Tags: orient | dead | donor | rule

Dangers of Ending 'Dead-Donor' Rule

Tuesday, 02 Sep 2008 10:59 AM

By Jane M. Orient, M.D.

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Previously, giving the gift of life meant donating blood. Obviously, you have to be alive to do that.

Now, to give the new, still more miraculous gift of life — such as your heart — you first have to be declared dead. But this could change, owing to three audacious operations performed recently at Children’s Hospital in Denver.

Three babies born with defective hearts got “new” hearts, increasing their life expectancy from several months to more than 15 years. Three sets of parents gave permission to take the hearts from their precious newborns, who had suffered asphyxia — oxygen deficiency — at birth. Though left with serious brain damage, and not expected to survive for long, these babies were not “brain dead.”

Once consent was obtained, a “do not resuscitate” order was written, and the babies became “non-heart-beating donors.” They were taken to the operating room, tubes were placed in their femoral artery and vein, a blood thinner was administered, and life support was discontinued. To ease the discomfort that may accompany removal of the breathing machine — such as intense air hunger — the babies received pain-killing and sedating drugs.

By the way, such drugs suppress the drive to breathe.

Then the transplant team waited for the heart to stop beating. Soon after this, the harvest began.

The use of “cardiac-dead” donors is not new. There were 793 such donors in 2007, representing some 10 percent of all deceased donors. But in these cases, only abdominal organs were transplanted. The hearts had been stopped for at least five minutes, to assure that the stoppage was truly irreversible. By then, the heart had probably been too damaged by lack of circulation to be useful as a transplant.

In Denver, one of the babies’ hearts had been stopped for only 75 seconds. The baby probably could have been resuscitated — except for the “do not resuscitate” order. But the doctors argued that by this time “auto-resuscitation” was probably impossible. At least, no one had ever documented a case in which a heart had spontaneously restarted after 60 seconds or longer without a heartbeat.

Of course, the stoppage was not irreversible. The hearts started beating promptly after being installed in the transplant recipients.

The success of the operations was reported in the Aug. 14 issue of The New England Journal of Medicine, along with three commentaries about the ethical implications.

Now that the transplantation of cadaver organs has become so successful, the demand for organs, especially in pediatrics, has soared, greatly exceeding supply. There is intense pressure not to wait too long before harvesting the organs, lest they become unsalvageable.

At first, brain death meant that the brain had no circulation and was turning to formless liquid. Soon the criteria started becoming less strict. Now many highly regarded hospitals cut corners, according to a survey presented at the 2007 meeting of the American Academy of Neurology.

And why not? “The definition of brain death is, after all, not a newly discovered law of nature but an arbitrary agreement,” notes professor Anna Bergmann in an article on how transplantation violates cultural taboos, in the summer 2008 Journal of American Physicians and Surgeons.

Donors are “as dead as necessary” [to meet legal requirements] and “as alive as possible” [to meet the needs of the transplantation industry], states professor Franco Rest. Rest is quoted at www.initiative-kao.de, a Web site begun by donors’ parents who later regretted their decision.

In The New England Journal, Robert D. Truog and Franklin G. Miller write that constant revisions in the concept of death are unsupportable, and tend to undermine trust in the transplantation enterprise. “The reason it is ethical [to take the organs] cannot be that we are convinced [the donors] are really dead,” they write.

Let’s do away with the dead-donor rule, they suggest. Instead, we should rely on “valid consent by the patient or surrogate” in order to “maximize the number and quality of organs available to those in need.”

Also in The New England Journal, James L. Bernat asks, “To what extent should society permit manipulation of an organ donor or alteration of the determination of human death for the good of organ recipients?”

At least at present, potential donors and their surrogates are free to choose to decline to be donors. They are not, however, free to choose their definition of death, or to receive “futile care,” write Arthur Isak Applbaum and colleagues in the May 13 JAMA. For doctors to accede to such wishes would “undermine the regulative ideals of medicine.”

The story of six babies in Denver, three still living and three now indisputably dead, raises transcendent questions: Do our rights arise from a “consensus” of “society”? Are rights subservient to “needs” of others? Who decides? And who owns our lives?

Jane M. Orient, M.D., an internist practicing in Tucson, Ariz., and author of "Sapira’s Art & Science of Bedside Diagnosis."

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