Hostname: page-component-78c5997874-lj6df Total loading time: 0 Render date: 2024-11-15T01:50:47.307Z Has data issue: false hasContentIssue false
  • English
  • Français

Imminent Death Donation: Ethical and Practical Policy Considerations

Published online by Cambridge University Press:  01 January 2021

Jordan Potter
Get access Rights & Permissions [Opens in a new window]

Extract

While the practice of organ donation after cardiac death has long been trending upwards in acceptance and use, it is still a highly controversial and practically inefficient method of organ procurement. One policy that has recently been proposed to try and alleviate some of the ethical and practical concerns with organ donation after cardiac death is the practice of imminent death organ donation. This type of live organ donation comes in patients at the end of their life who have decided to withdraw life-sustaining treatment, but still want to ensure that their organs are donated and not wasted, which isn't always the case with organ donation after cardiac death. This paper then gives some ethical and practical reflections and recommendations regarding the potential implementation of this controversial practice into regular transplant practice and policy.

Type
Independent Articles
Information
Journal of Law, Medicine & Ethics , Volume 46 , Issue 2: Law and the Opioid Crisis: An Inter-Disciplinary Examination , Summer 2018 , pp. 524 - 537
Copyright
Copyright © American Society of Law, Medicine and Ethics 2018

Access options

Get access to the full version of this content by using one of the access options below. (Log in options will check for institutional or personal access. Content may require purchase if you do not have access.)

