NEUROCRITICAL CARE ETHICS Ethical Considerations in Post-Mortem Sperm Retrieval in Brain Dead Patients By Salvador Cruz-Flores, MD, MPH and Michael Rubin, MD Case: A 35-year old man has a severe However, the case poses a higher level closed head injury resulting in progressive of contextual complexity that the deterioration in neurological function Cornell University guidelines fail despite best medical management such to cover. More broadly, would that brain death is expected. The patient posthumous reproduction is a designated organ donor on his driver’s promote or interfere with license. His family members are strong important human goals for proponents of organ donation and discuss the patient? What is the their desire to facilitate organ donation with evidence that supports Salvador Cruz- the treatment team. In addition, they request the notion that PSR Flores, MD, MPH posthumous sperm retrieval as part of the promotes or interferes organ procurement process. The patient’s with this patient’s sister stated that she had asked her brother human goals? Who (the patient) to be a sperm donor as she is can provide that married to another woman and the couple evidence and was planning on conceiving. The patient’s speak on behalf family was very supportive of this request. of the patient’s best interests? In In the patient’s location, there are no addition, there current state, local, or federal laws regarding are implications posthumous sperm retrieval. The hospital regarding respect Michael Rubin, MD and organ procurement organization have for the dead, the no formal policies regarding posthumous welfare of the sperm retrieval and prior requests for posthumous sperm child, and the retrieval were handled on a case-by-case basis through an autonomy of the emergency ethics consultation. Prior requests were denied physician. due to a lack of documentation that the patient would have authorized sperm retrieval. The neurological condition of this Question: In this scenario, is it ethical to proceed with patient and the posthumous sperm retrieval based on the family’s assertion absence of a written that the patient would have authorized it? If not, why does statement of consent the burden of proof differ from posthumous procurement call for substituted of other tissues? Can the sperm retrieval process and the judgement and implied ensuring ovum fertilization be considered separate actions or presumed consent from an ethical standpoint? which require an analysis of this patient’s values and Comment: Posthumous sperm retrieval (PSR) was fi rst reported human goals 2. In the absence in 1980 and while it is an uncommon situation, requests have of a spouse, this patient’s parents increased over time, pressing the question of whether it is ethically would assume such responsibility. permissible 1. The ethical analysis requires consideration of the The case, as described, establishes stakeholders that, in this case, include the patient, the patient’s that the patient’s sister had spoken with sister and her wife, the patient’s parents, the potential child from him about her and her wife’s intentions to the pregnancy, and the physicians and healthcare team. At the become pregnant and that he was agreeable to core of this request is the autonomy of the dying and incapacitated become a sperm donor. patient who is unable to provide consent 1,2. While no written confi rmation or witnesses are described, Without statute guiding this process, some institutions have some weight ought to be given to the fact that his family and, created their own policies as guidelines. Cornell University’s presumably, his parents as surrogate decision makers endorse guidelines for PSR specify four areas of consideration: a) issues and support the request. The implication of this support is that of consent, b) medical contraindications, c) resource availability, his parents have knowledge of the patient’s actions or values that and d) waiting time period prior to conception. Furthermore, indicate the patient’s approval. the guidelines stipulate that consent can only be provided by the wife of the deceased, the death must be sudden and from It could be argued that the patient’s family in general and the no communicable diseases, and retrieval must occur within 24 patient’s sister specifi cally may have a confl ict of interest as hours of death 3. In this case, following the Cornell University potential benefi ciaries of this decision and, as such, it would guidelines would result in turning down this family’s request invalidate the claim of the patient’s willingness to donate sperm. considering that the patient is not married. Some authors have argued that proceeding with PSR with the family’s consent represents a confl ict of interest given their position as direct benefi ciaries of such a decision. 10
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