Organ Retrieval Methods Spark Debate : Transplants: Doctors try expanding donor pool by preserving body parts of patients whose hearts and lungs fail. Ethicists are critical, especially when there is no family consent.
In a radical departure from conventional organ retrieval methods, transplant surgeons and coordinators are exploring controversial new techniques to increase the number of organ donors.
The developments, which have received little publicity, reflect a mounting crisis in organ transplantation: Although the number of patients waiting for transplants is surging, the supply of organs has leveled off.
There are more than 26,000 patients on the national waiting list for transplants, an increase of 10,000 patients over the last three years. More than 2,000 patients are dying annually while waiting for transplants, mostly patients waiting for hearts, kidneys and livers. The shortage of organs is so acute that last month, in an unprecedented procedure, surgeons at the University of Pittsburgh in Pennsylvania transplanted a baboon liver into a 35-year-old man dying of liver failure.
Currently, organs for transplantation are removed from hospitalized patients who are pronounced brain-dead, while they are maintained on a respirator and their hearts continue to beat. The continued circulation of blood prevents the organs from deteriorating.
Because procurement efforts tap only about half the pool of potential donors, physicians have searched for ways to obtain organs from other types of donors.
The new methods would enable doctors to get organs from not only victims of brain-death, but also from those pronounced dead because their heartbeats and respiration have irreversibly ceased. As a result, they may help expand the supply of organs, save lives, and fulfill the wishes of some donors and their families.
One approach, being studied at Loyola University in Maywood, Ill., involves “cold organ preservation” inside the bodies of people who die in hospital emergency rooms. This technique, which allows the organs to be retrieved up to five to six hours later, presents unique ethical problems.
Normally, the organ procurement process does not begin until family consent is obtained. But because a patient pronounced dead in the emergency room usually dies suddenly, doctors would have to begin preserving organs even before family members learn that their loved one is dead or have been asked to allow the removal of the organs.
Despite this concern, the reaction of families to the program has generally been positive, said Randy Heyn-Lamb, a transplant coordinator with the Regional Organ Bank of Illinois. The prospect of organ donation “sometimes makes a certain sense of what is otherwise a senseless death,” Heyn-Lamb said. “There is some comfort that their loved one is able to help someone else.”
Another experimental approach, being tested in the Pittsburgh area, utilizes terminally ill patients whom physicians and the family have decided to disconnect from life support.
Instead of removing such patients from machines in intensive care units or hospital rooms, as is normally done, such patients would be taken to operating rooms to die. As a result, their organs can be harvested as soon as they are pronounced dead. Arthur Caplan, a medical ethicist at the University of Minnesota, has termed the technique “snatch and grab.”
Physicians and medical ethicists said this approach also raises ethical concerns. For instance, physicians and families will make medical decisions about a patient not for the patient’s own benefit, but for the benefit of someone else. This may create a conflict of interest.
The new methods also may raise fears that the dying process will be manipulated solely to obtain more organs and that the organs obtained from cadavers after their hearts stop beating will be of dubious quality.
“People may be concerned that there is a tendency to retrieve organs when the donors are not truly dead,” even if this is not what physicians are doing, said Dr. James Burdick, chairman of the ethics committee of the United Network for Organ Sharing and director of the transplant service at Johns Hopkins Medical Center in Baltimore.
“The central technical question is: Are these people dead, according to criteria which would be employed if they weren’t potential organ donors?” said Alexander M. Capron of the USC Law Center.
For now, the new organ retrieval methods are being tested for kidneys--which can remain viable for 30 minutes to an hour after circulation ceases--and livers. Neither technique is currently being used in California, according to Barbara Schulman of the Regional Organ Procurement Agency of Southern California in Los Angeles.
Although obtaining organs from brain-dead cadavers has been widely accepted in the United States for more than two decades, the new approaches take medicine into uncharted areas.
The Regional Organ Bank of Illinois and physicians at Loyola University have been working on a program to recover organs from patients who die in emergency rooms. A similar proposal is under review at the University of Miami.
At first, physicians at Loyola sought permission from families before the organ preservation process began. All of the approximately 35 families that were approached said no.
Then, physicians and organ bank officials received approval from Loyola’s institutional review board, which oversees human experimentation at the university, to begin the process by preserving the organs within the body before contacting families to seek permission to actually remove the organs.
To preserve the organs, a surgeon makes a four-inch incision in the groin. Catheters are placed in a large artery and vein and are used to circulate a cold organ preservation solution through the kidneys.
