Wednesday, January 13, 2010

Organ Donation and Determining When Death Starts.

Yesterday's New York Times article is titled with the loaded question, "When does death start?" and tells the sad story of a parent whose daughter is hit by a truck. The grief-stricken mother realizes that her daughter has lost all but a few basic physical reflexes and requires life support to survive. And she knows that her daughter would have agreed to organ donation.

Organ transplantation must abide by the so-called dead-donor rule: a person has to be declared dead before any vital organs can be removed. Yet organs have to be alive if there is any hope of successful transfer to a recipient. Medical professionals have handled this paradoxical situation — finding a dead body with live organs — by fashioning a category of people with beating hearts who are said to be brain-dead, usually after a traumatichead injury, and who are considered just as dead as if they had rigor mortis.

To diagnose brain death, doctors typically go through a checklist of about a dozen items, including assessing reflexes like blinking, coughing and breathing, which are all controlled by the brainstem. The criteria are extremely strict, and only a tiny fraction of severely brain-injured people meet them. Kleinman realized that Amanda, despite her severe brain damage, was not one of them. There was, Kleinman told Beaulieu, another option — one that was still controversial and had never been pursued successfully at Children’s Hospital. The procedure was called donation after cardiac death, or D.C.D., and it would exploit the other way the law defines death: as the “irreversible cessation” of the heartbeat.

D.C.D. requires doctors to confront the shadowy question of exactly when somebody dies after the heart stops. To authorize D.C.D., doctors must follow a strict procedure. Amanda would be taken, technically alive, to an operating room, where her breathing tube would be removed. If her breathing ceased naturally and her heart stopped quickly (within an hour), she would be moved to an adjacent operating room and Kleinman would count off precisely five minutes, during which time Amanda would be prepped for surgery with antiseptics and surgical drapes, while Kleinman carefully watched for signs of a returning heartbeat. If there were none, Amanda would be declared legally dead; the stoppage would then be considered “irreversible.” Before her organs were seriously damaged by the lack of oxygen (every minute counts), the surgeons would rapidly open Amanda’s torso and remove them for transplant.

The article tangentially takes up the "pro-life" accusations that determining death "arbitrarily" - in this case, 5 minutes after the heart stops - is really a contrived criteria motivated by the desperate need for organs. In many segments of society, particularly among the black community, failure to agree to organ donation, say on driver's licenses, is fueled by the fear that doctors will see the person as less than human, not worth saving, and rush them off for organ harvesting.

It's a fear that "pro-life" advocates have manipulated in recent years to fight everything from removal of artificial nutrition and hydration (the US Conference of Catholic Bishops has just changed their hospital policies to include ANH as "obligatory") to removal from respiratory machines. All life - unconscious, unrecoverable, slated for a life of machines and vegetative state - is sacred in God's eyes, they say. Doctors are playing God by deciding when a patients is dead. Never mind that doctors are playing God by keeping the patient artificially alive.

Disability rights activists too are concerned that, disability as defined as everything from blindness to frailty at end of life or vegetative state, as they advocate in order to bring more attention and normalcy to disabled states, then brings great concern to qualifications like "quality of life" and "dignity." Particularly concerning aid in dying, disabled groups fear that the medical profession and society have consistently failed to value disabled lives as worthy of advanced medicine.

The Times article give a little history of attempts to define death:

The paradox of needing a dead donor with a live body was first addressed in 1968. Henry Beecher, a Harvard anesthesiologist and medical ethicist, convened a 13-member committee to write a definition of “irreversible coma,” or brain death, for The Journal of the American Medical Association. Not everyone accepted the four-page report’s conclusions. After Norman Shumway, a Stanford University surgeon, performed the first American heart transplant from a brain-dead donor, he was threatened with prosecution by the Santa Clara County coroner. As a result of the widespread disagreement over the meaning of “brain death,” President Jimmy Carter asked a blue-ribbon commission to examine the issue. The commission culminated in the Uniform Determination of Death Act in 1981, which defined death as “irreversible cessation of all functions of the entire brain, including the brainstem.” The procedure to diagnose brain death, however, was never codified into law, and as a result, it varies from hospital to hospital. In 1987, the nation’s pediatrics authorities tried to standardize the diagnosis, listing 14 different criteria to confirm brain death, like the absence of reflexes, and requiring, under certain conditions, additional X-rays and tests for brain-wave activity. Last year, in the journal Pediatrics, researchers from Loma Linda University reported that of 277 brain-dead children in California who were referred to the regional organ bank over many years, only a single child received the full set of diagnostic tests.

