives the donor kidney the best chance of working and of not being rejected by the recipient.

Safeguarding the Interests of live donors

The interests of the donor are safeguarded throughout the live kidney donation process. They have a different doctor to the recipient, enabling each doctor to focus on their particular patient without the possible conflict of interest, or pressure to help one over the other.

As the donor is seen by many health professionals throughout the process, there are many stages at which these professionals can determine whether organ donation is the right thing for a particular donor.. The healthcare team can also determine if the donor is being pressured, in which case a strategy can be formed to decline the donor in a way that keeps them safe from any possible family repercussions.

Coming forward as a potential live donor takes a great deal of courage. To go through surgery for no physical benefit is very brave. Potential donors do sometimes feel pressure to donate, not necessarily from their family but from within themselves. A person may feel they need to donate a kidney to their loved one, but also feel the need to look after their own family.

Overcoming these conflicting feelings is very difficult, and our advice for someone in this situation would be to not donate. Being a kidney donor requires single-minded determination and focus. If there is too much going on in the donor’s life it is likely to be too much for them to cope with.

Throughout the process, staff maintain the privacy of the donors’ information. At times a recipient will ask about how ‘their donor’ is getting on. Due to confidentiality reasons we cannot give information about the donor to the recipient. If a recipient wants information about the donor they will need to ask the donor.

Buying and Selling Organs

In some countries (such as India and Sri Lanka) some people sell their kidneys as a source of income. Invariably, these donors sell a kidney out of financial desperation and post-surgery are often treated poorly by the transplanting hospital.4 In New Zealand it is illegal to buy or sell organs for transplant. Nevertheless, this option is sometimes raised by people. In such cases, they are actively discouraged from going overseas to receive a kidney transplant. This is to try and reduce the demand in the organ market and to provide protection for donors who are driven by desperate circumstances to sell.5

Conclusion

Kidney transplantation is part of the wider treatment of kidney disease and offers a recipient the best chance of a better health outcome.

Kidney transplantation relies on brave and noble people to be donors – either after dying or as a live donor. Donors and their families are motivated by a strong desire to help someone in need.

For live donors, the desire to help someone and to improve the life of the recipient outweighs the short and long-term risks to their own health. Families of deceased donors often gain some comfort from the knowledge that the death of their loved one has given life to other people.

Tony Stephens is a Registered Nurse and works as Donor Liaison Coordinator in the Renal Department at Capital and Coast DHB.

Endnotes

  1. http://www.donor.co.nz/facts-and-myths/faqs/
  2. http://www.donor.co.nz/facts-and-myths/statistics/
  3. Reese, P, Boudville, N, Garg, A. (2015). Living kidney donation: outcomes, ethics and uncertainty. The Lancet. Vol 385, May 16: 2003-13
  4. Matas, A. (2012). Incentives for organ donation: proposed standards for an internationally acceptable system. American Journal of Transplantation. Vol 12(2): 306-12.
  5. http://www.declarationofistanbul.org/