Undermining Public Trust in Organ Donation

There is a story out today that I find very disturbing, for it both reflects the apparent urge among some organ professionals to cross crucial ethical boundaries and promotes public confusion about when someone can be properly declared dead. It involves heart transplants from babies and implies strongly that ethical rules were ignored in the organ procurement procedure. From the AP story:

The Denver cases are detailed in Thursday's New England Journal of Medicine. The editors, noting the report is likely to be controversial, said they published it to promote discussion of cardiac-death donation, especially for infant heart transplants.

They also included three commentaries and assembled a panel discussion with doctors and ethicists. Many of the remarks related to the widely accepted "dead donor rule" and the waiting time between when the heart stops and when it is removed to make sure that it doesn't start again on its own.

In two of the Denver cases, doctors waited only 75 seconds; the Institute of Medicine has suggested five minutes, and other surgeons use two minutes.

State laws stipulate that donors must be declared dead before donation, based on either total loss of brain function or heart function that is irreversible. Some commentators contended that the Denver cases didn't meet the rule since it was possible to restart the transplanted hearts in the recipients. "In my opinion, it's an open-and-shut case. They don't have irreversibility, and they don't have death," said Robert Veatch, a professor of medical ethics at Georgetown University.

When I agree with Robert Veatch, it is a rare day! I support "heart death" procurements with the 5 minute waiting period, and still support brain death as dead, despite some admittedly important issues being brought up about that matter--which we will not discuss here.

Alas, some wish to push boundaries beyond even brain and heart death protocols to people unquestionably alive. From the story:

But others argue the definition of death is flawed, and that more emphasis should be on informed consent and the chances of survival in cases of severe brain damage.

That sentence should have been explored more fully because it strongly implies advocacy to dismantle the dead donor rule, which I suspect (being me) that the editors of the NEJM would support. Be that is it might or might not be, there are many voices writing in the most prestigious and bioethics and medical journals in the world arguing to follow the Siren song of utilitarianism by dismantling of the dead donor rule--either by redefining death as a diagnosis of PVS, or just permitting procurement from the unquestionably living. We have discussed these matters here at SHS often (for example, this post) and I have covered it extensively in my other writing (for example, this NRO piece) and in Culture of Death.

If organ professionals and bioethicists want to destroy all public faith in organ transplant medicine, I can't think of a better way than taking organs before true irreversible cardiac arrest and pushing for procurement rights before actual death. The impulse to help sick people is laudable, but principles and standards that apply to transplant medicine exist for a reason. The time is now to stop pushing at the boundaries, otherwise that sound you will hear will be people tearing up their organ donor cards. And that would be a tragedy.

And for goodness sake people, create uniform rules for organ procurement to apply throughout the country so we don't have such varying procedures being followed in different hospitals!

FOLLOW UP: I have been told by someone I trust--but have not yet read it myself--that at least one of the NEJM articles referenced in the AP story does indeed advocate for doing away with the dead donor rule on the basis that both heart death and brain death diagnoses allow organs to be procured from people who are not really dead, so let's open it up some more. That's a disastrous opinion on many levels, assuming it was accurately represented to me. I am loaded with work at the moment but will read these articles as soon as I am able. More then.

Organ Harvesting Lawsuit: Potential Serious Breach of Organ Procurement Rules

Doctors and a San Luis Obispo hospital are being accused in a lawsuit of mistreating Reuben Navarro, a disabled dying patient toward the end that he would die sooner rather than later and that his organs could then be be procured. (Click here for PDF of Complaint.) Based on what has either been admitted or determined, there certainly appear to be some serious irregularities in this case, the facts about which definitely need to be investigated fully. These include denied allegations that the transplant surgeon made the decision to remove a respirator--which as discussed below, would be a real no-no--that Reuben's mother was told a lie that the respirator "had" to be turned off after five days in order to pressure her into consenting to organ harvesting, the injection of twenty-times the usual amounts of morphine when the patient was taken off a respirator but didn't die, and perhaps worst of all, that when Reuben didn't die, he was neglected for 9 hours without life support being reattached.

We have to be careful not to jump to conclusions, since allegations made are not facts proven. But these charges are very serious, which, if true, could amount to criminal as well as civil wrongdoing.

I am posting about this case not to prejudge it but to discuss the often misunderstood organ procurement policy that is supposed to be followed when procuring organs from the bodies of dead patients who are not, to use the vernacular, brain dead. Known in the transplant profession as "non heart beating cadaver donors," patients who die from cardiac arrest can have their organs procured for transplantation under the terms of what is sometimes called the "Pittsburgh Protocol." Space does not permit a full detailed listing of every step in this process, but here are the key points:

1. The medical teams and organ procurement teams are to be kept strictly apart so that there is a wall of separation between medical decision-making for the patient, including whether and when to terminate life-sustaining treatment, and the decision to donate organs and organ procurement.
2. If consent to procure is given, the family says their goodbyes and the patient is wheeled into the operating theater at the agreed upon time. Life support is removed. Proper palliative measures are permitted to prevent distress. If the patient goes into cardiac arrest and the heart stops, the transplant team waits to ensure that the arrest is irreversible. This time can range from 2 minutes (too short in my view) to five minutes (better).
3. If the patient does not experience cardiac arrest in 30 minutes (as in this case), life support is supposed to be reattached, and the patient returned to the care of his treating team. The patient is never again to be a candidate for organ procurement.

With these points in mind, we can see the serious nature of the lawsuit's allegations. On a broader scale, the time is long since nigh for national standards for organ procurement to be established with very clear and continuing training to ensure compliance. As it is, there is a hodge-podge, leading, perhaps, to confusion. If the people's confidence in transplant medicine--always thin--is to be maintained, this is a matter of great and growing urgency.

One last point: This case involves matters of such profound public import that no judge should permit the parties to enter into a "confidential settlement." Confidential settlements usually involve money changing hands in return for strict silence, which impedes the proper workings of the tort system, by for example, preventing unsafe products or serious abuses of law from becoming publicly known. For more on the wrongness of confidential settlements, see No Contest: Corporate Lawyers and the Perversion of Justice in America, which I coauthored some years ago with Ralph Nader.