An Ethical Dilemma
Defining Death:
An Ethical Dilemma
The cases of three infants receiving heart transplants in Denver, Colorado from three other dying infants who had not yet met the criteria for the Dead Donor Rule (DDR) raises important ethical questions for the medical field (O’Reilly ¶ 1). These questions include examining the criteria for death, what it is to be dying versus dead, whether the DDR should be rethought, issues of public trust, and consent and prognosis.
All 50 states recognize the DDR as law. According to it, “patients must be declared irreversibly dead before their vital organs can be retrieved for transplantation, provided there is consent from patients or surrogate decision-makers” (O’Reilly ¶ 8). Since a Harvard Medical School committee gathered to create the standards of the DDR in 1968, brain death is universally recognized as an ethical time to procure organs for transplant. However, in the past couple of decades, cardiac death has also become a legally and medically acceptable time for organ donation (O’Reilly ¶ 9). The infants in the Denver transplant cases appear to have fit the qualifications for cardiac death, they had severe neurological injury, and their organs were donated with the informed consent of their parents, saving the lives of three infants. However, the question about irreversibility remains. For example, if cardiac death is defined as a heart being stopped and unable to be started again, then it should not have been possible to restart the hearts of the three donor infants in the bodies of the three recipient infants.
Some physicians have called for new criteria regarding death and organ donation. In an article in Critical Care Medicine, Dr. Robert Troug and Dr. Walter Robinson wrote, “We propose that individuals who desire to donate their organs and who are either neurologically devastated or imminently dying should be allowed to donate their organs, without
first being declared dead” (2391). One significant advantage of this proposal is that it opens up a larger pool of organ donors and the possibility of saving more lives. If this were indeed the universally accepted standard for the ethics of organ donation, then there would be little to argue about concerning the Denver infants’ transplants. However, because arguments and questions remain, Troug and Robinson’s proposal cannot yet be considered a universally acceptable rule by which doctors, patients, and surrogate decision-makers can base their decisions on for organ donation.
Troug and Robinson’s proposal appears to require a reconsideration of the definition of the DDR. This could mean that it is necessary for another Harvard Medical School or similar committee to gather and re-write the DDR based on current medical knowledge, technology, and ethics. A significant goal of any such committee must be to preserve public trust and allay fears that the medical establishment could overstep its bounds in procuring organs for transplant patients.
Maintaining public trust is an essential part of the medical establishment so it can offer the best and most appropriate care for all patients. Some people may be suspicious of doctors’ intent if the DDR is changed to include patients who have not yet been declared brain dead. For instance, people may be reluctant to designate themselves as organ donors, fearing that doctors will view this as a reason to offer less care or time on life support when there still may be a chance for survival. Patients need to be reassured that their care will not be influenced by the possibility of some very wealthy person needing an organ transplant pushing physicians for a donor. Physicians need guidelines to make sure that they are not causing death via organ donation. In addition, patients or their designated surrogate representative need scientific information in language that they can understand detailing their rights, prognosis, and the fine points of informed consent. One way to maintain the public trust if a new definition of the DDR is to be made is to make sure “the physician team determining death . . . be strictly separated from the procurement team to prevent organ-procurement considerations from influencing the death determination” (Bernat ¶ 5).
A major issue in the area of considering using cardiac death as part of the definition of the DDR is the amount of time after the heart stops that death can be declared. More scientific evidence is needed to come up with a conclusive number concerning “what minimum duration of asystole ensures that autoresuscitation will not occur” (Bernat ¶ 9). This research should answer the questions, “Does the fact that a donor's heart is restarted in another patient prove that circulatory cessation was not irreversible? Or should the requirement of irreversibility be restricted to circulation within the donor?” (Bernat ¶ 10).
The Denver doctors were doing what they believed was in the best interest of their patients. What they did right was to make sure they had the consent of the families before withdrawing life support and transferring the hearts to the infants that had complex congenital heart disease (O’Reilly ¶ 1). However, they could have reduced the resulting controversy somewhat by waiting longer than 75 seconds before making the decision that cardiac death had occurred. The O’Reilly article does not mention if the physicians involved in the infants’ ICU care were under pressure by other physicians hoping to procure organs for their own patients; however, if this was the case, it should have been prevented. The fact that three infants’ lives were saved is commendable; perhaps equally of value is the ethical discussion the Denver physicians created by their actions which can lead to better standards for organ donation.
References
Bernat, James L. (14 Aug 2008). The Boundaries of Organ Donation after Circulatory Death. The New England Journal of Medicine, 359. Retrieved from http://www.nejm.org/doi/full/10.1056/NEJMp0804161
O’Reilly, Kevin (19 Jan 2009). Redefining Death: A New Ethical Dilemma. American Medical News. Retrieved from http://www.ama-assn.org/amednews/2009/01/19/prsa0119.htm
Truog, Robert D. & Robinson, Walter M. (2003). Role of Brain Death and the Dead-Donor Rule in the Ethics of Organ Transplantation. Critical Care Medicine, 31(9), 2391–2396. Retrieved from http://faculty.ksu.edu.sa/omar%20omari/Seintific%20Paper/Role%20of%20brain%20death%20and%20the%20dead-donor%20rule%20in%20the%20ethics%20of%20organ.pdf