References

Wilkinson, D. and Savulescu, J., “Should We Allow Organ Donation Euthanasia? Alternatives for Maximizing the Number and Quality of Organs for Transplantation,” Bioethics 26, no. 1 (2012): 34-35.Google Scholar
“OPTN/UNOS Ethics Committee - Meeting Summary,” (Chicago, IL, March 14, 2016), available at <https://optn.transplant.hrsa.gov/media/1584/ethics_meetingsum-mary_20160314.pdf> (last accessed May 22, 2018). The full project proposal can be found at: “Ethical Considerations of Imminent Death Donation,” OPTN/UNOS Ethics Committee, available at <https://optn.transplant.hrsa.gov/media/1918/ethics_ethical_implications_of_idd_20160815.pdf> (last visited May 22, 2018). Note: In their white paper the UNOS Ethics Committee narrowly defines IDD in the context of withdrawal of ventilator support, and they distinguish IDD in capacitated ventilator-dependent patients from “living organ donation by persons with certain fatal diseases.” While undoubtedly IDD would most often occur in the context of withdrawal of ventilator support, this author interprets IDD in a broader sense to include contexts where other life-sustaining interventions may be withdrawn after living organ donation. Thus, some of this article’s discussion may be inconsistent with the UNOS Ethics Committee’s conception of IDD and cross over into their white paper entitled “Living Organ Donation by Persons with Certain Fatal Diseases Who Meet the Criteria to Be Living Organ Donors,” which can be found here: <https://optn.transplant.hrsa.gov/media/2218/ethics_pcwhitepaper_201707.pdf> (last accessed June 1, 2018).+(last+accessed+May+22,+2018).+The+full+project+proposal+can+be+found+at:+“Ethical+Considerations+of+Imminent+Death+Donation,”+OPTN/UNOS+Ethics+Committee,+available+at++(last+visited+May+22,+2018).+Note:+In+their+white+paper+the+UNOS+Ethics+Committee+narrowly+defines+IDD+in+the+context+of+withdrawal+of+ventilator+support,+and+they+distinguish+IDD+in+capacitated+ventilator-dependent+patients+from+“living+organ+donation+by+persons+with+certain+fatal+diseases.”+While+undoubtedly+IDD+would+most+often+occur+in+the+context+of+withdrawal+of+ventilator+support,+this+author+interprets+IDD+in+a+broader+sense+to+include+contexts+where+other+life-sustaining+interventions+may+be+withdrawn+after+living+organ+donation.+Thus,+some+of+this+article’s+discussion+may+be+inconsistent+with+the+UNOS+Ethics+Committee’s+conception+of+IDD+and+cross+over+into+their+white+paper+entitled+“Living+Organ+Donation+by+Persons+with+Certain+Fatal+Diseases+Who+Meet+the+Criteria+to+Be+Living+Organ+Donors,”+which+can+be+found+here:++(last+accessed+June+1,+2018).>Google Scholar
Veatch, R. M. and Ross, L. F., Transplantation Ethics, 2nd edition (Washington D.C.: Georgetown University Press, 2015), 7.Google Scholar
President’s Commission for the Study of Ethical Problems in Medicine and Biomedical and Behavioral Research, Defining Death: Medical, Legal, and Ethical Issues in the Determination of Death (1982): 2.Google Scholar
Veatch and Ross, supra note 3, at 43-67.Google Scholar
Arnold, R. M. and Youngner, S. J., “The Dead Donor Rule: Should we Stretch It, Bend It, or Abandon It?,” Kennedy Institute of Ethics Journal 3, no. 2 (1993): 265-267.Google Scholar
Truog, R. D., Miller, F. G., and Halpern, S. D., “The Dead-Donor Rule and the Future of Organ Donation,” New England Journal of Medicine 369, no. 14 (2013): 1287-1288.Google Scholar
There is also the possibility of DCD from heart attack and accident patients, too, though these cases are not really relevant to the practice of IDD.Google Scholar
Veatch and Ross, supra note 3, 67-77.Google Scholar
Generally, patients must die within one to two hours after the withdrawal of life-sustaining treatment, depending upon the specific DCD protocol, in order to remain a candidate for DCD.Google Scholar
Wilkinson and Savulescu, supra note 1, at 35-36.Google Scholar
Truog, Miller, and Halpern, supra note 7, at 1287.Google Scholar
