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Not Dead Yet: Controlled Non-Heart-Beating Organ Donation, Consent, and the Dead Donor Rule

Published online by Cambridge University Press:  22 December 2009

DALE GARDINER  and
ROBERT SPARROW
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Extract

The emergence of controlled, Maastricht Category III, non-heart-beating organ donation (NHBD) programs has the potential to greatly increase the supply of donor solid organs by increasing the number of potential donors. Category III donation involves unconscious and dying intensive care patients whose organs become available for transplant after life-sustaining treatments are withdrawn, usually on grounds of futility. The shortfall in organs from heart-beating organ donation (HBD) following brain death has prompted a surge of interest in NHBD. In a recent editorial, the British Medical Journal described NHBD as representing “a challenge which the medical profession has to take up.”

Type
Special Section: Open Forum
Information
Cambridge Quarterly of Healthcare Ethics , Volume 19 , Issue 1 , January 2010 , pp. 17 - 26
Copyright
Copyright © Cambridge University Press 2010

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References

1. In U.S. nomenclature, Donation after Cardiac Death (DCD) programs.

2. In U.S. nomenclature, Donation after Brain Death (DBD) programs.

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5. See note 3, Bell 2003 and Steinbrook 2007; Whetstine L, Bowman K, Hawryluck L. Pro/con ethics debate: Is nonheart-beating organ donation ethically acceptable? Critical Care 2002;6(3):192–5; Gardiner D, Riley B. Non-heart-beating organ donation—Solution or a step too far? Anaesthesia 2007;62:431–3; Robertson J. Delimiting the donor: The dead donor rule. Hastings Center Report 1999;29(6):6–14; Zamperetti N, Bellomo R, Ronco C. Defining death in non-heart beating organ donors. Journal of Medical Ethics 2003;29:182–5; Youngner SJ, Arnold RM. Ethical, psychological, and public policy implications of procuring organs from non-heart-beating cadaver donors. JAMA 1993;269(21):2769–74.

6. This article is primarily a critique of current U.K.-controlled NHBD practice. However, we also hope our discussion will be relevant to debates about NHBD in other jurisdictions.

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8. The time period from when blood perfusion is inadequate to meet the tissue's needs to when the organ is perfused with cold fluids is known as the warm ischemic time. The time period from cold perfusion to transplantation into the recipient is known as cold ischemic time. See note 3, Bernat et al. 2006, for discussion of each of these.

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10. The current recommendations to diagnose death by cardiopulmonary grounds are a minimum of 2 minutes of pulselessness, as documented by an absent arterial line waveform, in the United States versus a minimum of 5 minutes of asystole, as documented by the absence of electrical activity by an electrocardiogram in the United Kingdom. See note 5, Gardiner, Riley 2007; see note 3, Bell 2003 and Bernat et al. 2006.

11. This is of considerable concern in potentially increasing the number of cases of Lazarus syndrome (autoresuscitation). Theoretically, it also might mean that brain function is reestablished. These possibilities in turn place significant pressure on the idea that these patients are dead by either brain or cardiac death criteria, which refer to the irreversible loss of function of these organs.

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15. One of the key principles of ethical donation practice as formulated in the original advice on this matter from the Judicial Council of the American Medical Association is that “A prospective organ transplant offers no justification for relaxation of the usual standards of medical care.” See note 7, Judicial Council of the American Medical Association 1968:342, point 2.

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19. One of the authors (Gardiner) is an intensive care specialist and has heard this opinion expressed a number of times in conversation at NHBD conferences.

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23. The move in the United Kingdom to secure “family lack of objection” rather than consent suggest that the United Kingdom is moving away from a concern for consent to donation even for HBD.

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35. See note 17, Campbell 2004:312.