 Without further ado, let me introduce you to Arthur Kaplan. Art is the doctors William F. and Virginia Connolly Mitty, professor and the head of the division of bioethics at New York University's Langone Medical Center. As you know, that's a medical center that was under severe duress. You've read about it in the last week, and I'm delighted that Art was able to get out of the city and be here today. Prior to going to NYU, Art was the director of the Center for Bioethics at the University of Pennsylvania, and it previously taught at the University of Minnesota, University of Pittsburgh, and at Columbia. Art and I were exchanging memories, which is not so easy for us as we get older, but we think we first met each other in 1979 at the Hastings Center when Art came to Hastings as a research associate. Art, as you know, is the recipient of many awards and honors, including the McGovern Medal of the American Medical Writers Association, the Franklin Award from the city of Philadelphia. In the past, he was named as one of the 50 most influential people in American healthcare by Modern Healthcare Magazine, one of the 10 most influential people in the ethics of biotechnology by the editors of Nature Biotechnology, and last year as one of the 10 most influential people in science by Discover Magazine. Today, Art will keynote our conference with a talk, and I think the title is behind me, Polluted Sources, Prisoners and Organ Donation. Please join me in welcoming Art Cap. An honor to get to give this talk, and it's wonderful to come to one of the gems of bioethics that Mark and his colleagues have built at University of Chicago. We were discussing a little bit before the meeting started, some of the sociology of the field, and there's really been, I think, no place that has done a better job training people and establishing scholarly record than here. So it's really just a great honor to come and speak. You may see me, at some point, sit over here. Because of the events at NYU with the flooding and everything that took place, I suffered an injury. Now, people have asked me, oh, did you get hurt? And I hurt my leg, I sprained my ankle. You know, saving preemies or helping people on sleds come down 20 flights. No. I was actually thrown out of the hospital pretty fast. I was there as part of an evacuation priority. They got rid of the ethicist very quickly. So I went home in the dark, and there I fell over my ottoman. However, that's only for you to know. Back in New York City, I am claiming to have been injured in the rescue effort and glorify my behavior somewhat out of this embarrassing stupidity. NYU, I should say, is severely impaired. The Manhattan VA, the Bellevue Inn, the Tisch hospital, which composed the three big hospital parts, are all on the East River side. They all got flooded into closure. So there is about 50% of NYU running some of the outpatient services and things that weren't based near the river. But the big hospitals are out, and it's quite an event. You will get to see something about it. I told Mark I've got an enormous amount of work personally right now. There are loads of doctors and residents and students with nothing that they can do very much. But one thing that goes on is bioethics research. Just take a computer, sit down, open it up, babble for a while, talk about something, papers emerge. So I have a team of, like I've never had before, I must have 100 people trying to do bioethics projects right now for at least the next month. And so I think you'll see a burst of right incoming out of NYU. You may wonder how could this happen? It's because of the disaster. It may be a version of lemons to lemonade for me. And I wish it wasn't happening this way, because obviously it's severely harming patient health in the city of New York and the surrounding area. There's no place for people, for example, with drug addiction to go, the Bellevue was closed, mental illness outpatient programs aren't there. So while people did get evacuated, a lot of the needs of chronically ill people and others that were handled, particularly in the big Bellevue city system facility are not getting addressed. So that's a big challenge and problem. So that's the report from back there. On a happier note, I'm going to talk today about shooting people in the head to get their organs. Because that is the polluted source that I want to spend a little time with about stretching to find new resources or sources rather than resources, sources to get organs for transplant. And I'll tell you a little bit of the history here. I got interested in the prisoner issue a long time ago. People were always asking me, would it be possible to use prisoners? Why don't we use prisoners more to get organs for transplantation? It's a very popular topic. Some of you know I talk on the media and sometimes I'm a guest on talk radio shows. I appear in between ads for recapping tires and other suspicious vitamin remedies that late night radio likes to advertise. But in the middle I'm often asked, why don't we use executed prisoners to get more organs if we're so short? And so that issue had been around and I had thought about it a bit and had sort of thought, I don't know, I guess maybe we should use prisoners. But I've come to think very differently and that's because I got caught up almost inadvertently in a discussion about how China was handling organ procurement. I was asked back in 2007 to chair a task force for the United Nations and the Council of Europe on organ trafficking. There are many things I could tell you about what came out of that. But one thing that came out of it was that roughly 60% of the world does not have a cadaver organ procurement system. They don't have it. So