Daniel Alan Shewmon, Olive View-UCLA Medical Center
7 December 2007
Joffe’s argumentation is cogent and convincing. The analogies of “kidney arrest” (with “brain arrest”) and of the drowning man (with DCD donors) are well chosen and illustrate the soundness of his logic. His objection to the weak construal of "irreversibility," on the basis that “patients in the identical physiological state are dead or alive based on their location and prediction of a future event (attempted resuscitation),” is also well argued and valid.
The only thing I might take issue with in the paper – and it is a very minor detail – is the implication (on p. 15) that “[harvesting organs] before death from patients whose prognosis is death” would necessarily “be a contributing cause of death.” I have described an approach to DCD by which the harvesting of organs before death neither causes death, nor accelerates it, nor disturbs the remaining (marginal) functional integrity of the organism during the final dying moments. See:
1. Shewmon DA: The dead donor rule: lessons from linguistics. Kennedy Institute of Ethics Journal 14(3):277-300, 2004.
2. Shewmon DA, Shewmon ES: The semiotics of death and its medical implications. In: Machado C, Shewmon DA (eds): Brain Death and Disorders of Consciousness. Advances in Experimental Medicine and Biology, Vol. 550. New York: Kluwer Academic/Plenum Publishers, 2004, pp. 89-114.
Competing interests
None.
Back to Lessons from Linguistics on Organ Donation after Cardiac Death: Organ Procurement or Physician Assisted Death.
Joseph Verheijde, Mayo Clinic Arizona
10 December 2007
Back to Lessons from Linguistics on Organ Donation after Cardiac Death: Organ Procurement or Physician Assisted Death.
Josephus L. Verheijde, Ph.D., Mohamed Y. Rady, M.D., Ph.D., and Joan L. McGregor, Ph.D
We agree with Dr Joffe that current organ procurement practice of “harvesting organs before death from patients whose prognosis is death” would necessarily “be a contributing cause of death.”
We wish to elaborate on Dr Shewmon’s comment about his description of an approach to donation after cardiac death (DCD), previously known as non-heart beating organ donation, by which the harvesting of organs before death neither causes death, nor accelerates it, nor disturbs the remaining (marginal) functional integrity of the organism during the final dying moments. Dr Shewmon provided a succinct description of the timeline of natural events during the process of dying (Table 1) [1]. Dr Shewmon also described a novel model of how and when organs can be removed for transplantation in DCD without theoretically inflicting harm or death on organ donors.
Table 1. Description of the timeline of natural events (E) during the process of dying[1].
Event =Description
E1= Apnea (Shewmon’s model for organ removal in donation after cardiac death)
E2a= Loss of arterial pulse (Current practice of organ removal in donation after cardiac death)
E2b= Electrical cardiac asystole on electrocardiogram
E3= Loss of potential for cardiac autoresuscitation
E4= Loss of potential for interventional resuscitation
E5= Onset of permanent loss of consciousness
E6= Loss of potential for recovery of consciousness
E7= Irreversible loss of all brain and brain stem functions (Legal statue for the Uniform Determination of Death Act 1981)
Dr Shewmon in the 2004 article states “I shall restrict discussion to the ideal DCD context: assuming the legitimacy of stopping life support (independent of transplant considerations), truly informed consent, lack of conflict of interest, medical certainty that apnea will supervene once the ventilator is discontinued, and the like. When the ventilator is withdrawn in the operating room, the first E to occur will be E1, final apnea; then will ensue E2, E3, E4, and E6, in that order. (Presumably E5, the onset of loss of consciousness has already taken place, whether from primary brain damage or from sedation for the procedure.) We should not base the timing of organ retrieval on which E represents “true” death, because this is an improperly posed question. Rather we should ask, “Beyond which of these events does the removal of organs X, Y, Z . . . neither kill nor harm the patient, even in the physical sense of accelerating the dying process?” The answer depends on which organs we are talking about. In the case of all organs except heart and lungs, removing them even before E1 will neither cause nor hasten death, because, in the ideal DCD context under discussion, by the time the loss of those organs might exert even the tiniest systemic effect, all the Es will have supervened long before. It takes days or weeks to die from renal or hepatic failure or intestinal non-absorption or pancreatic insufficiency; for the first several hours, absence of such organs has no significant adverse effect on the body. Between discontinuation of the ventilator and even the most conservative choice of E, the effects of hypoxia-ischemia will totally overshadow whatever infinitesimal adverse effects might theoretically result from an incipient lack of kidney or liver function, for example. Thus, for transplantation of noncardiopulmonary organs, it is utterly irrelevant ethically whether “brain death” is “really death,” or whether the Pittsburgh protocol’s 2 minutes of asystole is “really death,” or whether any other physical event is “really death.” Such questions are both malformulated and ethically beside the point. For heart and/or lungs, the moral requirement “to do no harm” by the extirpation is trickier. A solution suggested by some would be to place the patient on cardiopulmonary bypass, remove heart and lungs without affecting systemic circulation or oxygenation, then declare the bypass machine an ethically inappropriate—“extraordinary” or “disproportionate”— means of life support, just as the original ventilator was, and disconnect it.” (pages 293-294)[1].