Two puncture wounds are also made in the abdomen, allowing another cold solution to be circulated in the abdominal cavity. After the organ is stabilized inside the body, surgeons have five to six hours before they need to remove it.
Officials defended these procedures as “minimally invasive” and necessary to maintain the option of organ donation until the family reaches a decision.
In the eight such cases to date, none of the families had “a problem with what we did,” according to Lawrence Hopkins, the director of operations for the Illinois organ bank. In seven cases, the families later authorized retrieval of the kidneys, which have been studied in the laboratory. None have been transplanted to date.
During the hours that the organs are preserved in the body, “you can work with the family, they can take the emotional hit,” Hopkins said. After family members know their loved one is dead, “it is a much better time to ask them about donating kidneys.”
“We are portraying this as a way of preserving their option to donate rather than as portraying it as something we have done to their loved one for our own purposes,” Heyn-Lamb said.
Ethicists, including Caplan and Capron, took a different view. “This may appear to fuzz the line between caring for the patient and the grieving family and trying to obtain organs,” Caplan said. “Culturally, in our society, respect for the body is a critical value. Anything done to the cadaver without the express explicit permission of the family is likely to create enormous backlash against the transplant community.”
Caplan said he was surprised that the university approved the experiment.
Capron said that approval of the institutional review board might not be sufficient to sanction this “dramatic new method of preparing bodies for transplantation.” He said new state laws might be necessary to govern the process.
The second approach, of rapidly harvesting organs after the hearts of hospitalized patients stop, is more akin to the way organs were procured in the 1960s, before the advent of brain-death laws.
This method has been tested on 14 patients from eight hospitals near Pittsburgh. So far, 27 kidneys and nine livers have been successfully transplanted, said Brian Broznick, the executive director of the Pittsburgh Transplant Foundation. Similar programs are under way in the Netherlands and Japan.
Many busy kidney transplant centers “are either doing this occasionally or discussing the possibility of reinstituting the practice,” said Dr. J. Wesley Alexander, director of the transplantation program at the University of Cincinnati Medical Center.
In the Pittsburgh program, life support is withdrawn only in cases where there is no hope of recovery--such as for patients in persistent comas--and in accordance with the wishes of the family, Broznick said.
The recovery of organs does not begin until after the heart stops beating and death is certified by a physician not affiliated with the transplant program. The organs are immediately cooled within the body and removed 30 to 45 minutes later.
“I don’t think there have been any significant problems” with the organs, Broznick said. But almost all the kidneys and livers were transplanted in the Pittsburgh area; transplant surgeons elsewhere have refused them because of uncertainty that they would work.
Broznick said some families have found these procedures “easier to accept” than standard donation based on brain-death criteria. “In cases where the families do not want to see resuscitative efforts prolonged with their loved ones, this is an option for them,” he said.
George J. Annas, director of the law, medicine and ethics program at Boston University School of Medicine, said he found the approach “a little bizarre” and worried physicians would use the possibility of organ transplantation “as an inducement to stop treatment” earlier than normally.
In medicine, “more often we do it first and then ask the public if it is OK,” Annas said. “Usually, we get away with it because the public loves technology. But they may not be as forgiving” in this case.
ORGAN TRANSPLANTS
As the demands for organ transplants increases dramatically, the number of organ donors has leveled off and more patients are dying while waiting for transplant. These are the latest statistics on organ transplantation in the United States, according to the United Network for Organ Sharing in Richmond, Va. Bone marrow transplants are not included. National Waiting List: Dec. 31, 1988: 16,034 Feb. 29, 1992: 25,574
People Waiting for: (As of Feb. 29, 1992) Kidney: 19,851 Heart: 2,377 Liver: 1,825 Lung: 708 Pancreas: 652 Heart-Lung: 161
Deaths While on the Waiting List: 1988: 1,537 1989: 1,732 1990: 2,080
1991 Statistics
There were more than 16,000 organ transplants in the United States last year. Among them: 9,943 kidney transplants 2,946 liver transplants 2,127 heart transplants 535 pancreas transplants 400 lung transplants 52 heart-lung transplants
Number of Donors*
Cadaver Living** 1988 4,081 1,789 1989 4,012 1,894 1990 4,512 2,075 1991 4,534 2,225
* Multiple organs may be taken from one cadaver ** Almost all of these were for kidney transplants
