December 6, 2022

New protocol for death of organ donors makes doctors and bioethicists nervous

A new protocol for determining death for transplant surgery has created a controversy amongst surgeons and bioethicists.

An article in MedPage Today subtitled “Is it ethical to pull the plug in patients who aren’t brain dead, then restart their hearts?” highlights their concerns.

The new protocol is called normothermic regional perfusion with controlled donation after circulatory death (NRP-cDCD). It works like this, according to MedPage Today:

Consent is obtained to retrieve organs from the patient. The life support is withdrawn, and – if all goes according to plan – the patient’s heart stops.

“A dying process of up to thirty minutes of agonal phase can be tolerated,” cardiac surgeons from Vanderbilt University explained in a report published earlier this year.

Then there’s a “stand-off” period of a few minutes to see if the patient revives. If not, the patient is declared dead, and the surgical team gets to work.

“The donor’s arch vessels are clamped to exclude cerebral perfusion, and the donor is cannulated” prior to being attached to a bypass machine, the Vanderbilt report explains. “The typical period from incision to establishing extracorporeal flow is three to five minutes. Perfusion is continued for forty-five minutes, after which the organs are harvested in the usual manner.”

In short, the patient is pronounced dead according to cardiac criteria, then is made to be brain dead, and then is resuscitated. The obvious ethical issue is this: if the patient can be revived, how could he have been dead?

Matthew DeCamp, a bioethicist at the University of Colorado and a consultant to the American College of Physicians, opposes NRP-cDCD. “You’re reversing the conditions under which death is declared and taking active steps to ensure the progression to brain death,” he told MedPage Today. “The person is declared dead, and the subsequent actions invalidate that declaration.”

“The dead donor rule is ethically foundational to organ transplantation. It’s the idea that medicine looks out for the best interests of the patients — do no harm — and acts cannot be taken that would cause death,” DeCamp contends. “Resuscitating the patient and reversing those conditions engages with the ethics of the dead donor rule.”

Another prominent doctor, Wes Ely, a critical care physician and transplant pulmonologist at Vanderbilt University, told MedPage Today:

“We’re so hungry for organs right now that we are pushing all the limits. I just want us to be super-cautious. We need to press the pause button on this and have some more conversations so that we can set up boundaries and stay in the right lane. The dignity of the human who donates organs should never be sacrificed.”

Despite these criticism, the popularity of NRP-cDCD is growing. Its advocates argue that it is “safe and necessary to protect donated organs and increase their supply”.

Arthur Caplan, who is probably the most-quoted bioethicist in the United States, and colleagues, responded to criticisms from the American College of Physicians in the American Journal of Transplantation. They wrote that NRP-cDCD “is well established in many countries, it can enhance trust in medical practice and organ donation, and will increase the availability of optimal organs for life-saving transplants.”