I wrote recently
about the controversial news that surgeons in Denver had taken organs,
including the hearts, from newborn infants who had died in intensive
care.
In recent years the retrieval of organs from patients whose hearts have
stopped (so-called donation after cardiac death, DCD) has become more
popular. In part this is because of the problem that there is a
shortage of organ donors who are brain dead. It is also because of the
recognition that when patients die after removal of life support, their
organs may still be viable for transplantation.
The timing is critical. If patients take a long time to die when breathing machines are removed, their organs are no longer suitable for donation. The quicker organs are retrieved after the patient dies, the more likely they are to be viable. So, in many cases, patients are taken to the operating theatre while still alive, machines are switched off, and surgeons are ready to operate as soon as the patient is declared dead.
There are also some procedures that improve the viability of organs. For example, in the recently reported cases, donors were given prior to death drugs that help preserve their organs (eg heparin), and had catheters placed so that immediately after death cold fluid could be infused into the body. One concern about these pre-mortem procedures is that they have no benefit for the patient, and so some worry that they may breach the principle of non-maleficence. In other cases, surgeons have put the bodies of organ donors onto bypass machines – after death, so that organs could be sustained while the surgical teams prepared to remove organs. One concern about this, is that if a patient has ‘died’, and then their circulation is restored by being put on a bypass machine (including circulating the brain), they aren’t really dead any more.
These unconventional and investigational procedures test the legal boundaries of the determination of death, and the permissibility of organ donation. Other options are possible however. It may be worthwhile contemplating whether they would be acceptable.
One option would be extra-corporeal non-brain organ support (ECNBOS). Patients from whom life support has been decided to be withdrawn would have a surgical procedure to put in place a bypass machine that would support the circulation of all organs except the heart and brain. Life support (except the ECNBOS machine) would be withdrawn, and the patient’s heart allowed to stop naturally. Once the patient was declared dead, the organs could be removed.
The advantage of this procedure would be that organs could be retrieved even if it took some hours for the patient’s heart to stop. (ECNBOS as described wouldn’t allow the heart to be donated.) Currently DCD is only possible if the heart stops within half an hour of withdrawing life support. There would be no unseemly rush after life support were removed, and family could spend time with the patient after death, before organ removal. ECNBOS would not change the status of the patient, since cardiac death would lead to brain death. ECNBOS would not cause the patient’s death.
This radical alternative is unlikely to be immediately embraced. It would be technically possible, but difficult to isolate the heart and brain. It would require a major surgical procedure with no prospect of benefit to the patient. Although local and systemic anaesthesia could be provided, it might cause the patient pain or discomfort. It may not be clear whether the consent of a patient who had agreed during life to their organs being donated after death, would have had a procedure like this.
Let us set the last concern aside. Imagine a transplant surgeon who has had the misfortune to be in a car accident, and to have suffered devastating brain damage. He had previously made it clear to all and sundry that in such a condition he would not want to be kept alive, and moreover, that he would want all appropriate measures to be taken to allow his organs to be used for others in that circumstance. Would it be acceptable in this case for us to perform such a radical procedure in order to maximise the chance of his organs helping others?
There are some reasons to think that it would be. But, while ECNBOS would not cause death, it would again blur the boundaries between patients who are alive in intensive care, and those who are dead. It would highlight the conflict between actions that maximise the ability to donate organs, and the risk of interfering with the process of death. Some may also worry that if ECNBOS is permitted, it may lead surgeons to even more radical actions, including the active killing of patients, or the harvesting of organs from those who aren’t dead. If either or those options were on the [operating] table of course, then there would be no need for us to risk harming the live potential organ donor. But perhaps they should be. Which is worse?
References
When the heart stops: harvesting organs from the newly (nearly) dead PracticalEthicsNews 14/8/8