Doublethink and double effect; donation after cardiac death

In California a transplant surgeon has been charged with a felony in relation to the death in intensive care of a young disabled man (Ruben Navarro). (See also Matthew Liao’s blog from yesterday). Ruben had a severe degenerative disorder of the nervous system known as adrenoleukodystrophy, and had then suffered further brain damage after a respiratory arrest. The surgeon is accused of administering drugs to hasten Ruben’s death so that his organs could be used for transplantation. In the event Ruben’s death took some 8 hours after removal of life support, and none of the organs could be used.

What happened after Ruben Navarro’s life support was removed remains unclear. However this case highlights some of the problems of conflicting intentions when patients are allowed to die.

Most organ transplants occur after a patient is declared brain dead.
The patient’s heart and lungs are able to be supported by machines even
after they have suffered irreversible and severe brain-stem injury.
Permission is sought from families after the patient has ‘died’, and
the organs are subsequently retrieved.
A small, but increasing number of transplants occur after ‘cardiac
death’. The usual setting for this (as in the case in California) is
that of a patient on life support, for whom prognosis is felt to be
very poor (but they are not brain-stem dead). Removal of life support
is felt to be in the patient’s best interests. Many such patients die
soon after life support is discontinued, and their organs are then able
to be used for transplantation.

When we take a dying patient’s breathing tube out of their mouth, they
often gasp for breath. The machine has been making it easy for them to
breathe, and its removal can lead to discomfort or distress. For this
reason it is usual for such patients to be given pain killers (for
example morphine) and sedatives. However such medications may also
suppress their breathing, and may hasten their death. While physicians
are allowed (and encouraged) to seek to relieve a patient’s suffering,
there is a general feeling that that they are not allowed to hasten a
patient’s death. The ethical loop-hole that permits such actions is
called the ‘doctrine of double effect’. This in essence allows doctors
to give painkillers as long as their intention is to relieve suffering.
Hastening death is seen as a mere side effect of treatment.

One requirement of the doctrine of double effect is that if there were
a way of achieving the primary aim (relieving suffering) without the
‘side effect’ (hastening death), then this option should be taken. In
fact there are a number of sedatives and pain-killers available that
have much less effect in suppressing breathing than those that were
used by Ruben’s doctors, or those that are routinely used for dying
patients. If this were so important, then palliative care protocols
should stipulate the use of such medicines before the use of those like

The reason that doctors do not use such drugs I would suggest, is
because they hope to reduce the suffering of their dying patients both
in terms of the severity and the duration of their distress. They hope
that their patient will not linger, that they will not suffer long, and
such hopes are shared by the family (and often expressed previously by
the patient). In the case of a patient whose organs may be able to be
used to save others’ lives, their doctors and families also often hope
that they will die quickly enough that this will be possible.

I suggested earlier that there were conflicting intentions in the care
of dying patients. In fact, as in the sad case of Ruben Navarro, the
intentions and hopes of caregivers (that patients not suffer, that
their dying not be prolonged, and that some good may come out of their
death) converge rather than diverge. It is just that some hopes and
intentions are said to be permissible, and others are disallowed. This
leads to a kind of Orwellian doublethink in intensive care, wherein
doctors and nurses are forced to deny at a conscious level sentiments
that they sincerely feel.

The case of Ruben Navarro is a tragedy on multiple levels. A young
man’s death was prolonged, his mother’s desire that his organs be
available to save other’s lives went unfulfilled, a number of people
continue to wait on transplant lists for want of available organs, or
have died waiting. And confusion about permissible intentions and
actions in the care of the dying has led to what will be a bruising and
traumatic court case for the family, and the healthcare team involved.


Surgeon accused of hastening patient’s death to retrieve organs sooner
International Herald Tribune 27/2/08

Experts Are Concerned Court Case May Scare Off Potential Organ Donors
ABC News 28/2/08

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