Michael A. DeVita, MD; Arthur L. Caplan, PhD
Acknowledgment: The authors gratefully acknowledge the assistance of NCCUSL and in particular Robert Sade, MD, with preparation of this document for publication.
Potential Financial Conflicts of Interest: None disclosed.
Requests for Single Reprints: Michael A. DeVita, MD, University of Pittsburgh Medical Center Presbyterian Hospital, Room C-111, 200 Lothrop Street, Pittsburgh, PA 15213.
Current Author Addresses: Dr. DeVita: University of Pittsburgh Medical Center Presbyterian Hospital, Room C-111, 200 Lothrop Street, Pittsburgh, PA 15213.
Dr. Caplan: Department of Medical Ethics, Center for Bioethics, University of Pennsylvania, 3401 Market Street, Suite 320, Philadelphia, PA 19104-3308.
DeVita M., Caplan A.; Caring for Organs or for Patients? Ethical Concerns about the Uniform Anatomical Gift Act (2006). Ann Intern Med. 2007;147:876-879. doi: 10.7326/0003-4819-147-12-200712180-00008
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Published: Ann Intern Med. 2007;147(12):876-879.
In 2006, the National Conference of Commissioners on Uniform State Laws rewrote the Uniform Anatomical Gift Act. To overcome the problem of family members prohibiting organ donation from their deceased loved ones even when a donor card existed, the commissioners modified the act to prevent end-of-life care from precluding organ donation. An unintended consequence of the new wording creates the potential for end-of-life care that prioritizes care of the potential donor organs over care and comfort of the dying person. The commissioners have now revised the act, but the original version has already been legislated in many states, with others poised to follow. To protect dying patients' wishes about their end-of-life care, states that have legislated or are considering the original act must replace it with the revised version. A long-term and important ethical precept must stand: Care of dying patients takes precedence over organs. Another laudable goal must be promoted as well: Organ donation is an important part of end-of-life care.
Joseph L. Verheijde
Physical Medicine and Rehabilitation, Mayo Clinic Hospital, Mayo Clinic Arizona
December 20, 2007
The Revised Uniform Anatomical Gift Act (UAGA) 2006
The Revised Uniform Anatomical Gift Act (UAGA) 2006: Intrusion on the plurality of moral, cultural and religious values about end of life in the United States.
Joseph L. Verheijde, PhD MBA; Mohamed Y. Rady MD PhD; Joan L. McGregor PhD
We disagree with Drs. DeVita and Caplan that amended text of the Revised Uniform Anatomical Gift Act (UAGA) section 21(b) has resolved the real ethical concerns about end-of-life care (1, 2). Section 14(c) still creates a default rule to permit the application of life support systems and ignores contraindications to appropriate end-of-life care. The decision on life support systems for organ preservation remains the exclusive authority of procurement organizations evaluating potential donors. If the procurement organization determines that a potential donor is a prospective donor, only then, section 21(b) becomes applicable (2). Furthermore, in section 21(b) procurement organizations (despite inherent self-serving bias) are also included in the conflict resolution between appropriate end-of-life care in advance directives and organ procurement.
The Revised UAGA was crafted to achieve the goals set by the Institute of Medicine and the National Conference on Organ Donation after Cardiac Death (3, 4). Organ procurement was expanded to persons likely to die from cardiac or circulatory arrest and without antecedent neurological determination of death. Application of life support systems is essential for organ preservation until procurement is accomplished (2). There is no broad consensus that such donors are really dead during procurement (5). There has been little attention to the diversity of views represented in a pluralistic society such as the US with diverse cultural, ethnic, and religious affiliations(6).
We have previously highlighted additional serious ethical transgressions of the Revised UAGA (2). It created the default rule of presumption of intent to donate organs for transplantation except for individuals with documented refusal of organ donation (i.e. opting out system). The presumption of intent to donate is used to create a default (action) i.e. the application of life support systems to keep organs viable for transplantation. This default rule is intended to apply to individuals without explicit consent to organ donation and irrespective of advance directives. While the application of life support systems is a default action, consent is still required to procure organs . Section 9 expands the list of "reasonably available persons" who can consent to procure organs in a timely manner after attempts to contact next-of-kin have failed. The Revised UAGA creates multiple default rules culminating in "soft" presumed consent to organ donation. In essence, when priorities are unknown, the Revised UAGA invokes the right to donate organs superseding the right to self-determination and respect for different cultural and religious end-of-life values and practices. Effectively, we are erring on the side of taking care of organs before patients.
