Margaret R. McLean
Let's be frank-in the world of organ donation, the law of supply and demand is not working in our favor. Each year in the United States more people-approximately 18 per day-die awaiting a needed organ than live because of a successful transplant. As of April 5, 2010, almost 84,000 Americans were awaiting new kidneys and almost 16,000 were awaiting new livers.
A new pilot program funded by the US Department of Health and Human Services is trying to increase the number of organ donations by procuring the organs in the emergency room after patients' hearts have stopped. But the program has raised some red flags that must be addressed by anyone interested in improving the current system.
The first is, how can we tell whether the donor is dead or still in the process of dying? Since the dawn of organ transplantation in the 1950s, the development of an unambiguous definition of death has taken on both medical and ethical urgency. The Uniform Declaration of Death Act, formulated in 1981, defines brain death as the "irreversible cessation of all functions of the entire brain, including the brainstem." And, although there is no national standard to diagnose brain death, we have grown comfortable that once brain death is declared, the patient is truly dead.
But the chronic shortage of organs for transplant has led to dusting off another, older definition of death also contained in the Uniform Declaration: Cardiac death is the "irreversible cessation of circulatory and respiratory functions." In 2007, the United Network for Organ Sharing and the Joint Commission on Accreditation of Healthcare Organizations began requiring hospitals to provide patients the opportunity for organ donation after cardiac death (DCD).
For hospitals, this meant answering the question: How long does it take after the heart stops for a person to be declared dead so that the organs can be removed? To be certain that the heart will not spontaneously restart, most doctors wait five minutes, but some wait two, and in 2008, physicians at Children's Hospital in Denver waited just 75 seconds to try to increase the odds that the infant hearts they were procuring would still be useable.
Behind the controversy is a simple physiological fact. For organs to be useable for donation, they must be procured shortly after the heart stops beating. In fact, in DCD, preparations for donation may begin even before the patient is removed from mechanical support. Doctors may, for example, give the dying patient massive doses of the anticoagulant heparin to preserve the organs.
That brings us to the second major question: Are treatments with heparin or other interventions designed to protect the organs in the best interests of the donor or at least not harmful? Or, are we allowing the needs of the recipient to trump the needs of the donor? Is one person being sacrificed so that others may live?
The environment of the Emergency Room only exacerbates this confusion. Part of the problem is contextual-the focus in the ER is on saving lives, often in a time crunch. There is simply no time to inquire about the patient's donor status and contact the organ procurement organization.
But part of the problem here-and in the driving desire to increase the supply of transplantable organs-is ethical. The move toward organ donation in the ER and the advent of DCD have raised public and private fears that in our zeal to increase the supply of needed organs, dying patients will not receive aggressive intervention and perhaps their lives will be deliberately shortened. Indeed, our well-intentioned efforts to increase the supply of organs may be seeding an ironic reluctance to fill out a donor card or stick that little pink dot on our drivers licenses.
At the Markkula Center for Applied Ethics, we've worked with a number of hospitals to develop policies on organ donation and DCD. Underlying our deliberations has been a simple idea: No person should be used as the means to an end. Dying patients should be supported in their desire to "give the gift of life," but the dying person must not ever be thought of as a thing-a repository of organs that someone else could put to better use. Hence:
- Donors-and all who are dying-and their families must be treated with compassion, dignity, and respect.
- Donation must not cause or hasten death.
- Donation decisions must be made free from overt or subtle coercion.
- The care of the dying patient cannot be directed by the potential for organ donation.
- Loved ones must be given the opportunity to be at the bedside to accompany the patient in dying.
With these basic principles, we believe it is possible to create donor-centered policies that adequately manage conflicts of interest between the needs of the dying patient and the needs of the organ recipient.
Margaret R. McLean is the director of bioethics and associate director of the Markkula Center for Applied Ethics at Santa Clara University.