The dead donor rule and organ transplantation
Source: Convictions, issue number 15 - February 2009
A very interesting contribution to the whole consideration of the morality of the removal of organs from person said to be brain dead has come from an unexpected source. It is the New England Journal of Medicine that published last August 14 an article that demonstrates beyond all serious doubt that the harvesting of organs is done from persons that truly are living, and that in point of fact it is the harvesting of the organs necessary for life, such as lungs, heart, two kidneys, complete liver and pancreas, that is actually the cause of death.
The authors do not conclude that organ transplantation ought not therefore to be done, but to the contrary justify it on the purely utilitarian non-principle that the person was going to die in any case. This we cannot accept, for the end does not justify the means, and you cannot kill a person on account of the good that can come to another person. Nevertheless, the passage below illustrates the principle that the donor of the organs is indeed a living person, and hence that the act of taking the organs is the deliberately termination of life, and that organ transplantation can
only be justified as the taking of one life to save or prolong another life - that is, by playing God.
The title of the article is “The dead donor rule and organ transplantation” and it was written by Dr. Truong & Professor Miller. “Since its inception, organ transplantation has been guided by the overarching ethical requirement known as the dead donor rule, which simply states that patients must be declared dead before the removal of any vital organs for transplantation. Before the development of modern critical care, the diagnosis of death was relatively straightforward: patients were dead when they were cold, blue, and stiff. Unfortunately, organs from these
traditional cadavers cannot be used for transplantation. Forty years ago, an ad hoc committee at Harvard Medical School, chaired by Henry Beecher, suggested revising the definition of death in a way that would make some patients with devastating neurologic injury suitable for organ
transplantation under the dead donor rule.
The concept of brain death has served us well and has been the ethical and legal justification for thousands of lifesaving donations and transplantations. Even so, there have been persistent questions about whether patients with massive brain injury, apnea, and loss of brain-stem reflexes are really dead. After all, when the injury is entirely intracranial, these patients look very much alive: they are warm and pink; they digest and metabolize food, excrete waste, undergo sexual maturation, and can even reproduce. To a casual observer, they look just like patients who are receiving long-term artificial ventilation and are asleep.
The arguments about why these patients should be considered dead have never been fully convincing. The defi -nition of brain death requires the complete absence of all functions of the entire brain, yet many of these patients retain essential neurologic function, such as the regulated secretion of hypothalamic hormones. Some have argued that these patients are dead because they are permanently unconscious (which is true), but if this is the justifi cation, then patients in a permanent vegetative state, who breathe spontaneously, should also be diagnosed as dead, a characterization that most regard as implausible. Others have claimed that “brain-dead” patients are dead because their brain damage has led to the “permanent cessation of functioning of the organism as a whole.” Yet evidence shows that if these patients are supported beyond the acute phase of their illness (which is rarely done), they can survive for many years.
The uncomfortable conclusion to be drawn from this literature is that although it may be perfectly ethical to remove vital organs for transplantation from patients who satisfy the diagnostic criteria of brain death, the reason it is ethical cannot be that we are convinced they are really dead. Over the past few years, our reliance on the dead donor rule has again been challenged, this time by the emergence of donation after cardiac death as a pathway for organ donation. Under protocols for this type of donation, patients who are not brain-dead but who are undergoing an orchestrated withdrawal of life support are monitored for the onset of cardiac arrest. In typical protocols, patients are pronounced dead 2 to 5 minutes after the onset of asystole, on the basis of cardiac criteria (See footnote), and their organs are expeditiously removed for transplantation. Although everyone agrees that many patients could be resuscitated after an interval of 2 to 5 minutes, advocates of this approach to donation say that these patients can be regarded as dead because a decision has been made not to attempt resuscitation. This understanding of death is problematic at several levels. The cardiac definition of death requires the irreversible cessation of cardiac function. Whereas the common understanding of “irreversible” is “impossible to reverse,” in this context irreversibility is interpreted as the result of a choice not to reverse. This interpretation creates the paradox that the hearts of patients who have been declared dead on the basis of the irreversible loss of cardiac function have in fact been transplanted and have successfully functioned in the chest of another. Again, although it may be ethical to remove vital organs from these patients, we believe that the reason it is ethical cannot convincingly be that the donors are dead. At the dawn of organ transplantation, the dead donor rule was accepted as an ethical premise that did not require refl ection or justifi cation, presumably because it appeared to be necessary as a safeguard against the unethical removal of vital organs from vulnerable patients. In retrospect, however, it appears that reliance on the dead donor rule has greater potential to undermine trust in the transplantation enterprise than to preserve it. At worst, this ongoing reliance suggests that the medical profession has been gerrymandering the defi nition of death to carefully conform with conditions that are most favorable for transplantation. At best, the rule has provided misleading ethical cover that cannot withstand careful scrutiny. A better approach to procuring vital organs while protecting vulnerable patients against abuse would be to emphasize the importance of obtaining valid informed consent for organ donation from patients or surrogates before the withdrawal of life-sustaining treatment in situations of devastating and irreversible neurologic injury…”
Note: Asystole: Insuffi ciency of heart contractions, producing a drop in heartbeat rate.