First, Dr Shewmon’s argument about the removal of non-vital organs in DCD at E1 is based on the assumption that this action can only cause death from the systemic consequences of lack of liver, kidney or intestinal functions manifesting over days which is a much longer time than the timeline of natural events antecedent to death (Table 1). Nonetheless, the surgical procedures required to procure these organs have systemic consequences which can not be ignored since they can directly hasten or abbreviate the progression of natural events during the dying process (i.e. from E1 to E7) and therefore contribute to organ donor death.
The surgical procedures required to procure non-vital organs (liver, kidneys, pancreas, and intestine) in DCD have prominent and immediate systemic effects supporting their proximate roles in causing death through the following ways:
1) Intravenous medications such as heparin and phentolamine are given to DCD donors for organ preservation[2]. Phentolamine is administered to prevent vasospasm and also causes profound hypotension in organ donors. Systemic anticoagulation with heparin is administered to facilitate subsequent organ flush out which can also precipitate internal and/or external hemorrhage. Neither of the two drugs have palliative benefit except to only hasten the dying process [3, 4]. To the contrary, the effects of both drugs singly or in combination can induce early cardio-circulatory arrest or brain stem herniation (in acute cerebrovascular accidents) in organ donors.
2) The aorta and inferior vena cava are the two major blood vessels connected to the heart which are instrumented and interrupted during surgical procurement[2, 5-7]. The purpose of the vascular intervention is to enable rapid exsanguination of the entire circulating blood and its replacement with cold preservative fluids in organ donors.
a. Exsanguination can be performed through a femoral vein cannula opened to gravity to drain the circulating blood (external hemorrhage) with simultaneous infusion of cold preservative fluids into the arterial circulation via a separate cannula in the femoral artery.
b. The inferior vena cava and aorta are divided just above the bifurcation in the abdominal cavity to reduce venous return and congestion of abdominal organs.
c. The descending thoracic aorta is also clamped and the intrapericardial inferior vena cava is vented in the thoracic cavity for the rapid relief of liver venous congestion and exsanguination of blood from the donor.
3) Non-vital organs are artificially perfused in situ with cold preservative fluids within the native donor circulatory system.
4) The intra-abdominal cavity is rapidly filled and irrigated with saline ice slush at laparotomy for topical cooling of abdominal organs.
5) The intra-abdominal organs (kidneys, liver, pancreas and small intestine) are removed with major supplying and draining blood vessels en bloc. The en bloc method is not traditionally performed when intending to preserve life during surgery.
The above procedures have deleterious physiological consequences on the cardio-circulatory system which appear within seconds. It is important to recognize that the procurement of non-vital organs such the liver or kidneys from the abdominal cavity can shorten or abbreviate the timeline of the natural dying process within seconds because of direct invasion and disruption of the cardio-circulatory system in organ donors and unrelated to liver or kidney function. Utilizing Dr Shewmon’s timeline of events (table 1), physician actions at E1 or E2 in DCD to procure non-vital organs can intentionally expedite the transition to E7 (the moment of irreversible loss of all brain function) which is the moment of legal and uniform determination of death in most U.S. states (Table 1).