they rely on living persons to get organs. And China has a very large transplant tourism business. If you go up even today on websites, you can see sites that say if you need a liver transplant, if you come here to this particular hospital, you can get one into home in three weeks. And that's odd for a variety of reasons. It's hard to imagine that a donor would become available, to match the person. And it seems sort of an on-demand kind of thing that is hard to understand biologically. How would that work? But it does work. And Chinese officials, for example, say that they have done many, many transplants and they're rather proud of it, but they don't have a cadaver system. So where are livers and hearts coming from? Perhaps kidneys are coming from living persons. So we puzzled about this as part of the study that we did. We did some inquiries into what China was up to, and I'll talk about that a little bit later on. Not to hold you in suspense. I don't think the use of prisoners is a good idea. I'll try to make a moral argument about why that's so. Part of it is practical. Part of it is moral. I don't think it's a way to solve shortage in any real sense, any meaningful sense, and that's what we're going to head for the rest of my remarks. So the other thing that triggered interest was this. This gentleman, Christian Longo, is in prison on death row in Oregon. And he wrote an editorial in the New York Times last year in which he said, I was sentenced to death for the murder of my wife and my children. If I am executed, I would like to be an organ donor. And I don't see why I shouldn't be allowed to donate my organs, partly as a way to make up for my bad deeds, that I would like to pay back society in some way. And he basically said the Oregon prison officials would not let him be an organ donor. They already told him that, and if his sentence was carried out, he wasn't talking about donating while alive. He was talking about donating upon his execution. Whether he could donate while he's alive, I may have time to say something about it or may not, depending on how fast I get through this. But this was really a discussion about execution and then using someone after the execution. So one thing that struck me was, he did say in the editorial in the New York Times that he had killed his wife and children. So I thought I would look into that a little bit and without giving you all the gory details, he did kill them. He threw them all off a bridge from his car. He thought the family was in his way and he killed them so he could enjoy a more uninhibited free-spending lifestyle than his conservative Jehovah's Witness Church tolerated. He ran away to Mexico and had a really good time. He was finally caught there by federal agents, brought back and tried and sentenced to death. These murders were heinous and terrible. This guy is not a nice guy. What he did afterwards showed no remorse at all. He basically got rid of the life he had in order to pursue a more indulgent one. I'm not sure he could have just left and gone to Mexico. I'm not sure what this was all about. But the fact is, when you're talking about prisoners on death row, I want you to understand when someone says I want to somehow make good or pay back or redeem, you're up against some very bad crimes. And whatever your views are about the death penalty, and we'll say a little about that, one problem is if you're going to have the death penalty and you do terrible things like this, and then someone says, well, you expiate your guilt, one of the persons that I managed to talk to, I'm not going to tell you too much about how, but I did talk to one of the family members who survived this family, but a relative of these people who he killed. And they said they would find it repugnant in the extreme if this guy donated an organ and was written up as some kind of a hero for saving a life. If they wanted to punish him, they wanted to punish him with execution. They supported that. And they did not want anything happening to him that would make him out to be a better person than he was or forget the crimes that he had done. So as you know, when we talk about punishment, there are arguments about deterrence. That's why you put people in prison or kill them. And then there are arguments about retribution. Well, if you're on the retribution side and at least this one relative was, they did not at all support this action on his part, even knowing that someone might have their life saved. I mean, they just found it intolerable that this bad guy who had destroyed their lives, the relatives who survived the wife and the child would even be thought about as someone who would get the good credit for winding up saving or helping someone else. That's an old argument in punishment. Immanuel Kant and many other philosophers have written about it. We're not going to settle it here. But I want you to understand that part of the problem in using prisoners who are executed in some parts of the world is they are not nice people. And those who survived them or those who choose to punish them often do have retribution on their minds, not deterrence. And if you allow them to expiate, the retribution is not there. So just a fact to ponder about where that sets. Well, why would we permit prisoners like Longo to achieve any satisfaction or self-image improvement when they've committed terrible things? What will the families think? Well, I know what one family member thinks, not positive. Is there a motive, if you use executed prisoners for the state to keep executing people, if you don't think execution is a good idea, but the state finds that it can help with a supply of organs by continuing the practice of execution, or doctors