DuBois, J. M., “Is Organ Procurement Causing the Death of Patients?,” Issues in Law & Medicine 18, no. 1 (2002): 21-22. Note: While several prominent scholars have recently challenged the dead donor rule’s legitimacy, it is still a widely-accepted fundamental moral norm that guides the practices and policies governing organ donation in the United States today; thus, it should still be taken into account and respected in ethical analyses. See R. D. Truog, F. G. Miller, and S. D. Halpern, “The Dead-Donor Rule and the Future of Organ Donation,” New England Journal of Medicine 369, no. 14 (2013): 1287-1289 and F. G. Miller and R. D. Truog, Death, Dying, and Organ Transplantation: Reconstructing Medical Ethics at the End of Life (USA: Oxford University Press, 2011) for more information on these critiques and challenges to the dead donor rule.Google Scholar
Of note, many proponents of DCD justify their support of DCD by arguing that the loss of circulation necessarily leads to the eventual brain death of the patient, though the ultimate question is the timing rather than the fact of this matter. Other DCD supporters simply reject this ethical principle requiring brain death prior to procurement, because they argue that as long as enough time has passed for autoresuscitation of the heart to no longer be possible, then it is ethically justifiable to remove organs based upon the pronunciation of death by cardiopulmonary criteria.Google Scholar
Wilkinson and Savulescu, supra note 1, at 38.Google Scholar
LD-PPW was the official name that was given to this proposed method of IDD in incapacitated patients by the UNOS Ethics Committee in their recent investigation, but for the remainder of this article LD-PPW will simply be referred to as IDD.Google Scholar
“Ethical Considerations of Imminent Death Donation,” OPTN/UNOS Ethics Committee, available at <https://optn.transplant.hrsa.gov/media/1918/ethics_ethical_implications_of_idd_20160815.pdf> (last visited May 22, 2018).+(last+visited+May+22,+2018).>Google Scholar
Veatch, R. M., “The Conflict between Advance Directives and Organ Donation: A New Problem in End-of-Life Planning,” JAHR-European Journal of Bioethics 6, no. 12 (2015): 273-274; and P. Morrissey, “Kidney Donation Before Imminent Circulatory Death,” American Journal of Kidney Diseases 68, no. 4 (2016): 515-517.Google Scholar
See Wilkinson, D. and Savulescu, J., “Should We Allow Organ Donation Euthanasia? Alternatives for Maximizing the Number and Quality of Organs for Transplantation,” Bioethics 26, no. 1 (2012): 32-48; and R. M. Sade and A. Boan, “The Paradox of the Dead Donor Rule: Increasing Death on the Waiting List,” American Journal of Bioethics 14, no. 8 (2014): 21-23.Google Scholar
ten Have, H. and Jean, M. S., eds., The UNESCO Universal Declaration on Bioethics and Human Rights: Background, Principles, and Application (Paris: UNESCO Publishing, 2009), 126-132.Google Scholar
Kelly, D. F., Medical Care at the End of Life: A Catholic Perspective (Washington D.C.: Georgetown University Press, 2006), 29-31.Google Scholar
Buchanan, A., “Mental Capacity, Legal Competence and Consent to Treatment,” Journal of the Royal Society of Medicine 97, no. 9 (2004): 415-420.Google Scholar
Childress, J. F., “The Failure to Give: Reducing Barriers to Organ Donation,” Kennedy Institute of Ethics Journal 11, no. 1 (2001): 9-10.Google Scholar
Mezrich, J. and Scalea, J., “As They Lay Dying,” The Atlantic, April 2015 Issue, available at <http://www.theatlantic.com/magazine/archive/2015/04/as-they-lay-dying/386273/> (last visited May 22, 2018).+(last+visited+May+22,+2018).>Google Scholar
“OPTN/UNOS Ethics Committee - Meeting Summary,” (Chicago, IL, March 14, 2016), available at <https://optn.transplant.hrsa.gov/media/1584/ethics_meetingsum-mary_20160314.pdf> (last visited May 22, 2018).+(last+visited+May+22,+2018).>Google Scholar
Wilkinson and Savulescu, supra note 19, at 35-36.Google Scholar
Veatch, supra note 18, at 273-274; and Morrissey, supra note 18, at 515-517.Google Scholar
Wilkinson and Savulescu, supra note 19, at 42-43.Google Scholar
Veatch, supra note 18, at 273-274; Morrissey, supra note 18, at 515-517; and Wilkinson and Savulescu, supra note 19, at 42-43.Google Scholar
Mackler, A. L., Introduction to Jewish and Catholic Bioethics: A Comparative Analysis (Washington, DC: Georgetown University Press, 2003): 30-31.Google Scholar
