organ donation

I welcome Lawrence Masek’s response to my criticism of his journal article. I am sorry he didn’t appreciate my perspective, but I take nothing back.

Let’s start with a matter of little importance. Masek claimed I said his article would curl your toes. No, I wrote that I cover articles published in the professional journals because “some” of them would. Whether your digits react to his effort thusly is a matter for you to decide.

As to the substance of his rebuttal, Masek claims at great length that the dead donor rule, which forbids killing for organs, would also prohibit many common interventions in clinical medicine as “suicide.” He writes:

Permitting lethal organ procurement would enable patients to commit suicide by donating their vital organs, but the same is true of permitting lethal palliation and the refusal of life support.

This is verifiably untrue. Dying from a side effect of an ethical medical treatment like palliation is not suicide any more than a patient dying during heart surgery is euthanasia.

Good motives sometimes lead to terrible places. Such is the case with the understandable desire to increase the organ supply, which for years has tempted some bioethicists to stretch the ethics of transplant medicine beyond the breaking point.

Now, in the New York Times, three doctors promote the idea of “redefining death” to allow patients to be killed for their organs. First, the authors lament the difficulty of obtaining healthy organs from people whose hearts stop irreversibly after the removal of life support. They also bemoan the shortage of “brain-dead” donors. Then, after discussing a controversial approach that restarts circulation after cardiac arrest (but not to the brain) — which I have posted about before — they get down to the nitty-gritty of redefining death. From “Donor Organs Are Too Rare. We Need a New Definition of Death“:

The solution, we believe, is to broaden the definition of brain death to include irreversibly comatose patients on life support. Using this definition, these patients would be legally dead regardless of whether a machine restored the beating of their heart.

So long as the patient had given informed consent for organ donation, removal would proceed without delay. The ethical debate about normothermic regional perfusion would be moot. And we would have more organs available for transplantation.

The “dead donor rule” is the cement that binds the public’s trust in organ transplant medicine. Under the DDR (other than in living donations, such as of one kidney) organs cannot be procured unless donors, in the words of the Munchkins, are not merely dead but really most sincerely dead.

There are two means of declaring death. Let’s call the first “heart death,” that is an irreversible cessation of all cardio/pulmonary function. The other is popularly known as “brain death,” (death declared by neurological criteria) in which function in the whole brain and each of its constituent parts have irreversibly ceased. The key word in both means of declaring death is “irreversible.”

But something appears to have gone badly off the rails in the field of procuring organs after heart death. A long New York Times expose found cases of patients who were clearly alive when organ procurement began. At the same time, a very disturbing report by the Department of Health and Human Services contained similar findings.

First, the NYT. From “A Push for More Organ Transplants Is Putting Donors at Risk”:

Last spring at a small Alabama hospital, a team of transplant surgeons prepared to cut into Misty Hawkins.…Days earlier, she had been a vibrant 42-year-old with a playful sense of humor and a love for the Thunder Beach Motorcycle Rally. But after Ms. Hawkins choked while eating and fell into a coma, her mother decided to take her off life support and donate her organs. She was removed from a ventilator and, after 103 minutes, declared dead.

A surgeon made an incision in her chest and sawed through her breastbone. That’s when the doctors discovered her heart was beating. She appeared to be breathing. They were slicing into Ms. Hawkins while she was alive.

The horror! Why are such awful things happening?

There are some 91,000 people with severe kidney disease waiting for transplants. Alas, cadaver and living donors are insufficient to fill the need. That has some well-meaning activists pushing to increase the number of available kidneys by legalizing organ-selling. The psychiatrist and American Enterprise Institute senior fellow Sally Satel is probably the premier proponent of this approach. She has skin in the game, having received two living-donor organs. Writing in the Free Press, Satel promotes a bill that would allow kidney suppliers to become vendors and receive a tax credit. From, “I Had Two Kidney Transplants: I Want Donors to Get Paid.” But now, legislation is on the table that would save these patients’ lives while eliminating those concerns. On Read More ›

With so many people on the organ transplant waiting list, the ethics of organ donation have begun to buckle. These proposals are not only unethical, in my opinion; in some cases they also treat donors as objects rather than subjects. Each and any of them could undermine the public’s already thin trust in the organ transplant system, which would be a catastrophe. But an ethical way forward has also been researched assiduously, and it is beginning to bear fruit: xenotransplantation, that is, the use of pigs’ organs, genetically altered to be more compatible with humans. Early experiments offer cause for optimism. Recently, a woman who was dying of kidney failure received a pig kidney, and she seems to be doing well. Read More ›

In the Netherlands, Belgium, Spain, and Canada, people who want euthanasia can become organ donors. (A recent report in Spain showed that 13 percent of those euthanized donated organs.) Let’s call it “kill and harvest,” a policy heartily approved by our ever more crassly utilitarian medical establishment. Indeed, a recent study in JAMA Surgery applauds procuring the kidneys of the euthanized because, after five years, the organs of those killed by doctors and then transplanted have worked well — even better than kidneys donated by people after brain death. From the conclusion of the study, which discusses donation after circulatory death from euthanasia (DCD-V): This study found that DCD-V kidney transplantation yielded a lower incidence of DGF [delayed graft function] compared with DCD-III kidney transplantation Read More ›