Second, Dr Shewmon also explains a scenario when cardiopulmonary bypass machine (also called extracorporeal membrane oxygenation or artificial heart and lung machine) can be initiated before E1 in DCD to remove the native vital organs (heart and lungs) for transplantation while artificially maintaining systemic circulation and oxygenation in organ donors and then discontinue the cardiopulmonary bypass machine on the premise that such a procedure at the end of life is medically futile. On this premise, Dr Shewmon may argue that the discontinuation of a futile intervention and not prior removal of native vital organs is the proximate cause of death in organ donors. The above scenario is analogous to that of the initiation of mechanical ventilation (for artificial respiration) in a dying patient to administer neuromuscular blocking medications causing paralysis of the respiratory muscles (abolishing spontaneous respiration) and then discontinue mechanical ventilation on the premise that the intervention is medically futile at the end of life [8]. It is not the discontinuation of mechanical ventilation but the administration of neuromuscular blocking medications to induce respiratory muscle paralysis which is the proximate cause of death creating a liability of homicide [9].
Nowadays cardiopulmonary bypass is used to re-circulate normothermic oxygenated blood after 2 to 5 minutes of circulatory arrest in controlled DCD for organ procurement. [10]. When cardiopulmonary bypass is utilized on organ donors who have pulmonary disease, musculoskeletal disorders or spinal cord disease and with complete sparing of higher brain functions before death, medications are required to suppress reanimation for organ procurement. The administration of medications to suppress spontaneous cardio-circulatory, higher brain or lower brain stem functions to procure transplantable organs can be the proximate cause of death and is a criminally liable action[11].
Transplant practice advocates have consistently diverted attention away from the serious societal consequences of permitting organ procurement from the dying by unilaterally changing the terms of the debate on death. From the legal perspective the charge of homicide is based on the intent and proximate causation of death by organ procurement process. With regard to the morality and ethical acceptability of physician actions in assisting death for organ procurement, it is the different cultures, religious affiliations and ethnicities in a pluralistic society that should reach that verdict.
Joseph L. Verheijde, PhD, MBA, PT
Adjunct Professor of Bioethics
Arizona State University
Physical Medicine and Rehabilitation,
Mayo Clinic Hospital,
Mayo Clinic Arizona,
Phoenix, Arizona
Mohamed Y. Rady MD PhD
Professor
Critical Care Medicine,
Mayo Clinic Hospital,
Mayo Clinic Arizona,
Phoenix, Arizona
Joan L. McGregor, Ph.D.
Lincoln Professor of Bioethics
Professor Department of Philosophy
Arizona State University
References
1. Shewmon DA: The dead donor rule: lessons from linguistics. Kennedy Inst Ethics J 2004, 14:277-300.
2. D'Alessandro AM, Hoffmann RM, Knechtle SJ, Odorico JS, Becker YT, Musat A, Pirsch JD, Sollinger HW, Kalayoglu M: Liver transplantation from controlled non-heart-beating donors. Surgery 2000, 128(4):579-588.
3. Motta ED: The ethics of heparin administration to the potential non-heart-beating organ donor. J Prof Nurs 2005 21:97-102.
4. Phua J, Lim T, Zygun D, Doig C: Pro/con debate: In patients who are potential candidates for organ donation after cardiac death, starting medications and/or interventions for the sole purpose of making the organs more viable is an acceptable practice. In: Crit Care. vol. 11; 2007: 211.
5. Casavilla A, Ramirez C, Shapiro R, Nghiem D, Miracle K, Bronsther O, Randhawa P, Broznick B, Fung JJ, Starzl T: Experience With Liver And Kidney Allografts From Non-Heart-Beating Donors. Transplantation 1995, 59(2):197-203.
6. Moon JI, Nishida S, Butt F, Schwartz CB, Ganz S, Levi DM, Burke GW, Tzakis AG: Multi-organ procurement and successful multi-center allocation using rapid en bloc technique from a controlled non-heart-beating donor. Transplantation 2004, 77(9):1476-1477.
7. Muiesan P, Jassem W, Girlanda R, Steinberg R, Vilca-Melendez H, Mieli-Vergani G, Dhawan A, Rela M, Heaton N: Segmental Liver Transplantation from Non-Heart Beating Donors-An Early Experience with Implications for the Future. American Journal of Transplantation 2006, 6(5p1):1012-1016.
8. Truog RD, Burns JP, Mitchell C, Johnson J, Robinson W: Pharmacologic Paralysis and Withdrawal of Mechanical Ventilation at the End of Life. The New England Journal of Medicine 2000, 342(7):508-511.
