Death by organ donation?

August 24, 2008 4:42 AM

Is it time to redefine death? In a recent article in the NEJM, a team of doctors described decreasing the period after cessation of heart function in order to collect donations and increase their viability. This has spiked some debate over the definition of brain death and the "irreversibility" of asystole after removing life support. An introduction to the situation and the arguments. An interesting round table discussion, chaired by Atul Gawande. "The ethically relevant precondition is valid consent...with such consent, there is no harm or wrong done in retrieving vital organs before death, provided that anesthesia is administered." "This means that under current law, it is not possible to procure a transplantable heart after cardiac death. There are two possible ways out of this dilemma. Both involve legal changes." "To what extent should society permit manipulation of an organ donor or alteration of the determination of human death for the good of organ recipients?" Previously

More fun stuff:
Legal definitions: the death act (US); Transplantation and Anatomy Act, s45(1) (AUS); the UK has no precise definition for brain death.
Criteria for determining if someone is actually brain dead.
Statistics on US donors.
The status of the international organ trade.
The issues of the opt-in vs opt-out system
And, of course, how to donate: US, AUS, UK.

posted by shokod (26 comments total)

Sorry Canada, I couldn't find out much about you. Here's some statistics, though.
posted by shokod at 4:42 AM on August 24, 2008

doctors described decreasing the period after cessation of heart function in order to collect donations

I've always understood the period after cessation of heart function to be eternity.
posted by longsleeves at 5:28 AM on August 24, 2008 [1 favorite]

As usual the monthy python were decades ahead.
posted by elpapacito at 6:31 AM on August 24, 2008

Is that Larry Niven I hear calling?
posted by localroger at 6:37 AM on August 24, 2008 [1 favorite]

Mortality while awaiting a transplant is an order of magnitude higher in infants than in adults, and donors who died from cardiocirculatory causes offer an opportunity to decrease this waiting-list mortality.

This is a paper about pediatric heart transplants from a specific class of donors (those who died from cardiocirculatory causes as opposed to accidents, etc.) The data which is presented indicates that hearts collected as soon as possible after "death" from this class of donor generally make better replacement parts for waiting receipients than those taken longer after "death." (Nothing odd about that. Hearts harvested from live doners would probably be even better.)

The specific problem here, as opposed to death by accident, is that the time of cardiocirculatory "death" is at present difficult to determine. Caution leads to waiting longer than might be necessary. Because of this ambiguous definition, donor hearts from these infants may be less available for transplant or of lesser quality.

The old man in the Monty Python sketch was dispatched for the convenience of the family; the dead collector being only as reluctant as he needed to collect a few coins for his effort.

Bring our yer not yet declared dead infant with cardiocirculatory problems.
posted by three blind mice at 7:08 AM on August 24, 2008

There was an article in Newsweek about a year ago about people who "died" but were revived via a low-oxygen reperfusion method. Something to do with this. The idea was that the current method of saving lives- pumping in more oxygen- actually causes damage and ends up killing people.

So it's coming from the other side as well- once they figure out a protocol for doing low oxygen reperfusion, there (conceivably) will be even less time to harvest organs should it fail.

I'm all for organ donation, but it's a sticky situation.
posted by gjc at 7:56 AM on August 24, 2008

I haven't yet read all the links, but it's my current belief that in an enlightened society, consent to donate should be assumed to be given EXCEPT when an individual has previously indicated formally that he/she does not give consent (e.g. a "no consent" registry), or when one's religious affiliation would normally oppose an organ donation.

This still leaves the pesky problem of when exactly "death" is deemed to be.

Somewhat related - I've personally witnessed a situation where an elderly conscious patient and his/her family is advised that medically there's nothing more that can be done to reverse a patient's ailment, and that even though the patient could be kept alive and conscious almost indefinitely, it's strongly suggested that the person's "suffering" could be reduced by removal of the assistive technology (in this case a respirator) and allowing "nature to take its course". There was also an inference that the person's situation is consuming resources, which is true, but the mention pissed me off.

I mention the above just to stress that our level of medical technology is raising ethical dilemmas and that the medical establishment is already making the hard and possibly controversial decisions, without benefit of up-to-date ethical guidelines from society. So we really have to start discussing and resolving this.
posted by Artful Codger at 8:30 AM on August 24, 2008 [1 favorite]

There was an article in Newsweek about a year ago about people who "died" but were revived via a low-oxygen reperfusion method. Something to do with this. The idea was that the current method of saving lives- pumping in more oxygen- actually causes damage and ends up killing people.

