The Dead Donor Rule and its Detractors
Tarris Rosell, PhD, DMin
Program Associate
August 22, 2008
A recent New England Journal of Medicine article has created an ethics stir regarding death criteria for organ donation. Two heart transplants in Denver occurred in infants upon declaration of death by cardiac, not brain death, criteria—and just 75 seconds after a “flat-line” reading. The heart recipients are doing fine; but were their donors really “dead”? And does it matter?
Cadaveric donation for transplantation is premised on the “dead donor rule.” Up until recently, that has meant that only brain dead bodies could yield organs for transplant, since cardiac death declaration wasted precious minutes during which cell death ruined the heart, liver, lungs and kidneys.
Since there aren’t enough brain dead donors to meet the demand for organs, we have looked elsewhere. Living donors have increased the kidney supply, but don’t impact the shortage of hearts. So we adjusted federal guidelines for declaring death after a potential donor heart stops. The Institute of Medicine chose 5 minutes as the national standard.
Denver doctors chose 75 seconds because there is no data to show that a heart once stopped will restart of its own accord after 60 seconds. “Irreversible” cardiac function counts for what it means to be “dead”. Except that in the case of heart transplantation, those same hearts do indeed start beating again in other bodies, with help, and presumably would have done so in the bodies of the babies who “died”.
In a NEJM “roundtable” response, Dr. Bob Truog opines that we should dispense with the dead donor rule and focus on “valid informed consent” to donate in conjunction with a terminal prognosis due to “devastating neurologic injury.” His arguments are logical, his moral claims are well grounded, and he is almost convincing.
Indeed, much good is to be gained by his proposed approach. For those of us rather skeptical of current death criteria standards, the Truog solution simply makes them moot.
Yet there also is something morally unsettling about Dr. Truog’s proposal. It may only be “slippery slope” worries or attachment to tradition or distrust of the medical establishment or of our insatiable Western appetite for life extension at any cost.
I’m not certain that I can construct a persuasive ethics argument against Truog, nor that I even want to do so. But neither can I and the general public, I’m betting, quite go there with him—yet.
What do you think? Share and view your comments by clicking on "Comments" below this post.
Links:
Doctors debate when to declare organ donors dead, Associated Press, August 14
Infant Transplant Procedure Ignites Debate, Washington Post, August 14
New England Journal of Medicine, August 14, 2008
The Boundaries of Organ Donation after Circulatory Death, James L. Bernat, M.D.
Donating Hearts after Cardiac Death — Reversing the Irreversible, Robert M. Veatch, Ph.D.
The Dead Donor Rule and Organ Transplantation, Robert D. Truog, M.D., and Franklin G. Miller, Ph.D.
Program Associate
August 22, 2008
A recent New England Journal of Medicine article has created an ethics stir regarding death criteria for organ donation. Two heart transplants in Denver occurred in infants upon declaration of death by cardiac, not brain death, criteria—and just 75 seconds after a “flat-line” reading. The heart recipients are doing fine; but were their donors really “dead”? And does it matter?
Cadaveric donation for transplantation is premised on the “dead donor rule.” Up until recently, that has meant that only brain dead bodies could yield organs for transplant, since cardiac death declaration wasted precious minutes during which cell death ruined the heart, liver, lungs and kidneys.
Since there aren’t enough brain dead donors to meet the demand for organs, we have looked elsewhere. Living donors have increased the kidney supply, but don’t impact the shortage of hearts. So we adjusted federal guidelines for declaring death after a potential donor heart stops. The Institute of Medicine chose 5 minutes as the national standard.
Denver doctors chose 75 seconds because there is no data to show that a heart once stopped will restart of its own accord after 60 seconds. “Irreversible” cardiac function counts for what it means to be “dead”. Except that in the case of heart transplantation, those same hearts do indeed start beating again in other bodies, with help, and presumably would have done so in the bodies of the babies who “died”.
In a NEJM “roundtable” response, Dr. Bob Truog opines that we should dispense with the dead donor rule and focus on “valid informed consent” to donate in conjunction with a terminal prognosis due to “devastating neurologic injury.” His arguments are logical, his moral claims are well grounded, and he is almost convincing.
Indeed, much good is to be gained by his proposed approach. For those of us rather skeptical of current death criteria standards, the Truog solution simply makes them moot.
Yet there also is something morally unsettling about Dr. Truog’s proposal. It may only be “slippery slope” worries or attachment to tradition or distrust of the medical establishment or of our insatiable Western appetite for life extension at any cost.
I’m not certain that I can construct a persuasive ethics argument against Truog, nor that I even want to do so. But neither can I and the general public, I’m betting, quite go there with him—yet.
What do you think? Share and view your comments by clicking on "Comments" below this post.
Links:
Doctors debate when to declare organ donors dead, Associated Press, August 14
Infant Transplant Procedure Ignites Debate, Washington Post, August 14
New England Journal of Medicine, August 14, 2008
The Boundaries of Organ Donation after Circulatory Death, James L. Bernat, M.D.
