Non-heart beating organ donation: old procurement strategy—new ethical problems

Abstract

The imbalance between supply of organs for transplantation and demand for them is widening. Although the current international drive to re-establish procurement via non-heart beating organ donation/donor (NHBOD) is founded therefore on necessity, the process may constitute a desirable outcome for patient and family when progression to brain stem death (BSD) does not occur and conventional organ retrieval from the beating heart donor is thereby prevented. The literature accounts of this practice, however, raise concerns that risk jeopardising professional and public confidence in the broader transplant programme. This article focuses on these clinical, ethical, and legal issues in the context of other approaches aimed at increasing donor numbers. The feasibility of introducing such an initiative will hinge on the ability to reassure patients, families, attendant staff, professional bodies, the wider public, law enforcement agencies, and the media that practitioners are working within explicit guidelines which are both ethically and legally defensible.

Pre-mortem transplantation optimizing interventions: the legal status of consent

“…This can depress the patient's respiratory drive. 2 Anticoagulants (e.g., heparin) might be administered to prevent thrombotic obstruction of blood vessels that can occur after the arrest of circulation. This treatment might aggravate bleeding.…”

Donation After Cardiac Death and the Emergency Department: Ethical Issues

“…First, it appears to violate the principle of nonmaleficence by causing harm to the patient, or at least exposing the patient to potential harm, with no corresponding benefit. 21,24,25 Second, it appears to violate our obligation to act only in our patients' interests and not those of another (in this case, a potential recipient). 22 Because of these issues, some have suggested that any antemortem intervention not for the benefit of the patient is forbidden.…”

“…21,22 Finally, argue supporters of DCD, such protocols allow the health care team to honor the wishes not only of patients, but also of family members who would like to donate the organs of their loved ones. 22,23 Because relatives of the deceased may derive comfort from knowing that their relatives became organ donors, there is ethical value in facilitating this process.…”

“…There is a concern that, although the possibility of organ transplantation is not supposed to have any effect on resuscitation attempts and the decision to declare death, those resuscitating the patient may not try as hard if they know that the patient's organs can be transplanted and, indeed, may be more valuable if the resuscitation is briefer. 21,47,48 The Institute of Medicine suggests that this problem be addressed by having two separate teams: one that attempts resuscitation and one that takes over only after failed resuscitation and deals with potential organ retrieval. 1 Although the New York City protocol has two separate teams, 20 this is not practical in all cases.…”

Controlled non‐heart beating organ donation: neither the whole solution nor a step too far

“…The problematical aspects of NHBOD referred to above have been described previously [3] and widely debated within the intensive care community [4]. Nevertheless, in its published guidelines, the Intensive Care Society in the UK has given its unequivocal endorsement to NHBOD [5].…”