9. Rohr WB: Neuromuscular Blockade at the End of Life. The New England Journal of Medicine 2000, 342(25):1921-1922.
10. Bylaws Appendix B Attachment III - DCD Recovery Protocol Model Elements [http://www.unos.org/PoliciesandBylaws2/byLaws/pdfs/bylaw_145.pdf]
11. Ornstein C: Doctor charged in death of donor. A transplant surgeon is accused of attempting to hasten a patient's demise in order to make use of his organs. Available at LA Times Archives http://pqasb.pqarchiver.com/latimes/advancedsearch.html. In: The Los Angeles Times July 31, 2007. Los Angeles, CA.; 2007.
Competing interests
None declared
Reply to Verheijde et al
Daniel Alan Shewmon, Olive View-UCLA Medical Center
21 December 2007
I was most interested to read Dr. Verheijde and colleagues' detailed account of organ harvesting. I certainly agree with them that many aspects of the procedures, as currently done, could accelerate or even cause death, and I want to go on record as opposing such protocols for that reason. As I wrote in my disclaimer at the end of the cited article of mine, I don't advocate any particular protocol but was addressing the theoretical question whether it could be possible in principle to harvest such organs ethically.
Regarding general operative risks, I think these can be justified the same way they are in the case of healthy living donors of a single kidney or lobe of liver. This precedent could serve as a good exemplar for how to go about the ethical removal of both kidneys, etc. in the DCD (NHBD) setting: don't give drugs, clamp vessels, or do anything else that you wouldn't give, clamp, or do in a healthy live donor of a single kidney or lobe of liver - at least not until the circulation stops as a consequence of the ethical discontinuation of the ventilator.
Regarding their second point, about use of a cardiopulmonary bypass machine, I mentioned it because it has been suggested by others, but I did not endorse it. I agree with Verheijde et al that this would be merely ethical sleight-of-hand.
I strongly believe that "necessity is the mother of invention," and that other technical approaches to harvesting organs that avoid the risks and harms listed by Verheijde et al could be developed if the professional community felt a moral imperative to do so. If it is truly not possible to obtain viable organs without causing or accelerating the donor's death, then society must reorient itself to being content with not obtaining them.
Joffe is right on
7 December 2007
Joffe’s argumentation is cogent and convincing. The analogies of “kidney arrest” (with “brain arrest”) and of the drowning man (with DCD donors) are well chosen and illustrate the soundness of his logic. His objection to the weak construal of "irreversibility," on the basis that “patients in the identical physiological state are dead or alive based on their location and prediction of a future event (attempted resuscitation),” is also well argued and valid.
The only thing I might take issue with in the paper – and it is a very minor detail – is the implication (on p. 15) that “[harvesting organs] before death from patients whose prognosis is death” would necessarily “be a contributing cause of death.” I have described an approach to DCD by which the harvesting of organs before death neither causes death, nor accelerates it, nor disturbs the remaining (marginal) functional integrity of the organism during the final dying moments. See:
1. Shewmon DA: The dead donor rule: lessons from linguistics. Kennedy Institute of Ethics Journal 14(3):277-300, 2004.
2. Shewmon DA, Shewmon ES: The semiotics of death and its medical implications. In: Machado C, Shewmon DA (eds): Brain Death and Disorders of Consciousness. Advances in Experimental Medicine and Biology, Vol. 550. New York: Kluwer Academic/Plenum Publishers, 2004, pp. 89-114.
Competing interests
None.
Back to Lessons from Linguistics on Organ Donation after Cardiac Death: Organ Procurement or Physician Assisted Death.
10 December 2007
Back to Lessons from Linguistics on Organ Donation after Cardiac Death: Organ Procurement or Physician Assisted Death.
Josephus L. Verheijde, Ph.D., Mohamed Y. Rady, M.D., Ph.D., and Joan L. McGregor, Ph.D
We agree with Dr Joffe that current organ procurement practice of “harvesting organs before death from patients whose prognosis is death” would necessarily “be a contributing cause of death.”