I thought of the same thing. This seems like an odd discussion to be having now, consider we're discovering how to revive people longer after "death" as well as new ways to bring them back.

Hopefully it won't be long before we can grow new organs in the lab, and get rid of the waiting list entirely, as well as the complication of rejecting foreign tissue.
posted by [insert clever name here] at 8:45 AM on August 24, 2008

Doctors must be exacting
About the organ they're extracting:
With whispers and with gentle slices,
And baffles on medical devices,
No noisy pumps or electric pings;
Not a sound from anything.
Incisions made with muffled dread --
As a single noise could wake the dead.
posted by Astro Zombie at 9:37 AM on August 24, 2008 [6 favorites]

Organ donations needs something new. Perhaps trading them on a futures market in case of availability to offset insurance costs. This lends more incentive to keep them healthy.
posted by Brian B. at 10:10 AM on August 24, 2008

Christ, what's asystole?
posted by Rangeboy at 11:39 AM on August 24, 2008

Asystole is lack of mechanical and electrical activity in the human heart.
posted by ikkyu2 at 12:27 PM on August 24, 2008

wow. wowowowowowow. great post
posted by Addiction at 12:53 PM on August 24, 2008

Ahem, ikkyu2.

I think you might have gotten sucked into an in-joke.
posted by Astro Zombie at 12:54 PM on August 24, 2008

I haven't yet read all the links, but it's my current belief that in an enlightened society, consent to donate should be assumed to be given EXCEPT when an individual has previously indicated formally that he/she does not give consent (e.g. a "no consent" registry), or when one's religious affiliation would normally oppose an organ donation.

I disagree. I think an enlightened society would allow each individual his full choice in whether to donate or not.
posted by adoarns at 2:16 PM on August 24, 2008 [1 favorite]

I've always understood the period after cessation of heart function to be eternity

Time began, surely it will end.
posted by IvoShandor at 2:27 PM on August 24, 2008 [1 favorite]

I think an enlightened society would allow each individual his full choice in whether to donate or not.

If we logically assume that only willing potential donors should be given a slot for transplants themselves, then it follows that we should know who the potential donors are with least effort and most accuracy. Therefore it makes sense for everyone involved to state publicly if they choose to opt out of being a potential receiver. Otherwise it should be assumed as a matter of ethics, because failing to "opt in" for whatever reason could be death sentence in an emergency.
posted by Brian B. at 2:36 PM on August 24, 2008

I thought of the same thing. This seems like an odd discussion to be having now, consider we're discovering how to revive people longer after "death" as well as new ways to bring them back.

I think it has to do with why they are dying. Reviving someone whose underlying cause of death would simply cause them to die again doesn't make any sense. For example, if the heart is so diseased it can no longer sustain its function, it doesn't make any sense to just keep defibrillating it. On the other hand, if it was simply a transient electrical instability, then it does.

We've always known ways to revive people, but it doesn't make sense to do it in every case. Unless you can prevent death from happening over and over again, you may be doing harm.
posted by Mental Wimp at 2:45 PM on August 24, 2008

A lot of this discussion turns on the concept of irreversibility. Death has to be irreversible or it's not really death, even though coloquially people sometimes talk about having been "dead for five minutes" while they resuscitated them with CPR. That's not death; it was reversible.

Moreover, brain death criteria now establish death to be irreversible cessation of brain function. Cardiopulmonary arrest doesn't lead to instantaneous brain death; it starts a process of brain death that can take many minutes.

The issue with donation after cardiac death (DCD), esp. the case with infant heart donors, is that the very fact the hearts were donated and restarted shows the arrest of the heart wasn't irreversible. Some contend that the decision made beforehand not to do anything to intervene, effectively makes the process irreversible, or makes it irreversible in some ethical sense. This line of thinking I tend to agree with, but the possibility for abuse is certainly there.
posted by adoarns at 2:51 PM on August 24, 2008 [2 favorites]

> I disagree. I think an enlightened society would allow each individual his full choice in whether to donate or not.