do, is that the wrong incentive, if you will, you're creating a poor incentive rather than getting rid of capital punishment, either because it doesn't deter or it's not helpful in terms of real feelings of justice in the sense of retribution. But putting all that aside, is it even meaningful to talk about using prisoners as cadaver donors? And that was the part that I hadn't thought about earlier, but because of the Chinese issues and the request from Longo to permit the practice in the U.S., I delved into it a little bit more deeply. There is a statement from the World Medical Association that says prisoners should be eligible to donate after death if they wish, but you need safeguards to ensure that they make an unpressured choice. And they basically say, you have to make sure that the prisoner's giving good consent if you're going to use them. So it's not that medical ethics on a worldwide basis has said, we're not doing this. There is a reason to ask, is it even a good place to go to find organs? So first of all, the majority of executions in the world happen in China, far and away, more there than anywhere else, somewhere around 5,000 prisoners, and we'll come back to what kind of prisoners in a minute. Iran has about 400 a year. No other country executes more than 100 people a year. The only countries that actually execute more than 10 are Iraq, Saudi Arabia, Yemen, and us. So number one, there aren't a lot of executions. When we get into this whole issue about what would the impact be, there aren't a lot of people who are executed in the U.S. As of February 2011, there were 60 federal prisoners in the U.S. on death row. Since the reinstatement of the death penalty at the federal level, in 1988 there have been 68 people sentenced. There have been three that actually got executed, and six had their sentence commuted because of subsequent genetic and DNA evidence showing that they weren't guilty. So more people have actually been exonerated from death row at the federal prison level that have been killed in federal prisons. Again, you're looking at small numbers. 34 states permit the death penalty for state jurisdiction crimes. There were 46 executions there more, but it's been dropping rapidly. That number is going to continue to drop because of problems raised about the manner in which executions are carried out. Is it humane? Some of you know the manufacturers of some of the drugs used in executions are refusing to ship them if they know they're going to be used in executions. Some of the protests have come around execution about the inadequacy of the defense of some of the people at the state level who have been sentenced not having proper representation. And there are also issues about governors having second thoughts. It's been true in Pennsylvania. It's been true in Illinois. As to whether they're going to end New York, it's been true in Connecticut as to whether they're going to allow executions at all, even if the legislature has said, okay, the governor may be commuting everybody's sentence. So the bottom line, a key fact to understand is if you're thinking, as many Americans do, that we have a horde of people that we're executing and that must give us a horde of organs potentially to capture, that just isn't so. The numbers are tiny. We're not talking, I'm not saying it wouldn't be good to save one more life, but this is not a path that's going to lead us to getting a lot of organs unless you're doing a lot of executions, which is why we're going to come back to China. Most death row prisoners are not great organ donor candidates. Why? Well, I know on TV and in the movies, if you see a movie like The Longest Yard or the remake of The Longest Yard, the impression is that everybody who's in prison is in tip-top physical condition. They work out, they eat well, they are physical fitness nuts. So they're really in great shape. In reality, prisoners are not great candidates, particularly death row prisoners. For one thing, if you start appealing your sentence, you wind up getting old. And people appeal away. I think the appeals process raises the average age of prisoners well past 50 on death row. So a lot of them are up in their 60s. Secondly, they don't work out. And in fact, what they do do is get communicable diseases. There's plenty of HIV. There's plenty of hepatitis. There's plenty of other nasty bugs floating around. The people in the pool of those who might be executed are often obese, diabetic, infected with various agents and old. It isn't the place you would head if you were really looking for donors. I'm not saying you can't find any, but if you looked at the list and then shrunk it down as to who would actually be a viable candidate, it's even smaller than that list of potential candidates. It gets to be kind of tiny very fast. Then there's the problem of how you execute them. So if you gas the prisoner or hang the prisoner or poison the prisoner in some way or even execute them by firing squad, you are not treating their organs well. Now I know we're going to have a discussion after me, but some of the ins and outs of brain death pronouncement. In an execution, you spend an awful lot of time making sure the guy is dead by hanging around to make sure he's not doing anything. Like, five minutes. Nobody's there. Doctors Chuag and Bernard are not there with a neurological examination of the executed prisoner. You're kind of listening to the heart. You're sort of seeing as anything appear to be going on. And it takes time. So you're going to wait a nice long time. These organs are not only damaged by the means of execution, they are damaged by the time it takes to pronounce the person dead. So again, sounds nice in the abstract, use