We wish to elaborate on Dr Shewmon’s comment about his description of an approach to donation after cardiac death (DCD), previously known as non-heart beating organ donation, by which the harvesting of organs before death neither causes death, nor accelerates it, nor disturbs the remaining (marginal) functional integrity of the organism during the final dying moments. Dr Shewmon provided a succinct description of the timeline of natural events during the process of dying (Table 1) [1]. Dr Shewmon also described a novel model of how and when organs can be removed for transplantation in DCD without theoretically inflicting harm or death on organ donors.
Table 1. Description of the timeline of natural events (E) during the process of dying[1].
Event =Description
E1= Apnea (Shewmon’s model for organ removal in donation after cardiac death)
E2a= Loss of arterial pulse (Current practice of organ removal in donation after cardiac death)
E2b= Electrical cardiac asystole on electrocardiogram
E3= Loss of potential for cardiac autoresuscitation
E4= Loss of potential for interventional resuscitation
E5= Onset of permanent loss of consciousness
E6= Loss of potential for recovery of consciousness
E7= Irreversible loss of all brain and brain stem functions (Legal statue for the Uniform Determination of Death Act 1981)
Dr Shewmon in the 2004 article states “I shall restrict discussion to the ideal DCD context: assuming the legitimacy of stopping life support (independent of transplant considerations), truly informed consent, lack of conflict of interest, medical certainty that apnea will supervene once the ventilator is discontinued, and the like. When the ventilator is withdrawn in the operating room, the first E to occur will be E1, final apnea; then will ensue E2, E3, E4, and E6, in that order. (Presumably E5, the onset of loss of consciousness has already taken place, whether from primary brain damage or from sedation for the procedure.) We should not base the timing of organ retrieval on which E represents “true” death, because this is an improperly posed question. Rather we should ask, “Beyond which of these events does the removal of organs X, Y, Z . . . neither kill nor harm the patient, even in the physical sense of accelerating the dying process?” The answer depends on which organs we are talking about. In the case of all organs except heart and lungs, removing them even before E1 will neither cause nor hasten death, because, in the ideal DCD context under discussion, by the time the loss of those organs might exert even the tiniest systemic effect, all the Es will have supervened long before. It takes days or weeks to die from renal or hepatic failure or intestinal non-absorption or pancreatic insufficiency; for the first several hours, absence of such organs has no significant adverse effect on the body. Between discontinuation of the ventilator and even the most conservative choice of E, the effects of hypoxia-ischemia will totally overshadow whatever infinitesimal adverse effects might theoretically result from an incipient lack of kidney or liver function, for example. Thus, for transplantation of noncardiopulmonary organs, it is utterly irrelevant ethically whether “brain death” is “really death,” or whether the Pittsburgh protocol’s 2 minutes of asystole is “really death,” or whether any other physical event is “really death.” Such questions are both malformulated and ethically beside the point. For heart and/or lungs, the moral requirement “to do no harm” by the extirpation is trickier. A solution suggested by some would be to place the patient on cardiopulmonary bypass, remove heart and lungs without affecting systemic circulation or oxygenation, then declare the bypass machine an ethically inappropriate—“extraordinary” or “disproportionate”— means of life support, just as the original ventilator was, and disconnect it.” (pages 293-294)[1].
First, Dr Shewmon’s argument about the removal of non-vital organs in DCD at E1 is based on the assumption that this action can only cause death from the systemic consequences of lack of liver, kidney or intestinal functions manifesting over days which is a much longer time than the timeline of natural events antecedent to death (Table 1). Nonetheless, the surgical procedures required to procure these organs have systemic consequences which can not be ignored since they can directly hasten or abbreviate the progression of natural events during the dying process (i.e. from E1 to E7) and therefore contribute to organ donor death.
The surgical procedures required to procure non-vital organs (liver, kidneys, pancreas, and intestine) in DCD have prominent and immediate systemic effects supporting their proximate roles in causing death through the following ways:
1) Intravenous medications such as heparin and phentolamine are given to DCD donors for organ preservation[2]. Phentolamine is administered to prevent vasospasm and also causes profound hypotension in organ donors. Systemic anticoagulation with heparin is administered to facilitate subsequent organ flush out which can also precipitate internal and/or external hemorrhage. Neither of the two drugs have palliative benefit except to only hasten the dying process [3, 4]. To the contrary, the effects of both drugs singly or in combination can induce early cardio-circulatory arrest or brain stem herniation (in acute cerebrovascular accidents) in organ donors.
