July 4, 2022

Debate over controversial new heart donor rule for children

When is a child really dead?
Heart surgeons at Denver Children’s Hospital have found a way to increase the
supply of hearts for children who need a heart transplant. They have altered the
definition of when a donor child is dead. Writing in the New England Journal
of Medicine
, Dr Mark Boucek and colleagues explain how and why they
shortened the time that another child’s heart stopped beating before they
removed his heart. Between 2004 and 2007, with the approval of a local ethics
committee, and the consent of the parents involved, they removed hearts from
three children who had severe brain damage from oxygen deprivation during birth.
The hearts were then transplanted into three children with severe heart
problems. The doctors say that this reduces the time children spend waiting for
a donated heart and reduces the number who die on the waiting list.

However, the Denver protocols are highly controversial. One bioethicist,
George J. Annas, of Boston University, told the Washington Post, "This practice
cannot be ethically justified. The donors are not dead. I understand that they
would like us to change the definition of death, but they can’t do that by
themselves. It’s very problematic to start treating a baby as an organ donor
before it’s dead."

Another well-known bioethicist, Robert M. Veatch, of Georgetown University,
said that the operation was tantamount to murder. "The whole issue is whether
the infants from whom the hearts were taken were dead. It seems very clear to me
that they were not," he said. "I think it’s illegal, and if it’s illegal, what
we’re talking about is the physicians causing the death of the three patients,
and that would be homicide. It’s immoral. I think it should be stopped."

The quarrel is basically over how much time should elapse between the time a
heart stops beating and when it can be transplanted. From the recipient’s point
of view, this should be as little as possible. Most hospitals wait 5 minutes.
Some wait 2 minutes. But Boucek and his team waited 3 minutes for the first
child and only 1.25 minutes — 75 seconds – for the second and third children.
This raises doubts about whether the child was actually dead, as it is possible
for a heart to resume beating spontaneously.

Knowing that the issue would be highly controversial, NEJM commissioned
several bioethicists to comment. One point that they agreed on was that the
Denver protocol threatened the "dead donor" rule – that donors have to be dead
before vital organs can be removed. So what, asked Robert Truog, of Harvard
University, and Franklin Miller, of the National Institutes of Health. Because
the exact time of death is hard to define, they argue that "valid informed
consent" is a better criterion than whether a patient is actually dead.

Robert Veatch took a very different approach. He asks how doctors can assert
that there is an "irreversible loss of cardiac function" in a donor if the heart
begins to beat shortly thereafter in the chest of the recipient.

In keeping with its broadly utilitarian outlook, the NEJM took a benign view
of the controversial procedure. Its editorial comment concluded: "one conclusion
is clear. As a result of their investigational protocol, three babies are now
alive; had the procedures not been performed, it is virtually certain that all
six babies would be dead."