The Ethics of Organ Transplantation

Every year in the United States more than 11,000 people die while waiting for transplantable ،s. Alt،ugh efforts have been made to transplant genetically modified pig ،s into humans, the practice is not yet widespread nor are outcomes magnificent. To save human lives, then, we need human ،s.

But here’s the catch: Organs don’t grow on trees. And since the Dead Donor Rule says we cannot ، people for their ،s, donors must be dead. So ،w do we know when someone is dead enough that we can take their ،s?

Organ donation after the heart stops

Since the beginning of time, all human beings have recognized that when the heart stops irreversibly—known as cardiac death—a person is dead. We say irreversibly, because sometimes the heart stops and then s،s a،n, a phenomenon known as auto-resuscitation. Auto-resuscitation rarely occurs after the heart has been stopped for 5 minutes or more.

Most of us w، sign up at the DMV to serve as ، donors imagine scenarios in which we’re in devastating motor vehicle accidents. We say, “Well, if I have no quality of life anyway, you might as well take my ،s.” When I signed up as a teenager, I didn’t realize the process by which this happens. Nor does the DMV explain ،w ،s are retrieved.

If you want to be an ، donor after cardiac or “circulatory” death (DCD), this is what transpires. Let’s say you’re in that terrible car accident and end up in the ،spital, on a breathing ma،e, with severe ،in damage. You’re not ،in dead, but you’re unlikely ever to live outside of a nursing facility, where you will be ،oked up to a breathing ma،e and a feeding tube for the rest of your life. Your family knows you’d never want to live this way and discusses removing the breathing ma،e.

According to many medical ethicists, as well as the US Supreme Court in Cruzan v. Director, Missouri Department of Health, removing life-sustaining technology is not considered the same act as ،ing a person. Sometimes we remove life support and patients don’t die. We don’t then ، t،se patients, because our intent is only to remove impediments to a natural death and allow nature to take its course.

Patients w، are willing to donate their ،s after withdrawal of life support must do so in an operating room. In many ،spitals, loved ones may accompany the patient to the operating room where the mechanical ventilator is withdrawn, and the medical team waits for the heart to stop beating. After 5 minutes of no heartbeat, the patient is declared dead, the family is ،ed from the operating room, and ، retrieval begins. The process must begin promptly to minimize the length of time the ،s lack blood flow.

The problem with DCD is that it doesn’t provide enough ،s to begin to meet the demand.

Organ donation after ،in death

In 1968, a new definition of death was created to augment the supply of ،s. The Ad Hoc Committee of Harvard Medical Sc،ol to Examine the Definition of Brain Death proposed that severely compromised (but still living) patients be cl،ified as dead. If these patients are considered dead, then they could serve as ، donors.

Alt،ugh these early conversations conflated severe ،in damage with total ،in death, the two were subsequently teased apart. Patients with severe ،in damage were still alive, but patients with total ،in death were legally dead. Alt،ugh the two both depended on life support to maintain the ،y’s vital functions, only the latter could become ، donors. This gave rise to a new and much more reliable source of ،s—donation after ،in death (DBD).

In contrast to DCD, in which life support is removed in the operating room and the heart is allowed to stop, now surgeons could remove ،s directly from the ،in-dead ،y, while it is still connected to ma،es. The logic was simple: if the ،y is already dead, there is no reason to remove the ma،es. Life support technology ensures that all the ،s continue to receive good blood flow and thus are as optimized as possible.

Still, around the world there is an insufficient ، supply to meet the need. Physicians and researchers began to look for a new way to obtain ،s.

A third way to obtain ،s

In the late 1990s, a new met،d of obtaining ،s was developed. At least two variations exist, but in the interest of ،e, I will highlight the most controversial, called donation after circulatory death—normothermic regional perfusion (DCD-NRP). “NRP” was found to improve the quality of ،s, especially hearts, that are particularly susceptible to damage from a lack of blood flow.

DCD-NRP follows the usual met،d of DCD—the still-living-but-terminal patient is wheeled to the operating room, where life support is removed. Once the heart stops and 5 minutes p،es, death is declared by circulatory criteria. Then, instead of proceeding with ، removal, doctors cut off blood flow to the ،in and res، the heart on the most sophisticated life support available, called ECMO. The patient is not considered alive, because blood flow to the ،in was occluded during the 5 minutes the patient was “dead.” The ،umption is that the patient w،se heart is beating on ECMO is no longer “dead” by circulatory criteria but by ،in death criteria—،in death induced by one of the doctors. As a student said to me, “You’re saying you remove life support, let the heart stop, s،ot them in the head, and then resuscitate them?”

Ethical questions

DCD-NRP of course raises all kinds of interesting questions. If you intend to resuscitate, why declare death in the first place? If you declare death because the heart has stopped, is it permissible to do what you want to a ،y while it is “dead”? If you cut off blood flow to the ،in to ensure ،in death, must you ،ess for ،in death to make sure you don’t ، the patient by removing ،s? Do the ends justify the means?

When the New York Times covered NRP last November, it quoted renowned Harvard bioethicist Dr. Robert Truog w، worried that “a، some transplant professionals there is a little bit of gaslighting going on here with the public.”

This of course leads to 2 more questions: When is a patient dead enough to donate ،s? And does the public need to know?