This paper examines the relationship between reported visual impairment and unintentional injury mortality. Data indicate that severe, bilateral visual impairment is associated with an increased risk of unintentional mortality among adults in the United States. This would seem to support that saving a person from blindness is halachically as if he is being saved from a life-threatening desease (suma kamet). Department of Epidemiology and Public Health, University of Miami School of Medicine, Miami, Florida 33101, USA. dlee@med.miami.edu

The purpose of this study was to examine the association between reported visual impairment and mortality among a nationally representative sample of American adults. The study’s findings show that severe visual impairment and less severe VI, to a lesser extent, are associated with increased risk of all-cause and cardiovascular-related deaths in American women; no link was found for men. These findings, though not fully understood, are similar to other previous studies on cardiovascular disease. For more information regarding the significance of the link between visual impairment and halacha, please see the explanation of Lee et al’s “Visual Impairment and Unintentional Injury Mortality: The National Health Interview Survey 1986–1994.”

This 2006 article argues for the establishment of a regulated system of kidney sales. This proposal comes in the wake of celebrity endorsements, public relations campaigns, and driver’s license organ donor registration which have failed to meet the increasing demand for organs. As a proponent of organs sales, Friedman argues, “The case for legalizing kidney purchase hinges on the key premise that individuals are entitled to control of their body parts even to the point of inducing risk of life.” This position is in direct opposition to medical association stances worldwide. In reality, black market organs sales are not uncommon in the developing world, allowing marketeers to take advantage of patients desperate for this life-saving procedure and donors living in poverty. To manage these increasing problems, Drs. Friedman propose the establishment of a fair market price, estimated to be about $40,000, to be paid by a federal agency working in collaboration with the United Network for Organ Sharing (UNOS). This agency would be self-sustaining and could reduce the long-term cost of managing end-stage renal disease by eliminating the need for costly and painful dialysis. The paper concludes with an acknowledgment that the development of another government agency, while not ideal, can reasonably deal with the ethical and medical challenges inherent in the present organ crisis.

The first of two articles in this file, “Organs for Change,” provides a concise history of organ transplantation, clinical medical ethics, and their intersections. Of transplantation’s ethical issues, Dr. Siegler says, “if you can grasp the ethical issues in transplantation, you grasp the major ethical issues in medicine.” Clinical medical ethics emerged as a field in the 1970s, challenged by the two major principles of organ donation: how to fairly increase supply and methods for equitable distribution. Dr. Siegler and his colleagues developed methods for ethical oversight with surgical innovation and establishing paired kidney exchange (including a Congressional amendment to the 1984 ban on organ sales). Fairly increasing organ supply continues to be a challenge as waiting lists are growing without a commiserate number of donors. Dr. Siegler’s solution includes further amendment of the 1984 ban to allow for a regulated system of organ sales.

While the concept of brain death is widely accepted, no universal criteria exist for its determination. This study compared guidelines from 80 countries finding that all standards specified exclusion of confounders, irreversible coma, absent motor response, and lack of brain-stem reflexes (see Wijdicks, “The Diagnosis of Brain Death” for more information). The majority of countries had medical practice standards (88%), legal standards (69%), utilized some form of apnea testing (59%), and required more than one physician’s declaration (50%). Specifics varied widely on the qualifications of the physician, methods of apnea testing, and observation time before pronouncement of death. Regional differences were also noted, such as mandatory laboratory tests in Europe and Asia. Within the United States, brain death determination has been left to each state to decide (44 states and the District of Columbia have guidelines) whereas most African countries do not. Even if guidelines are not standardized, it is clear there is a universal acceptance of brain death as a concept. Dr. Wijdicks concludes his survey with a call for an international task force on brain death guideline standardization, or, alternatively reexamination and revision of each country’s individual guidelines should cultural and religious beliefs dictate national policy.

One of the big questions surrounding living kidney donation (uninephrectomy) is donor safety. This study looked at the survival rates, causes of death, and kidney function of Swedish kidney donors more than 20 years after donation. The study’s most significant finding was that donor survival rates were considerably higher than in the general population. This result was most likely due to the strict evaluation process (one out of three applicants is chosen), which selects for the healthiest candidates. Renal function and causes of death were similar to the general population. These findings demonstrate no long-term risk associated with uninephrectomy, suggesting the practice is safe.