New Dilemmas Over Organ Donation
Paula Harrington was driving her daughter, Kerrie, to a shopping trip one evening last October when she lost control of the car while fiddling with the CD player. Kerrie was not injured in the violent accident that followed, but her mother suffered a devastating head injury.
Paula, 49, was taken to Massachusetts General Hospital in Boston, where doctors determined that her prognosis was grim. The family agreed that she should be taken off the ventilator that was keeping her alive.
The Harringtons also agreed to something more controversial--and increasingly common. They consented to leave the ventilator in place to keep blood flowing through Paula’s organs until transplant surgeons could get ready to remove her kidneys for donation.
As it turned out, that meant waiting 10 extra, agonizing hours. When the ventilator was finally withdrawn, Paula breathed raggedly on her own for about 15 minutes, then her heart stopped. As the family said a quick, last goodbye, Paula’s body was rushed to the operating room.
Paula Harrington had joined the small but growing number of patients called “nonheartbeating” donors. Unlike the roughly 6,000 people a year who donate organs after being declared brain-dead (that is, after being declared dead because of irreversible cessation of all brain function), nonheartbeating donors are people whose ventilators are withdrawn while they are still alive because their prognosis is hopeless.
They are then declared dead after their hearts and lungs stop functioning, which usually happens minutes after the ventilator is withdrawn but can take longer. After the declaration of death by a doctor, their organs are removed for transplantation.
Only about 500 people have become nonheartbeating organ donors since the practice began in the 1990s, but the numbers are expected to rise as more hospitals develop guidelines for this kind of organ donation. About 122 U.S. medical centers have performed nonheartbeating donor transplants, according to the United Network on Organ Sharing.
The possibility of a new source of transplant organs could help alleviate a small part of the shortage of donor organs. In the United States today, more than 70,000 people are waiting for donated organs, with fewer than 20,000 organs likely to become available this year. Every day, an average of 15 people die for lack of an organ transplant.
Some ethicists, however, are questioning this organ donation procedure because, although the patient’s breathing and heartbeat have stopped, they are not brain-dead.
Sometimes, families permit the patient to be whisked away, still alive and on a ventilator, to the operating room for organ recovery. Only in the operating room is the ventilator removed, the heart and lungs stop and the patient declared dead.
That, contends Boston University health law professor George Annas, borders on “ritualized surgical savagery.” Often, he says, “the family likes to be with someone when they die, even if they’re in a coma. They can hold hands; it’s a quiet, calm thing.”
If the patient is taken off to die in the operating room, it makes death “more technical and impersonal,” says Annas. “This might be justifiable if you could save a lot of lives this way, but you can’t. No one expects nonheartbeating donation to have a major impact on the organ shortage.”
An even more problematic question is this: When is a nonheartbeating donor really dead? How long do doctors have to wait after heart and lung function have ceased before deciding that the patient will not spontaneously revive?
At the University of Pittsburgh, death is declared if there has been no spontaneous heartbeat or respiration for two minutes after heartbeat and respiration have stopped. At many other hospitals, doctors wait five minutes, the period specified in a 1997 report by the Institute of Medicine, an arm of the National Academy of Sciences.
Every minute counts, notes Kevin O’Connor, director of donation services at the New England Organ Bank. After a potential donor’s heart and lungs stop working, blood ceases to flow through the kidneys and other organs. Kidneys should be removed for donation within an hour. (Hearts are not recovered from nonheartbeating donors because they are not likely to regain function; livers can sometimes be used.)
In truth, there is no good evidence on how long an interval there should be between cessation of heart and lung function and declaration of death, said Dr. Bob Arnold, a medical ethicist at the University of Pittsburgh School of Medicine.
The lack of uniformity in guidelines across the country means that, at least in theory, there could be two similar patients whose hearts have stopped. In one case, doctors might perform CPR, and in the other, they might start recovering organs, says Dr. Walter Robinson, a lung specialist at Children’s Hospital in Boston and a medical ethicist at Harvard Medical School.
Ethicists also worry that the growth of nonheartbeating donor protocols may further harm public trust in organ donation. For instance, about 7,500 people every year are declared brain-dead and medically suitable as organ donors. Yet, for various reasons, families agree to donate organs only half the time, Arnold says, even though there is no question that the patient is dead.
With nonheartbeating donors, ethicists worry, if there were the merest perception that patients were not really dead or that they were being prematurely withdrawn from ventilators to recover organs, that fragile trust could be eroded.
“There has to be a separation of the rationale to withdraw care from the indication to recover organs,” says Dr. Francis Delmonico, medical director of the New England Organ Bank.
Another concern among some ethicists is the practice of giving specific medications to a dying patient in order to preserve their organs for transplant. The rule of thumb in medicine is that drugs are given to patients only if they themselves might benefit. The medications at issue--blood thinners and blood vessel dilators--probably don’t harm a dying patient, and they clearly help maintain circulation to the organs. But this issue of medication for nonheartbeating donors is so thorny that the Institute of Medicine recommends that it be resolved on a case-by-case basis with the family’s consent.
Dr. John Potts, director of research at Massachusetts General Hospital, says the key is to ensure that organ donation not be allowed to cloud either the actual events around the death of a patient or public confidence that the need for organ donation is not being met at the expense of the dying patient or their family.
The Harrington family seems to agree with that. One of the two patients who received a kidney from Paula Harrington rejected the organ and is awaiting a new transplant. The other recipient is doing well.
Kerrie Harrington says her family finds consolation that their tragedy led to the saving of someone else’s life. “None of us,” she says, “have ever had a second thought.”
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Judy Foreman writes a syndicated column on health issues. She is a fellow in medical ethics at Harvard Medical School. She can be reached at foremanj@bellatlantic.net. Her column appears occasionally in Health.
