The last few posts have been about medical ethics, both practical issues and more abstract ones. A recent symposium in The New England Journal of Medicine is an excellent place for you to read and ponder a major ethical conundrum. The symposium consists of three editorials (here, here, and here), as well as a live round table discussion, which you can watch here. The editorials are brief, easy to read for non-physicians, and the video of the round table lasts 17 minutes. The issue at hand is what is called cardiac donation after cardiac death.
I’ve written before about how the demand for organs to transplant far exceeds the supply of available organs, and thus many patients waiting on a transplant list will die on a transplant list, still waiting. This is particularly the case for a small subgroup of those patients — very small children needing heart transplants. The symposium is centered around a scientific report in the same issue of the journal, in which three infants received successful heart transplants. To understand the ethical issue you need to know how organ transplantation is done.
The ethical cornerstone of the practice seems simple and obvious — an organ donor must be dead before he can donate organs. But that means we must all agree upon what “dead” is. Until several decades ago the standard definition of death was irreversible cessation of cardiac function — the heart stops and cannot be restarted. Since then we have added a definition of brain death to that — irreversible cessation of all brain function, including what we call the brain stem. Nearly all organ donors are declared dead by brain death criteria.
The infants in this case series, however, did not receive their new hearts from brain-dead persons. All three organ donors were devastated and dying, but they did not fulfill brain death criteria. Their families had made the heart-wrenching decision to withdraw life-support, a perfectly ethical decision. Once that was decided, the donors’ hearts stopped, were removed three minutes later for one patient and seventy-five seconds later for the other two, and then transplanted in the needy infants. The problem some see with this protocol is that a heart that is removed from one person and then placed in another, and which restarts there, has clearly not lost “irreversible function.”
The core issue, I think, is that when we die the organs within us die in stages, not all at once. At what point are we dead? Any line we draw is arbitrary until all our organs and the cells within them are dead. By that time, of course, they are useless to save anyone else’s life by transplantation. One of the writers in the symposium believes donation of a heart by this protocol is unethical because, by definition, the donor isn’t dead. Another writer points out the historical arbitrariness of our definition of the precise moment of death.
For myself, I participate in donation after cardiac death protocols and believe them to be ethical. But I also acknowledge the complexity of the issue. I highly recommend you watch the video round table. If you are interested in really delving into how complicated problems in medical ethics are worked out, I also recommend the brief articles. It is an emotional and difficult topic, but I know of no better way to illustrate for you how the PICU can highlight some of our most difficult ethical issues.
- What is death, and when is dead really dead? Facebook 1 Twitter Google+ 1 LinkedIn 1 The recent media...
- Organ transplants in children Facebook 3 Twitter 1 Google+ LinkedIn I have dealt with...
- On brain death and the Jahi McMath story Facebook Twitter Google+ LinkedIn The recent and unfolding tragedy of...
- The mathematics and politics of allocation of organs for transplant Facebook 3 Twitter Google+ 1 LinkedIn 11 We have a...
- The basic concepts of medical ethics are important for everybody to know Facebook 8 Twitter Google+ 1 LinkedIn 1 It seems lately...
Leave a Reply
12/02/2014 • Every fall I write about bronchiolitis because it is one of the most common respiratory ailments affecting infants and children under about two years of age. It is the most common reason infants end up ...more
09/22/2014 • Respiratory syncytial virus infection, aka RSV, is a common infection in children. A key aspect of RSV is how poor a job our immune systems do in fighting it off. Virtually all children are infected ...more
03/10/2014 • Below is a guest post by Dr. David Tilstra. Dr. Tilstra is President of CentraCare Clinic and on the Board of Directors of CentraCare Health, a large health system (6 hospitals, more than 400 physicians) ...more
02/13/2014 • It seems lately that questions of medical ethics are coming up more and more in the news, things like the rights of patients to make decisions, definitions of futile care, and end of life care. ...more