2) The aorta and inferior vena cava are the two major blood vessels connected to the heart which are instrumented and interrupted during surgical procurement[2, 5-7]. The purpose of the vascular intervention is to enable rapid exsanguination of the entire circulating blood and its replacement with cold preservative fluids in organ donors.
a. Exsanguination can be performed through a femoral vein cannula opened to gravity to drain the circulating blood (external hemorrhage) with simultaneous infusion of cold preservative fluids into the arterial circulation via a separate cannula in the femoral artery.
b. The inferior vena cava and aorta are divided just above the bifurcation in the abdominal cavity to reduce venous return and congestion of abdominal organs.
c. The descending thoracic aorta is also clamped and the intrapericardial inferior vena cava is vented in the thoracic cavity for the rapid relief of liver venous congestion and exsanguination of blood from the donor.
3) Non-vital organs are artificially perfused in situ with cold preservative fluids within the native donor circulatory system.
4) The intra-abdominal cavity is rapidly filled and irrigated with saline ice slush at laparotomy for topical cooling of abdominal organs.
5) The intra-abdominal organs (kidneys, liver, pancreas and small intestine) are removed with major supplying and draining blood vessels en bloc. The en bloc method is not traditionally performed when intending to preserve life during surgery.
The above procedures have deleterious physiological consequences on the cardio-circulatory system which appear within seconds. It is important to recognize that the procurement of non-vital organs such the liver or kidneys from the abdominal cavity can shorten or abbreviate the timeline of the natural dying process within seconds because of direct invasion and disruption of the cardio-circulatory system in organ donors and unrelated to liver or kidney function. Utilizing Dr Shewmon’s timeline of events (table 1), physician actions at E1 or E2 in DCD to procure non-vital organs can intentionally expedite the transition to E7 (the moment of irreversible loss of all brain function) which is the moment of legal and uniform determination of death in most U.S. states (Table 1).
Second, Dr Shewmon also explains a scenario when cardiopulmonary bypass machine (also called extracorporeal membrane oxygenation or artificial heart and lung machine) can be initiated before E1 in DCD to remove the native vital organs (heart and lungs) for transplantation while artificially maintaining systemic circulation and oxygenation in organ donors and then discontinue the cardiopulmonary bypass machine on the premise that such a procedure at the end of life is medically futile. On this premise, Dr Shewmon may argue that the discontinuation of a futile intervention and not prior removal of native vital organs is the proximate cause of death in organ donors. The above scenario is analogous to that of the initiation of mechanical ventilation (for artificial respiration) in a dying patient to administer neuromuscular blocking medications causing paralysis of the respiratory muscles (abolishing spontaneous respiration) and then discontinue mechanical ventilation on the premise that the intervention is medically futile at the end of life [8]. It is not the discontinuation of mechanical ventilation but the administration of neuromuscular blocking medications to induce respiratory muscle paralysis which is the proximate cause of death creating a liability of homicide [9].
Nowadays cardiopulmonary bypass is used to re-circulate normothermic oxygenated blood after 2 to 5 minutes of circulatory arrest in controlled DCD for organ procurement. [10]. When cardiopulmonary bypass is utilized on organ donors who have pulmonary disease, musculoskeletal disorders or spinal cord disease and with complete sparing of higher brain functions before death, medications are required to suppress reanimation for organ procurement. The administration of medications to suppress spontaneous cardio-circulatory, higher brain or lower brain stem functions to procure transplantable organs can be the proximate cause of death and is a criminally liable action[11].
Transplant practice advocates have consistently diverted attention away from the serious societal consequences of permitting organ procurement from the dying by unilaterally changing the terms of the debate on death. From the legal perspective the charge of homicide is based on the intent and proximate causation of death by organ procurement process. With regard to the morality and ethical acceptability of physician actions in assisting death for organ procurement, it is the different cultures, religious affiliations and ethnicities in a pluralistic society that should reach that verdict.
Joseph L. Verheijde, PhD, MBA, PT
Adjunct Professor of Bioethics
Arizona State University
Physical Medicine and Rehabilitation,
Mayo Clinic Hospital,
Mayo Clinic Arizona,
Phoenix, Arizona
Mohamed Y. Rady MD PhD
Professor
Critical Care Medicine,
Mayo Clinic Hospital,
Mayo Clinic Arizona,
Phoenix, Arizona
Joan L. McGregor, Ph.D.
