Saturday, August 16, 2008

Killing the Dead Donor Rule: Undermining the Ethics of Organ Donation in the New England Journal of Medicine

I have now read "The Dead Donor Rule and Organ Transplantation" in the NEJM (359:7, August 14, 2008), by Robert D. Troug, MD, a physician at Harvard Medical School, and Franklin D. Miller, a bioethicist at the NIH. It makes for frightening reading. My comments will of necessity be long, so I will do this in two posts for ease of reader digestion.

The authors claim that brain dead isn't really dead, since, as one example, some patients declared dead by neurological criteria secrete certain hormones. Nor, they argue, is heart death under the organ procurement protocols death because the patients could perhaps be resuscitated.

Their answer to this alleged ethical problem is to just explode the dead donor rule entirely. (I don't know about Miller, but Troug has been mining this particular vein for several years.) There is no link (have copy), but here is the gist of the argument:

The uncomfortable conclusion to be drawn from this literature is that although it may be perfectly ethical to remove vital organs for transplantation from patients who satisfy the diagnostic criteria of brain death, the reason it is ethical cannot be that we are convinced they are really dead.
No. If we are convinced that the patients are not really dead--and be clear, I don't accept this premise--then there is no ethical way to take their organs and we will have to wait until death is unquestionable. Otherwise, medical ethics becomes mere medical expediency.

The authors resurrect the old false equivalence between removing life support as an action causing death and active killing--which bioethicists spent years arguing was not the case--and correctly so. When life support is removed, the death is natural. If you take someone's heart before they are dead, the person died from their heart being removed! Distinction huge, difference monumental.

In the next post I will ask why we should trust their new proposed paradigm of killing for organs to be properly supervised.

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