Joseph L. Verheijde, PhD MBA PT, Department of Physical Medicine and Rehabilitation, Mayo Clinic Hospital, Mayo Clinic Arizona, Phoenix, Arizona. Adjunct Professor of Bioethics, Arizona State University, Tempe, Arizona.
Mohamed Y. Rady, MD PhD, Department of Critical Care Medicine, Mayo Clinic Hospital, Mayo Clinic Arizona, Phoenix, Arizona.
Joan L. McGregor, PhD, Lincoln Professor of Bioethics, Department of Philosophy, Arizona State University, Tempe, Arizona.
1. DeVita MA, Caplan AL. Caring for Organs or for Patients? Ethical Concerns about the Uniform Anatomical Gift Act (2006). Ann Intern Med. 2007;147(12):876-879.
2. Verheijde JL, Rady MY, McGregor JL. The United States Revised Uniform Anatomical Gift Act (2006): New challenges to balancing patient rights and physician responsibilities. Philos Ethics Humanit Med 2007;2:19
Available at http://www.peh-med.com/content/2/1/19
3. Committee on Increasing Rates of Organ Donation-Board on Health Sciences Policy-Institute of Medicine. Organ Donation: Opportunities for Action. Washington, D.C.: The National Academies Press; 2006. (Childress JF, Liverman CT, eds.
4. Bernat JL, D'Alessandro AM, Port FK, et al. Report of a National Conference on Donation after Cardiac Death. Am J Transplant. 2006;6(2):281 -291.
5. Bernat JL. Are Organ Donors after Cardiac death Really Dead? J Clin Ethics. 2006;17(2):122-132.
6. Grasser PL. Donation after Cardiac Death: Major Ethical Issues. The National Catholic Bioethics Quarterly 2007;7(3):527-544.
Michael A DeVita
University of Pittsburgh
February 6, 2008
Caring for donors or patients?
We thank Dr. Verheijde and colleagues for their comments. We agree that the revised UAGA 2006 remains imperfect and contentious. The original sections 14c and 21b required provision of critical care procedures and support to maintain the potential for organ donation. NCCUSL was trying to discourage clinicians from hastily discontinuing life sustaining treatments (LST) prior to an assessment of the potential for organ donation. NCCUSL argued that a majority of Americans want to become organ donors after death, and so care alteration that prevents that option precludes the will of the majority. They purport to have data showing that many persons who might become brain dead have LST stopped prior to assessment of donor status. In its efforts to prevent failure to procure organs from persons desiring to donate, NCCUSL effectively prevented another shared will of Americans, namely to have control over their end of life care (EOL). When we spoke directly with NCCUSL about this issue, they agreed that the UAGA 2006 allowed donation to trump other EOL considerations, including advance directives and family wishes. They subsequently made changes. Section 21b now 1) recognizes that organ donation consideration is part of EOL care, and 2) states clearly that organ donation should not interfere with quality EOL care. NCCUSL reasoned that because section 21 now makes these points, an adjustment to 14(c) was moot. We feel the changes establish equipoise between donation and EOL care, and so there is enough merit to warrant our support. Regarding Dr. Verheijde et al's second assertion, we believe it is simply wrong. Multiprofessional, governmental, and ethical groups that have provided support. (1) We also disagree with Verheijde regarding the proper balance between respecting wishes about EOL care and organ donation. We support both organ donation and quality EOL care. Some may see organ donation and EOL care as mutually exclusive considerations, but that is not usually the case. Fortunately, with thoughtful discussion it may be possible to accommodate both. With permission, briefly continuing life support to enable organ donation may allow an important EOL goal to be achieved. Finally, we believe future work on the UAGA should include EOL professionals since transplant recipients are not the only constituency that needs to be represented in their deliberations.
1. DuBois JM, DeVita MA. Donation after cardiac death in the United States: How to move forward. Crit Care Med 2006; 34: 3045-47.
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