the organs of executed prisoners. The very process of how we execute and how we pronounce death in that particular population makes it even more remote that you're going to get a viable organ post-execution. The only real way to do it is to either bring back the guillotine and move quickly or do what the Chinese do which is to shoot people in the head and yank organs out immediately. It's sort of what we would call the uncontrolled donation after cardiac death experience. So those are the ways that you preserve the organs. Most execution methods are not good for organ procurements. So as I said, you have to wait a long period of time to make sure they are dead. You're basically running a kind of strange non-heart beating donor problem discussion for some of these modes of execution. I don't think even on a good day since executions are publicly witnessed, the events are going to take place in a prison setting, and it's going to be very hard for American doctors, according to their own codes of ethics, to come in and yank out parts immediately after the execution and have that part televised. Televised executions would be done in some of the states, they are, and it would be macabre. So there are other disincentives. You might say, well, let's execute the guy under conditions that we would maximize the chance to get organs, but either execute him in a hospital setting or bring the hospital setting into the guy, and that ain't going to happen either. The AMA is on record as not being happy with capital punishment anyway, starting to get involved at this level to procure parts as part of an execution is not going to fly. So bottom line of this, as much as it gets kicked around by various outlets, or Christian Wango in the New York Times, the ability, practically speaking, to use prisoners who are executed as organ donors is almost nothing, and it's probably worth nobody's time to talk about it ever again, just so you don't get on one hand on the other hand ethicists here, at least in the U.S. and Yemen. Now, China is a little different. China does have a lot of executions. They don't have a cadaver system at all for getting organs. They do thousands of transplants, some hearts, some livers, some kidneys. The demand for organs in China is astronomical. It's a big country with a big population. They could use four to five times the number of donors than we have, for example, to meet their needs, so it is something that they are keenly interested in, and many of the hospitals involved in doing transplants are affiliated with military hospitals that are nearby where the executions are. So there's a link between military medicine in China and the execution of prisoners. The facilities are often close to one another. Public hospitals and sort of government-run entities do do transplants as well, but the military has found it very lucrative to be in the transplant business. So there are a lot of people making money out of transplants who are on the military side, and the military side in China tends to be somewhat autonomous relative to the government side. So you'll see why that becomes important in a minute as well. So big internal demand for organs. A lot of business in transplant tourism. We saw that in our study. The military in particular makes money from this, running their military hospitals where they put a lot of the transplant programs. Probably 20,000 livers are claimed by Chinese official statistics to have been done in the past 10 years in China, and they say on their same websites that about 1,475 of those were living lobe of liver donors. Well, there's no cadaver system, and they got about a tenth of the transplants done by living donation. They have to be getting them from executing prisoners. And in fact, in more recent years, they have not admitted that for a long time. They denied it, but now they admit that they are using executed prisoners as the prime source. In China, consent, I would say, is non-existent if you want to follow the WMA guidelines about prisoners as to their interest or willingness to be an organ donor. Particularly when it's a transplant tourist who has a particular blood type and antigen type, and you're blood typing and antigen typing your prisoners, I don't really think there's a lot of consent involved because basically if your number comes up and you match the transplant tourist, then you're going to get executed. So I wouldn't say it's the most voluntary system in the world. Aside from that problem, if you are a prisoner in China, you can be a prisoner because you've done heinous things like Christian Longo and killed your family. You can also be a prisoner because you belong to Falun Gong, the spiritual movement that we hear about in China. You can also be a prisoner because you're a Tibetan or a Uyghur political resistor. And there are reasons to think, which I'll talk about later if you're interested, that Falun Gong in particular and political prisoners are over-represented in the people who are executed to get their parts because they tend to be younger and healthier. The Falun Gong people are in pretty good shape. So they become more of interest if you're looking for organs than others might be. So I know from some of the work we did on the commission, the UN Task Force, that there is an over-representation of younger people in the pool, and that probably points to an oversampling of people who didn't commit heinous crimes but are there for other reasons. So the notion of prisoner itself is rather contentious when you talk about what's going on in China. Now, I'm going to, just in the interest of some time here, these are statements from some of the public officials in China saying, you know, we know in the