Lincoln Professor of Bioethics
Professor Department of Philosophy
Arizona State University
References
1. Shewmon DA: The dead donor rule: lessons from linguistics. Kennedy Inst Ethics J 2004, 14:277-300.
2. D'Alessandro AM, Hoffmann RM, Knechtle SJ, Odorico JS, Becker YT, Musat A, Pirsch JD, Sollinger HW, Kalayoglu M: Liver transplantation from controlled non-heart-beating donors. Surgery 2000, 128(4):579-588.
3. Motta ED: The ethics of heparin administration to the potential non-heart-beating organ donor. J Prof Nurs 2005 21:97-102.
4. Phua J, Lim T, Zygun D, Doig C: Pro/con debate: In patients who are potential candidates for organ donation after cardiac death, starting medications and/or interventions for the sole purpose of making the organs more viable is an acceptable practice. In: Crit Care. vol. 11; 2007: 211.
5. Casavilla A, Ramirez C, Shapiro R, Nghiem D, Miracle K, Bronsther O, Randhawa P, Broznick B, Fung JJ, Starzl T: Experience With Liver And Kidney Allografts From Non-Heart-Beating Donors. Transplantation 1995, 59(2):197-203.
6. Moon JI, Nishida S, Butt F, Schwartz CB, Ganz S, Levi DM, Burke GW, Tzakis AG: Multi-organ procurement and successful multi-center allocation using rapid en bloc technique from a controlled non-heart-beating donor. Transplantation 2004, 77(9):1476-1477.
7. Muiesan P, Jassem W, Girlanda R, Steinberg R, Vilca-Melendez H, Mieli-Vergani G, Dhawan A, Rela M, Heaton N: Segmental Liver Transplantation from Non-Heart Beating Donors-An Early Experience with Implications for the Future. American Journal of Transplantation 2006, 6(5p1):1012-1016.
8. Truog RD, Burns JP, Mitchell C, Johnson J, Robinson W: Pharmacologic Paralysis and Withdrawal of Mechanical Ventilation at the End of Life. The New England Journal of Medicine 2000, 342(7):508-511.
9. Rohr WB: Neuromuscular Blockade at the End of Life. The New England Journal of Medicine 2000, 342(25):1921-1922.
10. Bylaws Appendix B Attachment III - DCD Recovery Protocol Model Elements [http://www.unos.org/PoliciesandBylaws2/byLaws/pdfs/bylaw_145.pdf]
11. Ornstein C: Doctor charged in death of donor. A transplant surgeon is accused of attempting to hasten a patient's demise in order to make use of his organs. Available at LA Times Archives http://pqasb.pqarchiver.com/latimes/advancedsearch.html. In: The Los Angeles Times July 31, 2007. Los Angeles, CA.; 2007.
Competing interests
None declared
Reply to Verheijde et al
21 December 2007
I was most interested to read Dr. Verheijde and colleagues' detailed account of organ harvesting. I certainly agree with them that many aspects of the procedures, as currently done, could accelerate or even cause death, and I want to go on record as opposing such protocols for that reason. As I wrote in my disclaimer at the end of the cited article of mine, I don't advocate any particular protocol but was addressing the theoretical question whether it could be possible in principle to harvest such organs ethically.
Regarding general operative risks, I think these can be justified the same way they are in the case of healthy living donors of a single kidney or lobe of liver. This precedent could serve as a good exemplar for how to go about the ethical removal of both kidneys, etc. in the DCD (NHBD) setting: don't give drugs, clamp vessels, or do anything else that you wouldn't give, clamp, or do in a healthy live donor of a single kidney or lobe of liver - at least not until the circulation stops as a consequence of the ethical discontinuation of the ventilator.
Regarding their second point, about use of a cardiopulmonary bypass machine, I mentioned it because it has been suggested by others, but I did not endorse it. I agree with Verheijde et al that this would be merely ethical sleight-of-hand.
I strongly believe that "necessity is the mother of invention," and that other technical approaches to harvesting organs that avoid the risks and harms listed by Verheijde et al could be developed if the professional community felt a moral imperative to do so. If it is truly not possible to obtain viable organs without causing or accelerating the donor's death, then society must reorient itself to being content with not obtaining them.
Competing interests
None.