Organ donation after medical assistance in dying or cessation of life-sustaining treatment requested by conscious patients: the Canadian context

Abstract

In June 2016, following the decision of the Supreme Court of Canada to decriminalise assistance in dying, the Canadian government enacted Bill C-14, legalising medical assistance in dying (MAID). In 2014, the province of Quebec had passed end-of-life care legislation making MAID available as of December 2015. The availability of MAID has many implications, including the possibility of combining this practice with organ donation through the controlled donation after cardiac death (cDCD) protocol. cDCD most often occurs in cases where the patient has a severe neurological injury but does not meet all the criteria for brain death. The donation is subsequent to the decision to withdraw life-sustaining treatment (LST). Cases where patients are conscious prior to the withdrawal of LST are unusual, and have raised doubts as to the acceptability of removing organs from individuals who are not neurologically impaired and who have voluntarily chosen to die. These cases can be compared with likely scenarios in which patients will request both MAID and organ donation. In both instances, patients will be conscious and competent. Organ donation in such contexts raises ethical issues regarding respect for autonomy, societal pressure, conscientious objections and the dead-donor rule. In this article, we look at relevant policies in other countries and examine the ethical issues associated with cDCD in conscious patients who choose to die.

Deceased organ and tissue donation after medical assistance in dying and other conscious and competent donors: guidance for policy

“…Workshop participants identified potential problems that might arise when combining these practices (e.g., that the decision to donate organs might influence the decision to pursue MAiD), but these were felt to be manageable. Organ donation has taken place after WLSM and MAiD in a relatively small number of cases in Canada and other jurisdictions [6][7][8] without any apparent negative effects. Organ donation organizations should exercise caution regarding allocation of organs from donors with undiagnosed or rapidly progressive neurodegenerative diseases, as these may pose elevated risks to recipients.…”

“…The most important ethical concern that arises from the combination of MAiD or WLSM and organ donation is the possibility that the decision to proceed with MAiD or WLSM might be driven by the desire to donate organs. 7 Workshop participants felt that the best way to mitigate this risk is to ensure that organ donation discussions do not occur until after the decision is made regarding MAiD or WLSM. An additional safeguard would be to not offer organ donation in cases of MAiD or WLSM specifically, but respond only to organ donation requests initiated by patients themselves.…”

Barriers to live and deceased kidney donation by patients with chronic neurological diseases: Implications for donor selection, donation timing, logistics, and regulatory compliance

“…The barriers to deceased donation relate predominantly to the concept of SD‐DCD. The situations in which conscious individuals express the wish to proceed with withdrawal of life‐sustaining treatment followed immediately by DCD are emotionally often difficult, charged, and challenging for all those who are involved . This prompted the American Society of Transplant Surgeons’ (ASTS) Ethics Committee to issue a guidance statement in 2015 that characterizes “conscious DCD” (terminology as per original ASTS document) as “ethically appropriate based on the ethical principle of Autonomy ” (capitalization and emphasis as per original document) .…”

Organ donation after medical assistance in dying at home

“…2,3 Although the criteria for MAiD differ by country, the combination pro cedure is of interest to any country that has legalized MAiD. 4 In the Netherlands, the combination of MAiD followed by organ donation is legal and endorsed by Eurotransplant. 5,6 Medical assis tance in dying is generally performed in the comfort of the patient's home by their family physician.…”