Potter, J., “The Pinciple of Double Effect in End-of-Life Care,” The National Catholic Bioethics Quarterly 15, no. 3 (2015): 526-528.Google Scholar
Granted, there might be cases where an organ procurement intervention would be unduly risky to the patient, such as a case with an unstable patient who will almost assuredly arrest and die in the operating suite, and it is within the ethical purview of the transplant team to refuse these types of requests that present unjustifiable risks to the patient, as is consistent with physician obligations to follow the standards of medical practice in other instances of risky interventions.Google Scholar
“OPTN/UNOS Ethics Committee – Meeting Summary,” Chicago, IL, April 3, 2017, available at <https://optn.transplant.hrsa.gov/media/2147/ethics_meetingsummary_20170403.pdf> (last visited May 22, 2018); and “OPTN/UNOS Ethics Committee – Meeting Summary,” Richmond, VA, October 2, 2017, available at <https://optn.transplant.hrsa.gov/media/2306/20171002_ethics_committee_minutes.pdf> (last visited May 22, 2018).+(last+visited+May+22,+2018);+and+“OPTN/UNOS+Ethics+Committee+–+Meeting+Summary,”+Richmond,+VA,+October+2,+2017,+available+at++(last+visited+May+22,+2018).>Google Scholar
Figueiredo, F. M., Capaverde, F. B., Londero, G. G., Costa, M. G. et al., “Organ Donation in Suicides,” Transplantation Proceedings 39, no. 2 (2007): 344-345.CrossRefGoogle Scholar
Post, L. F., Blustein, J., and Dubler, N. N., Handbook for Health Care Ethics Committees (Baltimore: Johns Hopkins University Press, 2007), 31.Google Scholar
Kelly, supra note 21, at 39-41.Google Scholar
Torke, A. M., Alexander, G. C., and Lantos, J., “Substituted Judgment: the Limitations of Autonomy in Surrogate Decision Making,” Journal of General Internal Medicine 23, no. 9 (2008): 1514-1515.Google Scholar
Id., at 1514-1515.Google Scholar
Veatch, supra note 18, at 274.Google Scholar
Kopelman, L. M., “The Best Interests Standard for Incompetent or Incapacitated Persons of All Ages,” Journal of Law, Medicine & Ethics 35, no. 1 (2007): 187-189.Google Scholar
Post, Blustein, and Dubler, supra note 35, at 31.Google Scholar
Id., at 34-35.Google Scholar
Brown-Saltzman, K., Diamant, A., Fineberg, I. C., Gritsch, H. A., Keane, M., Korenman, S., Lewis, M. et al., “Surrogate Consent for Living Related Organ Donation,” JAMA 291, no. 6 (2004): 729.Google Scholar
Kant, I., Groundwork of the Metaphysics of Morals, edited by Gregor, M. J. (Cambridge: Cambridge University Press, 1997), 37-38.Google Scholar
Falomir-Pichastor, J. M., Berent, J. A., and Pereira, A., “Social Psychological Factors of Post-Mortem Organ Donation: A Theoretical Review of Determinants and Promotion Strategies,” Health Psychology Review 7, no. 2 (2013): 202-247; and T. Wen, “Why Don’t More People Want to Donate Their Organs?” The Atlantic, November 10, 2014, available at <https://www.theatlantic.com/health/archive/2014/11/whydont-people-want-to-donate-their-organs/382297/> (last visited May 22, 2018).CrossRefGoogle Scholar
Parker-Pope, T., “The Reluctant Organ Donor,” The New York Times, April 16, 2009, available at <https://well.blogs.nytimes.com/2009/04/16/the-reluctant-organ-donor/> (last visited May 22, 2018).+(last+visited+May+22,+2018).>Google Scholar
Smedley, B. D., Stith, A. Y., and Nelson, A. R., eds., Unequal Treatment: Confronting Racial and Ethnic Disparities in Health Care (Washington: The National Academies Press, 2002): 162-163.Google Scholar
Bach, P. B., Cramer, L. D., Warren, J. L., and Begg, C. B., “Racial Differences in the Treatment of Early-Stage Lung Cancer,” New England Journal of Medicine 341, no. 16 (1999): 1198-1202.Google Scholar
Smedley, Stith, and Nelson, supra note 47, at 164-165.Google Scholar
Green, C. R., Anderson, K. O., Baker, T. A. et al., “The Unequal Burden of Pain: Confronting Racial and Ethnic Disparities in Pain,” Pain Medicine 4, no. 3 (2003): 286.CrossRefGoogle Scholar
Veatch and Ross, supra note 3, at 7.Google Scholar
Ayanian, J. Z., Cleary, P. D., Weissman, J. S., and Epstein, A. M., “The Effect of Patients’ Preferences on Racial Differences in Access to Renal Transplantation,” New England Journal of Medicine 341, no. 22 (1999): 1667.Google Scholar
