Organ Procurement
Until 30 years ago, death was defined as a cessation of heart
and lung function. After advances in mechanical ventilation and resuscitation therapy,
it became apparent that there were situations in which the brain was severely and
irreversibly damaged, even in the presence of heart and lungs that could be kept
functioning by medical intervention.
The diagnosis of brain death is discussed elsewhere in this textbook.
In organ procurement, after the declaration of death using neurologic criteria,
the patient is declared dead before being brought to the operating room, and the
organs are then retrieved while body homeostasis is maintained through mechanical
ventilation, pharmacologic therapy, and other standard resuscitative techniques.
[133]
Controversies about the ethics of organ recovery
center on non-heart-beating cadaver organ donation, now known as donation
after cardiac death (DCD).[134]
In DCD,
the patient is not declared dead before being brought to the operating room for organ
recovery. In this case, it is determined that the patient has no significant likelihood
of survival after the withdrawal of life support, and rather than withdrawing treatment
and letting the patient die outside of the operating room, treatment is withdrawn
in the operating room. If, after withdrawal of treatment, the patient progresses
to cardiac arrest and, after a brief interval, is declared dead by cardiac criteria,
organ procurement (usually only the kidneys) is performed.
DCD protocols offer the potential of increasing the number of
organs available for donation.[135]
[136]
[137]
Some argue there is no ethically relevant
distinction between withdrawing care in the intensive care unit, because continued
therapy would not be worth the likely benefits, and withdrawing care in the operating
room and proceeding rapidly with organ recovery. Others argue that these protocols
seriously alter the dying process by shifting the decision-making at the end of life
away from a sole focus on the best interests of the dying patient and by interfering
with the ability of the family to stay with the patient and to grieve.
Other approaches have been suggested to increase organ donation
rates. One technique is to use donor cards. In most areas, however, donor cards
are not binding, and they provide little more than evidence to the family that their
loved one was, at one point, interested in organ donation. The most effective nonlegislative
way to increase organ donation is public awareness leading to discussion among family
members, allowing family members to make clear to each other where they stand on
organ donation.
Legislative initiatives to increase organ donation include the
required request law, presumed consent, and presumed consent with family agreement.
In the United States, the required request law mandates that hospitals that receive
federal funds must ensure that family members are asked about organ donation. In
some European countries, presumed consent laws permit organ procurement without any
interaction with decision-makers. A tempered version, presumed consent with family
agreement, asks the decision-maker for agreement to the proposed organ procurement.
This helps establish organ donation as normative while respecting the decision-maker's
right to refuse organ donation. Presumed consent laws appear to increase organ donation
in Europe, but serious objections have been raised in the United States, primarily
centered on the rights of the family to control the body of a person after death
and concerns about excessive or unwarranted government intrusion into privacy.