past year that the shortage of organs is a bottleneck in the development of our transplant capacity. We can do it. We have the skill set to do it and the resources to do it, but we don't have voluntary donation. On the other hand, it's difficult in China because Chinese culture has an attitude that organ donation from cadavers is not the way to treat the body. And it is something that is strongly felt by many people in China. On the other hand, it is something that was strongly felt by many people in the U.S. 40 years ago, 50 years ago. It was something that was strongly felt by many people in Israel. It was something that was strongly felt by many people in Japan. If you don't get moving to try to set up a cadaver system, you get, I'll put this deliberately, addicted to your supply of prisoners. You've got to start moving the culture toward an acceptance of cadaver organ procurement if you're going to get away from execution on demand to get parts. And the time, I think, is way past due for the international community to be pushing China to do this. So the health ministry says it now requires previous sentence to death give consent. I'm going to say I don't believe it as long as transplant tourism on demand is there. And they say they're also starting to get consent from the prisoner's family. There's no evidence that anybody's ever provided that anybody's talking to anybody's family. It's said by the government officials. It also says the Chinese courts will review all prisoner cases. I don't believe that either. However, there is goodwill on the part of some government officials in China to start to make the move toward cadaver procurement systems. There is not, however, movement in the military. And that's where the tension exists in sort of getting off the prisoners over to a cadaver procurement system for the whole country. And when I say many countries do not have cadaver systems, they're talking to about places like Bogota. I mean, big countries with huge populations who have no capacity to get anything because they have not taken on the cultural and political challenge of trying to convince their populations to support cadaver donation. Despite the state intent to, and recently, this is all in the past year to obtain organs, move away from getting organs from execution, the medical and scientific communities in the U.S. and elsewhere have done very little to make their moral abhorrence of this state of affairs widely known. Presentations about transplantation in China, outcomes for liver things or better solutions to preserve organs, continue to be made at international conferences, publications about the experience with transplantation in China peer-in-peer review journals, pharmaceutical companies interested in immunosuppression continue to do studies and mark it in China. So something like the world has said, gee, shooting people in the head and may not be legitimate prisoners and pulling out their parts with a fog of discussion about consent is not a morally good thing. So after getting a view of this, and I wanted to present this to you because this is an example of maybe bioethics in action when the students here go home at Thanksgiving and their relatives say to them, I don't know why you do that bioethics stuff. What the hell difference does it ever make? Here's the answer, and I'm going to be ending on this. I wrote a piece in The Lancet last year, and I said we should boycott articles submitted to The Lancet and other journals about transplantation. We should not publish them until such time as there's reason to believe there's a serious effort to get away from the use of executed prisoners. Some journals, you can see which ones, came on board the boycott. Others, New England Journal, JAMA, British Medical Journal, remain silent and still do. Haven't really entered into this boycott campaign. I think the case, however, is pretty open and shut that this style of getting organs in a major nation should not be accepted. I don't think we should be quiet or silent about it, and I tried to recruit bioethicists to the cause of saying let's boycott and pay attention to what's going on in China and try to highlight it as a human rights violation. And many bioethicists have responded and signed The Lancet letter and other things to try and continue to draw attention to the practice. So without going on and on here, let me wrap up by saying this. It seems to me prisoners generally in the U.S. there aren't enough executions. The sample of people who could be donors is exquisitely tiny and you'd probably have to get involved in practices to procure their organs that would not bring esteem to the American medical profession. Be gross. China has relied on a system behind closed doors, sometimes in vans of killing people on demand to get parts. There clearly is not much consent associated with that and their whole notion of prisoner is morally suspect. They're addicted to that source. The international community and the bioethics community should do more to push them away from that particular addiction. I think there have been noises by people of goodwill out of China that they want to change but they're not changing fast enough and they're going to need more support from us to push military medicine in the direction that I think is the ethical way to go. So I hope I've convinced you, at least when you call into the next late night radio talk show with your idea about prisoners and cadaver donation that that's probably not going to fly and that we should be paying attention to what's going on in China as one of the current international bioethics problems that I think we could do something about continuing to put heat on China to change. Thank you.