Donation after cardiocirculatory death: a call for a moratorium pending full public disclosure and fully informed consent

Abstract

Many believe that the ethical problems of donation after cardiocirculatory death (DCD) have been "worked out" and that it is unclear why DCD should be resisted. In this paper we will argue that DCD donors may not yet be dead, and therefore that organ donation during DCD may violate the dead donor rule. We first present a description of the process of DCD and the standard ethical rationale for the practice. We then present our concerns with DCD, including the following: irreversibility of absent circulation has not occurred and the many attempts to claim it has have all failed; conflicts of interest at all steps in the DCD process, including the decision to withdraw life support before DCD, are simply unavoidable; potentially harmful premortem interventions to preserve organ utility are not justifiable, even with the help of the principle of double effect; claims that DCD conforms with the intent of the law and current accepted medical standards are misleading and inaccurate; and consensus statements by respected medical groups do not change these arguments due to their low quality including being plagued by conflict of interest. Moreover, some arguments in favor of DCD, while likely true, are "straw-man arguments," such as the great benefit of organ donation. The truth is that honesty and trustworthiness require that we face these problems instead of avoiding them. We believe that DCD is not ethically allowable because it abandons the dead donor rule, has unavoidable conflicts of interests, and implements premortem interventions which can hasten death. These important points have not been, but need to be fully disclosed to the public and incorporated into fully informed consent. These are tall orders, and require open public debate. Until this debate occurs, we call for a moratorium on the practice of DCD.

Donation After Circulatory Death

“…Some ethicists (65) and clinicians (67) argue that the DCD donor is not dead, but rather in the process of dying; others emphasize the difference between ''irreversible'' and ''permanent'' cessation of cardiac function (68)Va crucial factor in end-of-life care.…”

Addressing Consent Issues in Donation After Circulatory Determination of Death

“…However, by artificially correcting the circulatory failure, ECMO can undermine the cardiovascular basis on which death was previously determined and interrupt the natural sequence of events leading to irreversible destruction of brain function ). More importantly, restoration of circulation and oxygenation can potentially result in reanimation of the diminishing brain function, thereby allowing the recently deceased person to regain some degree of consciousness and/or perception of pain and anxiety prior to, and during, the organ removal process Bernat 2013a;Dejohn and Zwischenberger 2006;Doig 2006;Doig and Zygun 2008;Joffe et al 2011). Such potential occurrences are rarely discussed in the informed consent process of cDCDD.…”

“…Patients who assert a desire to donate their organs likely also have other important interests, such as the desire to minimize pain and suffering for themselves and distress for their loved ones. They may also have expectations regarding end-of-life care or the specific treatment of their remains that are not consistent with the organ procurement process (Joffe et al 2011). While recommending bodies certainly agree that adequate pain and symptom management for the donor must be integrated into the cDCDD protocol (American Medical Association 2005; Committee on Bioethics 2013; Gries et al 2013), symptom management needs that result from invasive or uncomfortable premortem interventions, and potentially hasten the patient's death, are ethically troublesome.…”

Increasing Rates of Kidney Failure Care in Canada Strains Demand for Kidney Donors

“…Some critics question whether DCD respects the "dead donor" rule or the proper determination of a patient's death. 26 The practice is still not undertaken in some countries (e.g., Germany, Portugal). International studies suggest that, due to a greater risk of damage to the organs during a cardiocirculatory death, there are 1.5 fewer transplanted organs per cardiocirculatory death donor than per brain death donor, as well as a higher risk of complications for some types of organs.…”