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Not Dead Yet: The Fight over ‘Death’ in Organ Transplantation



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When is a person really and truly dead? The debate over the definition of “death” has raged for years, not least because hearts that stop beating can start again, either spontaneously or through resuscitation. Surely, if there is time enough, physicians and family members can be confident in concluding death has come to a loved one. But when the beloved is an organ donor, fixing the moment of death is a matter of great urgency; minutes matter, even seconds.

Deceased organ donors are either “non-heart-beating” or “brain dead.” In the latter case, someone is said to be “medically dead” even while their heart continues to pump. “Brain death” is exceedingly controversial, but logistically presents a luxury of time to wrangle over ethics and still comply with a person’s wish to be an organ donor. This is not the case with non-heart-beating patients, because when the heart stops beating, circulation also stops, and organ-sustaining chemicals and oxygen are cut off. This creates a situation of some urgency.

This week, the Washington Post reported on a new controversy brewing over protocols in organ transplantation. The United Network for Organ Sharing (UNOS), the Virginia corporation that coordinates U.S. organ donation under a contract with the federal government, has proposed loosening certain standards and protocols for the retrieval of organs for transplantation. Specifically, the group plans to get rid of the two-minute wait time for removing organs after a person’s heart stops beating, and the explicit ban on evaluating someone as a potential organ donor before his family has made the decision to stop efforts to save him.

Apparently the two-minute rule used to be the “five-minute rule,” set by the National Academy of Sciences in 1997, which concluded that removing organs after “cardiac death” was ethical as long as tight rules were followed, including waiting “at least five minutes after the heart stops to make sure it doesn’t spontaneously start beating again,” according to the Post. Yet the story notes instances where hospitals cut down the wait time, like the Children’s Hospital in Denver, where “surgeons tried standing by only 75 seconds before taking hearts from brain-damaged newborn babies.” The backlash that followed caused the Denver hospital to increase the wait time to two minutes.

Bioethicist Wesley Smith writes in his Secondhand Smoke blog: “A key to me in this area was a sufficient waiting period: I have always considered 2 minutes to be too short for comfort, but have been okay with 5 minutes.” On the proposed change, he writes: “Are they out of their minds?”

Under the current UNOS policy, death is the “irreversible cessation of circulatory and respiratory functions.” “Irreversibility” is then further defined: In clinical situations where death is expected, “the period of observation necessary to determine that circulation will not recur spontaneously (auto-resuscitation) may be only a few minutes.” In cases where life-sustaining therapy is withdrawn, irreversible cessation occurs when “spontaneous circulation does not return after 2 minutes of cessation of circulation.”

The proposed change would remove all definitions of “irreversibility” (see “Proposal to Update and Clarify Language”), thus allowing organ harvesters to begin their work, in theory, immediately. #more#

The second change in protocol sounds like an open door for abuse, and judging from some of the comments to the Post’s story, there are too many bad experiences already.

The language to be eliminated reads: “Before evaluating a patient as a DCD [donation after cardiac death] candidate, the hospital’s primary healthcare team and the legal next-of-kin must have decided to withdraw ventilated support or other life-sustaining treatment and that decision must be documented in the patient’s chart.”

Without this language, then, people can be “evaluated” for their donor potential even while doctors and family members are in the throes of trying to save them. One can be forgiven for imagining a roving band of organ harvesters shopping for good specimens while the sick man in the bed turns and shouts, “But I’m not dead yet!” 

According to corporate papers, UNOS policies are “voluntary” for member hospitals and organizations, and a 45-day period for public comment is required on proposed policy changes. The comment period on these changes ended in June; a final decision is left to the discretion of the UNOS board of directors, which convenes in November.

There is little argument over whether organ transplantation is ethical and laudatory; the only real dispute is how it is done and when. The proposed changes in protocol, made by a non-profit corporation under contract with the feds, seem profoundly unwise if not downright dangerous. Certainly they threaten to erode the public’s trust in the whole prospect of organ donation, which Smith calls a mile wide but an inch deep, the result of which could be fewer organ donors, not more.

And just imagine what it could be like under Obamacare.

— Cathy Ruse is senior fellow for legal studies at the Family Research Council.



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