Hall, E. C., James, N. T., Wang, J. M. G., Berger, J. C., et al., “Center-Level Factors and Racial Disparities in Living Donor Kidney Transplantation,” American Journal of Kidney Diseases 59, no. 6 (2012): 849-857; C. Bratton, K. Chavin, and P. Baliga, “Racial Disparities in Organ Donation and Why,” Current Opinion in Organ Transplantation 16, no. 2 (2011): 243-249; and B. L. Kasiske, J. F. Neylan, R. R. Riggio et al., “The Effect of Race on Access and Outcome in Transplantation,” New England Journal of Medicine 324, no. 5 (1991): 302-304.Google Scholar
Siminoff, L. A., Burant, C. J., and Ibrahim, S. A., “Racial Disparities in Preferences and Perceptions Regarding Organ Donation,” Journal of General Internal Medicine 21, no. 9 (2006): 999-1000.Google Scholar
Nair-Collins, M., Green, S. R., and Sutin, A. R., “Abandoning the Dead Donor Rule? A National Survey of Public Views on Death and Organ Donation,” Journal of Medical Ethics 41, no. 4 (2015): 297-302.Google Scholar
“2012 National Survey of Organ Donation Attitudes and Behaviors,” U.S. Department of Health and Human Services, September 2013, available at <https://www.organdonor.gov/dtcp/nationalsurveyorgandonation.pdf> (last visited May 22, 2018); and D. S. Goldberg, S. D. Halpern, and P. P. Reese, “Deceased Organ Donation Consent Rates among Racial and Ethnic Minorities and Older Potential Donors,” Critical Care Medicine 41, no. 2 (2013): 499-504.+(last+visited+May+22,+2018);+and+D.+S.+Goldberg,+S.+D.+Halpern,+and+P.+P.+Reese,+“Deceased+Organ+Donation+Consent+Rates+among+Racial+and+Ethnic+Minorities+and+Older+Potential+Donors,”+Critical+Care+Medicine+41,+no.+2+(2013):+499-504.>Google Scholar
Wahlberg, D., “Imminent Death Organ Donation Could Help Others, Stir Distrust,” Wisconsin State Journal, last modified July 6, 2015, available at <http://host.madison.com/wsj/news/local/health-med-fit/imminent-death-organ-donation-could-help-others-stir-distrust/article_6c5d178a-48bc-5eee-9ba6-6c5c72fce62d.html> (last visited May 22, 2018).+(last+visited+May+22,+2018).>Google Scholar
“OPTN/UNOS Ethics Committee - Meeting Summary,” (Chicago, IL, March 14, 2016), accessed January 3, 2018, available at <https://optn.transplant.hrsa.gov/media/1584/ethics_meetingsummary_20160314.pdf> (last visited May 22, 2018).+(last+visited+May+22,+2018).>Google Scholar
This scenario is similar to the case mentioned briefly earlier from the UCLA Medical Center Ethics Committee. In this case, the ethics committee allowed surrogate consent for IDD based upon both (a) a close relative (first cousin) needing a kidney who was a match with the patient, and (b) the patient’s previous character and values, which were thoroughly demonstrated by the family to be significantly altruistic (e.g. the patient was a firefighter). This is despite the fact that neither the family nor friends had knowledge of the patient’s preferences and values regarding organ donation. More difficult scenarios would be whether to allow surrogate consent for IDD in this case if (a) the potential recipient was a stranger rather than a relative, or (b) the potential recipient was a relative, but there was no substantial evidence of the patient’s prior altruistic character, which treads into a moral gray zone. For more detail on this case, see: Brown-Saltzman, K., Diamant, A., Fineberg, I. C., Gritsch, H. A., Keane, M., Korenman, S., Lewis, M. et al., “Surrogate Consent for Living Related Organ Donation,” JAMA 291, no. 6 (2004): 728-731.Google Scholar
In cases where an incapacitated patient is a registered organ donor, it is ethically appropriate and justifiable for the transplant team to approach the patient’s surrogate decision-makers regarding the possibility of IDD. Given the patient’s past preferences for organ donation, this justifies the transplant team inquiring about the possibility of IDD in order to best respect the patient’s preferences and values. Of course, as already detailed above, a positive organ donor status does not necessarily justify pursuing IDD on its own, and more positive evidence is required to justifiably pursue IDD from an ethical perspective; however, a positive organ donor status does at least justify an inquiry regarding IDD to the surrogate decision-makers.Google Scholar