The story goes back to 1993. During the early era of transplantation, “death” for the purpose of organ donation had been defined as irreversible cessation of all brain function (that is brain death, both “higher” and “lower” centers) as a result of a seminal report by the ad hoc Committee of Harvard Medical School.[1] The transplant community and society then asked a question: Since the traditional definition of death for everyone else had always been irreversible cessation of heart function, might that definition be ethically applied to donors too? As always in transplantation’s story, organs were at a premium. In 1993, a controversial publication ushered in the era of cardiac death criteria for donors.[2] Cardiac death represents the withdrawal of life support from terminal, consenting (the person or surrogate) individuals and a pronouncement of death after the passage of enough time to ensure irreversible cessation of heart function and the absence of autoresuscitation (the heart starting again on its own). Organs were now at an even greater premium.
Why was the publication controversial? The designated time elapsed between the donor’s heart stopping, or developing severe arrhythmic dysfunction, was arbitrarily set at 2 minutes. Renee C. Fox, an ethicist critical of the policy, described the protocol as an ignoble form of cannibalism![3] Critics suspected that the 2-minute criterion represented an optimum interval that insured fresh, functioning organs for the recipient rather than an interval that was empirically consistent with essential irreversibility, and therefore, death in a person. The Institute of Medicine thoughtfully assisted with adjudication. The committee proposed a time more consistent with the dead donor rule and a criterion of irreversibility—5 minutes. If that time is viewed from a pragmatic and utilitarian perspective, variations on the controversy over cardiac death criteria will persist. Waiting longer favors the donor and human dignity, but since organs deteriorate the longer blood flow diminishes, the recipient may lose the potential, donated organ. This is especially true for the heart.
The August 14th, 2008 issue of the New England Journal of Medicine should serve as a wake up call for transplantation bioethics.[4] A Pediatric transplant center successfully retrieved 3 hearts from infants who were declared dead by cardiac criteria, or at least that is what is purported. Remember the controversy related to 2 versus 5 minutes? The time between the cardiac terminus and retrieval in these 3 children was 3, 1.25 and 1.25 minutes respectively. Since the critique of the Pittsburgh protocol and the Institute of Medicine’s 5-minute time rule, where is the public policy support to decrease the interval? What about decreasing to a time of less than 2 minutes? There is none. The interval was adjusted to retrieve more and better organs for infant recipients in the face of a terrible shortfall. It seems infants have become just “lesser” and smaller adults in the context of human dignity.
The article was also a clarion call to the Journal and its readership. It warranted four separate editorial commentaries and a video roundtable. Veatch argued that the criterion for irreversible cardiac cessation was not met in the study.[5] I agree completely. If it was not, the organs were retrieved before these children died, and thus their removal killed them, breaking the dead donor rule. Bernat says that the medical community will not find the protocol acceptable.[6] Again I agree completely, but our voices need to be heard loud and clear. Unfortunately, Truog and Miller think that the cavalier behavior in the name of “more organs” may become an opportunity to revise the dead donor rule.[7] This is categorically wrong. Killing people for their organs, adults or infants, is without question despicable and immoral behavior. When the most important constituency, that is, potential donors, learns that their organs are more important than their life and dignity whither goes transplantation?
[1] “A Definition of Irreversible Coma: Report of the Ad Hoc Committee of the Harvard Medical School to Examine the Definition of Brain Death.” Journal of the American Medical Association 1968; 205:337–340.
[2] “University of Pittsburgh Medical Center Policy and Procedure Manual: Management of Terminally Ill Patients Who May Become Organ Donors after Death.” Kennedy Institute Ethics Journal 1993; 3:A1–A15.
[3] Fox, Renee C. “‘An Ignoble Form of Cannibalism’: Reflections on the Pittsburgh Protocol for Procuring Organs from Non-Heart-Beating Cadavers,” Kennedy Institute of Ethics Journal 1993;3:231–39.
[4] Boucek, M. M., Mashburn, C., Dunn, S. M., et al. “Pediatric Heart Transplantation after Declaration of Cardiocirculatory Death.” New England Journal of Medicine 2008; 359: 709–714.
[5] Veatch RM. “Donating Hearts after Cardiac Death—Reversing the Irreversible.” New England Journal of Medicine 2008; 359:672–673.
[6] Bernat JL. “The Boundaries of Organ Donation after Circulatory Death.” New England Journal of Medicine 2008; 359:669–671.
[7] Truog RD, Miller FG. “The Dead Donor Rule and Organ Transplantation.” New England Journal of Medicine 2008; 359:674–675.
