September 27, 2022

QUALMS OVER DONATIONS AFTER CARDIAC DEATH

A controversial standard for determining death is multiplying the number of organs available in the US, but creating bioethical quandries. “Donations after cardiac death” (DCD) have risen from 268 in 2003 to at least 605 in 2006, enabling surgeons to transplant more than 1,200 kidneys, livers, lungs, hearts and other organs. “It’s starting to go up exponentially,” says James Burdick, who is in charge of organ donation at the federal Department of Health and Human Services.

Donation after the heart stops beating was the norm until brain death became the standard in the early 1970s. The shortage of organs has prompted a revival of the practice and the National Academy of Sciences’ Institute of Medicine has declared it ethical so long as strict guidelines are followed. Organs are removed after the heart stops beating, normally at least five minutes, to ensure that the patient is really dead. The decision to withdraw care must be kept separate from the decision to donate organs.

However, some bioethicists and doctors have misgivings about all this. First of all, DCD gives the macabre impression that doctors are hovering over a body waiting for a person’s organs. It can also interfere with a peaceful death and deny relatives time to grieve. Pressure could be applied to relatives to discontinue care prematurely. “It’s worrisome when you stop thinking of the person who is dying as a patient but rather as a set of organs, and start thinking more about what’s best for the patient in the next room waiting for the organs,” says Gail A. Van Norman, of the University of Washington at Seattle.

Although the criteria sound strict, they are only recommendations. In Denver, for instance, surgeons at Children’s Hospital wait not 5 minutes, but 75 seconds, before removing organs from infants. A California doctor is being investigated for apparently trying to hasten the death of a potential donor.

And if the practice becomes established, what about the future? David Crippen, a University of Pittsburgh critical-care specialist, asks, “Now that we’ve established that we’re going to take organs from patients who have a prognosis of death but who do not meet the strict definition of death, might we become more interested in taking organs from patients who are not dead at all but who are incapacitated or disabled?”