Where did I say one shouldn't have full choice? All I'm saying is that if someone hasn't bothered to formally indicate their their choice, then the default position should be that donation is permitted.
posted by Artful Codger at 2:55 PM on August 24, 2008

adoarns has it with the issue of reversibility being the hot topic. The criterion used in the fetal transplants is that no known heart has ever autoresuscitated (started back on its own) after 60 seconds and so after 75 seconds it is "ok" to begin collecting. Irreversible damage precludes the viability of a heart.
Also interesting is the use of ECMO (extracorporeal membrane oxygenation) to keep the tissue supplied with oxygen so it is as healthy as possible for transplant.
I thought the criteria for brain death to be quite thorough (as you'd hope), especially the part about spraying ice-cold water into a person's ears while checking their eyes for nystagmus (rapid movement of the eyeball).
In regards to the opt-in or opt-out systems (ie if a person should have to register to be a donor or to not be a donor), I personally feel that an opt-out system is better. If a person cares enough about whatever reasons they have for not wanting to donate organs, then they must make it well known (a la the cards that Jehova's witnesses carry around to ensure they don't receive blood transfusions). Survey and research show that most people are supportive of organ donation but a lot of them are apathetic about registering, especially here in Australia where the donor rate is one of the lowest in the world. Many countries in Europe (eg Belgium) have the opt-out system (aka presumed consent) of the soft subgroup: if your are on life support and your family refuses to have your organs collected, then their wishes are agreed. Only Spain is of the so-called hard subgroup: it doesn't matter what the family wishes - your organs are gone. Obviously, it has the highest donor rate in the world.
posted by shokod at 4:18 PM on August 24, 2008

Where did I say one shouldn't have full choice? All I'm saying is that if someone hasn't bothered to formally indicate their their choice, then the default position should be that donation is permitted.

You're right. I was being inelegant. I still think opt-in is most compatible with an enlightened society, although clearly there's a lot of room for people to argue what one of those is.
One disadvantage of opt-out is that it may too easily allow the appearance of healthcare workers working diligently for organs instead of the patients' interests. Moreover, with opt-in the families it seems the families are more likely to be consulted and to be satisfied with whatever happens.
One lecturer I heard on the state of donation after cardiac death in Pennsylvania mentioned that having the organ donor imprimatur on one's driver license is considered sufficient for the medical center to harvest organs, even using DCD protocols, against the wishes of the family. Given that getting the sticker on one's license requires no informed consent, this seems fairly shady. And anyway as long as there's controversy over DCD, it seems unwise to press on with it in a hostile environment.
posted by adoarns at 8:00 PM on August 24, 2008 [1 favorite]

I thought the criteria for brain death to be quite thorough....

This is one reason there are so few traditional cadaveric donors. Brain death is a fairly rare thing in combination with relatively healthy organs. The patient has to have absolutely no sign of brain function at all, including brain stem function. Besides the cold caloric test mentioned, there is an apnea test, where the vent is shut off for awhile to see if the patient makes any even slight effort at breathing. With an intact brainstem, there'll be at least an effort. Confirmatory testing includes getting an EEG showing an absolute flatline and/or ultrasound showing lack of blood flow to the brain.

These are stringent criteria and are designed to be as accurate as possible with what is after all an irreversible decision. A confirmatory opinion is universally required.

Frustration with the small pool of truly brain dead patients, and the somewhat larger pool of irreversibly brain-damaged patients who are not brain dead but nevertheless have no chance of meaningful recovery, has led to things like donation after cardiac death.
posted by adoarns at 8:07 PM on August 24, 2008 [1 favorite]

Brain death is a fairly rare thing

It's funny, our lecturer (a transplant surgeon here in Brisbane, Australia) told us an anecdote from another transplant surgeon at a conference in the States: the American doctor leaned over and told him, "you guys will never have the organ donation numbers like we have over here until guns are made legal - with all the gunshots to head, we fare much better" or something really sad like that.
I'm all for the Spanish system, personally.
posted by shokod at 2:53 AM on August 25, 2008

This is why I'm not an organ donor. I'm not into doctors killing me, thanks.
posted by jock@law at 8:28 AM on August 25, 2008

Opt-out donation is so obviously wrong as to be non-debatable. It violates every rationale for civilization if our default position is that one class of people can kill another class of people to use their organs.
posted by jock@law at 8:31 AM on August 25, 2008