The writer of the story, Darshak Sanghavi, a pediatric cardiologist at University of Massachussetts Medical School, gets at the controversy surrounding the determination of death and the harvesting of organs by citing a recent case:

As Gary Greenberg wrote in The New Yorker, donating organs in such a manner, deliberately and with anesthesia, could simply be “a particular way to finish our dying, at the hands of a surgeon, after some uncertain border has been crossed.” But Francis Delmonico, a professor of surgery at Harvard Medical School and a national leader in organ transplantation, fervently defends the need to establish death before removing organs. “I understand a family’s anguish and inability to have consolation when a child doesn’t die after removal of life support,” he explains, “but I don’t see this as a patients’-rights issue. It’s a matter of public trust in the system.”

Donation after cardiac death already arouses suspicion. Just as transplant surgeons like Norman Shumway were once harassed for procuring organs from brain-dead donors, a California-based surgeon, Hootan Roozrokh, was tried for dependent-adult abuse, a felony, after participating in an attempted D.C.D. A nurse who objected to the proceedings later registered a complaint about how painkillers were administered to the patient. Prosecutors charged him with trying to hasten the patient’s death. Though none of this held up in court — Roozrokh was acquitted last year — the trial left many transplant surgeons shaken. Just think of the outcry, Delmonico cautions, if families and doctors also decided it was acceptable to euthanize patients to procure their organs. “You would destroy organ donation in this country,” he said.

It's an important issue and a well-written article. Though I include excerpts, I recommend you read the entire article at the link above.

UPDATE: from the conservative lifenews, an article on this NYTimes article by Judie Brown that does nothing to understand the challenges faced by parents, like those described by Sanghavi, and everything to bash parents or medical proxies in difficult positions over the head with an ideological position that has little science or medical foundation.

This is not dialogue that Brown invites, this is a law, given to her by doctrinal authority and some hefty self-righteousness, which she demands be enforced, regardless of the patient's rights, faith, particular diagnosis, or a parent's wishes. Sanghavi produced a searching article that examined the challenges medicine and patients face as technology allows here-to-fore life-saving procedures. Inability of the Right to engage in conversation regarding these very nuanced and difficult decisions and ethics will not further advance science or humane response, it will continue to mire the Right in rigid and unchanging, draconian, impossible positions that label them deniers of science and modernity. As a community, we are here to solve emerging problems together. Brown shows that the "pro-life" position may have clout, resources, soldiers, and media outlets but it still lacks compassion for human suffering. Hers is a sad and telling position-piece on obsolescence.

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Blogger Michael Kirsch, M.D. said...

I am concerned that the definition of death is being revised in an effort to capture more organs for donation. I don't agree with this. Defining death should be addressed as a separate issue, not tainted by organ procurement. One life is not worth more than another.

January 17, 2010 at 10:02 AM  
Blogger Ann Neumann said...

Thanks so much for writing, Dr. Kirsch. I've responded with a new post. You can find it at

I think hierarchy of lives' importance is a strawman argument. Of course medicine should never make such decisions. (I know there are bioethicists out there who disagree when they get into their rationing conversations. I posit that informed patient choice diminishes the power of such points.)

I recommend doing what we do now: leave donation up to the patient and/or their proxies.

Doctors don't know everything and shouldn't be expected to: they are to *inform* patients of the medical possibilities and leave the *consent* up to the patient.

Very best, Ann

January 17, 2010 at 12:04 PM  
Anonymous Egg Donors said...

Great Post.....

I found your site on stumbleupon and read a few of your other posts. Keep up the good work. I just added your RSS feed to my Google News Reader. Looking forward to reading more from you down the road!

Thanks for sharing....

February 5, 2010 at 3:13 AM  
Blogger Ann Neumann said...

Hello Egg Donors,

Thanks for coming by and for the encouragement! I too look forward to more communication down the road!

Best, Ann

February 5, 2010 at 5:36 AM  

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