Donating Hearts after Cardiac Death — Reversing the Irreversible, Robert M. Veatch, Ph.D.
The Dead Donor Rule and Organ Transplantation, Robert D. Truog, M.D., and Franklin G. Miller, Ph.D.
posted by Practical Bioethics at
12:49 PM
6 Comments:
I share your concern that the public is not ready to dispense with dead donor rule. I think it would probably reduce the number of willing organ donors.
There is a better way to put a big dent in the organ shortage -- allocate donated organs first to people who have agreed to donate their own organs when they die.
Giving organs first to organ donors will convince more people to register as organ donors. It will also make the organ allocation system fairer. People who aren't willing to share the gift of life should go to the back of the waiting list as long as there is a shortage of organs.
UNOS has the power to make this common-sense policy change, but it has not yet chosen to do so.
Anyone who wants to donate their organs to others who have agreed to donate theirs can join LifeSharers. LifeSharers is a non-profit network of organ donors who agree to offer their organs first to other organ donors when they die. Membership is free at www.lifesharers.org or by calling 1-888-ORGAN88. There is no age limit, parents can enroll their minor children, and no one is excluded due to any pre-existing medical condition.
Denver doctors chose 75 seconds because there is no data to show that a heart once stopped will restart of its own accord after 60 seconds. “Irreversible” cardiac function counts for what it means to be “dead”. Except that in the case of heart transplantation, those same hearts do indeed start beating again in other bodies, with help, and presumably would have done so in the bodies of the babies who “died”.
I think a more pathophysiologic way of thinking about this exception related to death is that the death of the baby is due to "cardio-vascular system standstill" that is not attempted to be reversed rather than the heart itself is dead. That is, if the baby's own heart and lungs or the physician cannot provide and move oxygenated blood to the vital organs, particularly the brain within a limited time period (whether it is 75 seconds or 5 minutes), there is no possibility that pronouncing death of the baby will be in error. ..Maurice.
Thank you, "Dave" and Dr. Bernstein for your thoughtful responses. Dave's suggestion seems to me worthy of public dialogue. At first blush it does seem reasonable and equitable to give some precedence in organ allocation to wait-listed persons who have indicated willingness also to be donors in death. If one has no religious or other moral objections to receiving body parts from another human, it is hard to understand what legitimate moral objections might be rendered to donating one's own organs. Whether there are pragmatic or logistical barriers to implementing such a policy, I don’t know. Anyway, it is an interesting proposal.
Dr. Berstein also raises a proposal worth discussing, I think. He wants to stick with the “dead donor rule,” but revise death criteria to include something like “cardio-vascular system standstill with refusal of resuscitation attempt.” A 75 seconds declaration of death then could be considered legal, accurate, certain, and reasonable on pathophysiologic grounds and current auto-resuscitation data. Why not? Dr. Truog’s emphasis on valid informed consent would surely be part of Dr. Bernstein’s criteria. Would there need also to be clear evidence of “devastating neurologic injury,” or could someone well informed and consenting be considered a donor candidate upon issuing a DNR directive?
Tarris Rosell, PhD, DMin
Dr. Rosell wrote: "...could someone well informed and consenting be considered a donor candidate upon issuing a DNR directive?"
In the usual sense, DNR directive refers to a request not to begin resuscitation in the event of an unexpected cardio-pulmonary failure, usually written in the context of it being a futile procedure for the patient or that any recovery by resuscitation would lead to a unwanted quality of life. In such a case, clinically, the arrest is not a scheduled event, the duration of the arrest when first discovered can be variable and perhaps too long to initiate procurement of healthy organs for transplant and there would be even further delay to call and set up the organ procurement surgical team. In the case of patients who are able to make a decison (or if lack capacity, their surrogate make the decision) to terminate ongoing life-support or in the case of termination of life support of a patient who is "dead by neurological criteria", the moment of termination is a scheduled event, the procurement team can be present and the progression to cardio-respiratory arrest is clinically observed so that the organ procurement can be begun without a delay harmful for the organs.
Therefore, I would say that the use of a DNR itself as a marker for a organ donor would not be clinically appropriate.
Thank you, Dr. Bernstein. All of this is helpful clarification regarding the typical DNR scenario. Yet my query remains. If the patient does NOT have "devastating neurologic injury," but there is request that resuscitation not be attempted (and DNR order issued), if cardio-respiratory arrest is both expected and observed, and if there is valid informed consent to become a tissue and/or organ donor--might it be ethically appropriate to declare death after just 75 seconds and proceed with recovery of tissue and/or some organs (perhaps even the heart, if not damaged due to disease, etc)? Too many "if"s?
I totally agree with organs donation, in case of an accident if the person's injure is fatal, and many of the organs are intact, I dont see why they can be used to save other person.
sv77
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