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How Can We Ethically Increase the Supply of Transplantable Organs?

James F. Childress, PhD
[+] Article and Author Information

From University of Virginia, Charlottesville, VA 22904.


Potential Financial Conflicts of Interest: Employment: University of Virginia; Consultancies: Roche Genetics Scientific and Ethics Advisory Committee; Honoraria: Association of Liver Disease, University of Indiana.

Requests for Single Reprints: James F. Childress, PhD, Institute for Practical Ethics and Public Life, University of Virginia, PO Box 400800, Charlottesville, VA 22904-4800.


Ann Intern Med. 2006;145(3):224-225. doi:10.7326/0003-4819-145-3-200608010-00010
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The waiting list for solid organ transplantation in the United States now exceeds 92 000 persons (approximately 67 000 of whom need a kidney transplant), and the list grows longer each year (1). In 2005, more than 28 000 solid organs, mainly kidneys (16 477 kidneys), were transplanted (12). Not surprisingly, given this gap between supply and demand, vigorous debates have erupted about how best to increase and to allocate the supply of transplantable organs.

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Organ recovery after circulatory determination of death: re-visiting the dead donor rule
Posted on August 3, 2006
Mohamed Y Rady
Department of Critical Care Medicine, Mayo Clinic Hospital, Phoenix, Arizona
Conflict of Interest: None Declared

The uniform determination of death relies on irreversible cessation of circulatory or neurological function. The unitarian determination of death by either neurologic or circulatory criteria rather than fulfilling both criteria simultaneously is widely accepted as the standard for organ recovery from deceased donors[1]. In the Unites States, the criteria for circulatory determination of death at 5 to 10 minutes of apnea, unresponsiveness and pulselessness can permit the procurement process to begin with the least warm ischemia time and best transplantable organ function [2]. The concept of irreversible cessation of circulatory function and definition of death at the time of organ recovery become difficult to reconcile if in situ organ perfusion or extracorporeal circulation and oxygenation are initiated to improve organ viability in the potential organ donors[3]. Return of full neurological function during in situ extracorporeal circulation is well documented in many victims of in-hospital and out-of-hospital cardiac arrest because they are neurological intact prior to the circulatory death [4, 5]. Artificial circulatory support for organ procurement can also lead to cerebral and coronary resuscitation and re-animation or return to life. Balloon occlusion of the thoracic aorta has been employed to diminish the likelihood of return of cardiac and neurological function without substantial evidence of the total suppression of cerebral function or activity during the surgical recovery of organs [3]. Under such circumstance, organ donation can no longer be considered to fulfill the dead donor rule. The abandonment of the dead donor rule has been proposed to avoid the conceptual confusion and inconsistencies arising from the determination of death for organ donation and subsequent procurement of transplantable organs [6]. The lack of public knowledge and media coverage of the proposals and processes related to donation after circulatory death is a major obstacle to an informed choice and participation in this type of organ donation.

References

1. 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).

2. Ethics Committee, American College of Critical Care Medicine; Society of Critical Care Medicine. Recommendations for nonheartbeating organ donation: a position paper by the Ethics Committee, American College of Critical Care Medicine, Society of Critical Care Medicine. Crit Care Med. 2001;29:1826-1831.

3. Magliocca JF, Magee JC, Rowe SA, et al. Extracorporeal support for organ donation after cardiac death effectively expands the donor pool. J Trauma-Injury Infect & Crit Care. 2005;58:1095-1101; discussion 1101- 1102.

4. Martin GB, Rivers EP, Paradis NA, Goetting MG, Morris DC, Nowak RM. Emergency department cardiopulmonary bypass in the treatment of human cardiac arrest. Chest. 1998;113:743-751.

5. Younger JG, Schreiner RJ, Swaniker F, Hirschl RB, Chapman RA, Bartlett RH. Extracorporeal Resuscitation of Cardiac Arrest. Acad Emerg Med. 1999;6:700-707.

6. Truog RD, Robinson WM. Role of brain death and the dead-donor rule in the ethics of organ transplantation. Crit Care Med. 2003;31:2391-2396.

Conflict of Interest:

None declared

Routine Recovery of Cadaveric Organs for Transplantation
Posted on August 10, 2006
Aaron Spital
Elmhurst Hospital Center, Mt. Sinai School of Medicine
Conflict of Interest: None Declared

Professor Childress adeptly summarized recent Institute of Medicine (IOM) recommendations designed to increase the supply of transplantable organs (1). According to the IOM report, we should continue to rely on public good will but work harder to stimulate it through education, creation of donor registries, and improvement in techniques for obtaining consent. In my opinion, with the notable exception of encouraging donation after cardiac death, the IOM's recommendations are somewhat disappointing because they are not fundamentally different from previous suggestions. We need a new approach to organ procurement, not more of the same.

Let's start with the relevant facts. 1) The list of patients waiting for an organ transplant is very long and growing. 2) Many of these people will die while waiting. 3) Transplantation would prevent a large number of these deaths. 4) Many more usable cadaveric organs are available than are recovered. 5) The major barrier to organ procurement is the large number of families who refuse to allow organ recovery from a recently deceased loved one. The result is a deadly link wherein requiring consent leads to a loss of lives that could have been saved were consent not necessary.

To these facts let's add some hypotheses. 1) In general, life should be preserved; according to Professor Harris, "there is almost universal agreement that death is usually the worst harm that can befall a person who wants to live" (2). 2) Ethical policies that save more lives are preferred to those that save fewer. 3) Routine recovery of all transplantable cadaveric organs without consent would provide more life saving organs than any other procurement policy (3). 4) A strong burden of proof falls upon those who support less efficient organ procurement strategies to show why routine recovery should be rejected. Nevertheless, this proposal was summarily dismissed by the IOM panel as an unacceptable violation of autonomy (4). I believe this was a lost opportunity. The ethical arguments supporting routine recovery are compelling (2,3) and had the panel carefully considered this plan it might have reached a different conclusion.

Whenever I think about this issue, the words of the famous Bob Dylan song (5) come to mind: "how many deaths will it take till he knows that too many people have died?" Perhaps I am wrong and it is better to let people die than to remove cadaveric organs routinely. But if this is so, I beseech our ethicists to show us clearly why.

References

1. Childress JF. How can we ethically increase the supply of transplantable organs? Ann Intern Med. 2006;145:224-25.

2. Harris J. Organ procurement: dead interests, living needs. J Med Ethics. 2003;29:130-34.

3. Spital A, Erin CA. Conscription of cadaveric organs for transplantation: let's at least talk about it. Am J Kidney Dis. 2002;39:611-15.

4. Childress JF, Liverman CT, eds. Organ Donation: Opportunities for Action. A report from the Institute of Medicine. National Academies Press, May 2006, pp102, 106. Accessed August 7, 2006 at: http://darwin.nap.edu/books/030910114X/html/106.html

5. Dylan B. Blowin' in the Wind, 1962.

Conflict of Interest:

None declared

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