Voices Online Edition
VOICES - Vol. XX No. 1 - Eastertide 2005
Should We Be Dying to Donate?
by Nancy Valko, RN
Studies "suggest there might be significant public acceptance of future [organ donation] policies that violate the dead donor rule, or that further extend the boundary between life and death to include brain-damaged patients".1 Tracy C. Schmidt, Kennedy Institute of Ethics Journal, September 2004
"The coroner emphasized that he was not opposed to organ transplants, and was a registered donor himself. 'But I want to be dead first', he said".2 Mark Young, a Colorado coroner who ruled a suicide victim's death a homicide because organ donation standards were allegedly not followed, October 2004
"I am sure euthanasia for organ donation will become legal sooner or later".3 Sujatha, mother of 25-year-old K. Venkatesh, December 2004
Last year was a milestone year in organ transplantation. The 50th anniversary of the first successful organ transplant occurred in 2004. And this year also it was revealed that the number of transplants involving one kidney, part of a liver, etc., from a living, healthy person now surpassed the number of transplanted organs obtained from cadavers.
Donations of tissues, like corneas, bone marrow, skin, etc., also increased. Even better, new developments were showing promise in improving the function of major organs, which could potentially relieve the great numbers of people needing organ transplants.
But 2004 was also a year when more disturbing questions about transplant ethics were raised.
In September, the prestigious and influential Kennedy Institute Journal of Ethics devoted an entire issue to discussing the ethical issues surrounding death and organ donation. Some ethicists suggested expanding donation beyond brain death and non-heartbeating organ donation (NHBD) by redefining death and/or providing exceptions to the dead donor rule. One ethicist even stated, "A patient, while still competent, may choose to have organs removed prior to death, through an advance directive".4
Some of the ethicists cited an Ohio poll showing widespread public confusion over whether terms like "brain death", "vegetative state" and "coma" described a living or dead person as an opportunity to change the rules about organ donation. One ethicist argued that the lack of public outcry to a 1997 "60 Minutes" TV segment and other articles about the newer practice of non-heartbeating organ donation "suggests that the public is not greatly concerned about these issues".5 Non-heartbeating organ donation (also called donation after cardiac death) describes a procedure where a person declared hopelessly ill but not brain dead has his or her life support removed. When (or if) the heart stops, organs are removed for transplantation.
Last October, Colorado coroner and paramedic Mark Young sent shockwaves through the organ transplant community when he ruled that a 31-year-old man's death was a homicide as the result of his organs being removed, rather than the result of a self-inflicted gunshot wound to the head. Mr. Young contended that the standard of brain death was not adequately met although he believed that the doctors acted in good faith and did not intentionally cause the death. No charges were filed and Mr. Young said his intent was to address concerns about the differing protocols hospitals use for declaring brain death. Transplant experts vigorously condemned the coroner's actions and worried that the case would have a negative impact on future organ donation. However, they were forced to admit that the standards for determining brain death could vary even from hospital to hospital, a little-known but disturbing fact to most of the public.
In December 2004, an ethical firestorm was ignited in India and parts of Europe after 25-year-old K. Venkatesh, a young man with muscular dystrophy who developed respiratory failure, petitioned the high court of India to allow his life-sustaining ventilator to be removed so that he could donate his organs. Media articles routinely termed his proposal "euthanasia". However, young Venkatesh had the support of his mother as well as many others, some of whom pointed to the practice of non-heartbeating organ donation in the US and some other countries.
The high court eventually denied Venkatesh's request, stating that organs can be harvested only from brain-dead patients, but newspaper articles and editorials portrayed his case as a call to both legalize euthanasia and change the standards for organ donation. Not surprisingly, the US media ignored the story.
Can What You Don't Know Kill You?
Several years ago, I served on a hospital medical ethics committee and I had several "Maalox moments" when the discussion concerned organ donation.
In one case, a young doctor suggested that we drop the EEG (brain wave) test from the hospital's policy on brain death tests required for organ donation, citing a personal survey he did that showed testing requirements varied -- often widely -- among other hospitals in the area. He maintained his position even after a stroke victim initially thought brain-dead was found to still have some brain activity on the EEG. I was shocked when I found myself alone on the committee when I argued against dropping the test. I was even accused of being "insensitive" to people who need organs in favor of people who were probably going to die soon anyway.
This kind of misguided zeal for organs has led many ethicists and transplant experts to try to develop new ways of increasing organ donations, usually without public input or even awareness. For example and as I have written before, the controversial issue of NHBD was developed in the early 1990s to allow families or even conscious people on ventilators to withdraw life support so that organs can be harvested if or when the heartbeat stops without a diagnosis of brain death. Most people are not aware of this and most of the organ donation web sites I've seen still continue to provide fact sheets mentioning only brain death and emphasizing that every effort will be made to "save your life" before donation is considered.
Other strategies propose changing organ donation rules requiring patient or family consent for donation to "presumed consent", which legally assumes that everyone is automatically willing to be an organ donor unless they have documented an objection to it. Some states already have laws to enforce organ donation if a person has signed an organ donation card, regardless of family objections. A US Health and Human Services (HHS) advisory committee has recommended that hospitals be required to notify organ procurement organizations prior to the withdrawal of life support so that such patients can be evaluated as potential organ donors.6 In 2002, the Association of Organ Procurement Organizations sent a letter to the head HHS proposing that a hospital's failure to identify a potential organ donor be reported as serious medical error.7 Financial incentives for organ donation are also being proposed to increase the pool of potential organ donors. Educational programs for promoting organ donation are entering many school systems and especially aimed at new teen drivers.8
The most outrageous proposal of all is performing outright euthanasia to obtain organs. When Jack Kevorkian removed the kidneys of one of his victims and offered them for transplantation in 1998, the world was stunned and horrified. However by 2003, the prestigious journal Critical Care Medicine published an article by Drs. Robert D. Troug and Walter M. Robinson in which they stated "We propose that individuals who desire to donate their organs and who are either neurologically devastated or imminently dying should be allowed to donate their organs, without first being declared dead".9
Make Informed Decisions
Honesty is always the best policy, especially when it comes to life-and-death issues. However, in the area of organ donation, ethical problems and disputes tend to happen below the public's radar in favor of promoting organ donation and reassuring the public.
But despite the danger of undermining public confidence in the worthy goal of organ donation, it is critical that the public be adequately informed about all the ethical issues and given an opportunity to have a voice in determining policies before just signing an organ donor card can be considered truly informed consent.
1 "The Ohio Study in Light of National Data and Clinical Experience" by Tracy C. Schmidt. Kennedy Institute of Ethics Journal, September 2004, Vol. 14, No. 3.
2 "Denver Coroner Rules 'Homicide' in Organ-Donor Case", LifeSiteNews.com. October 12, 2004. Available online at: www.lifesite.net/ldn/2004/oct/04101208.html
3 "AP HC rejects writ for organ harvesting", the Deccan Herald, 12/16/04. Available online at www.deccanherald.com/deccanherald/dec162004/n11.asp
4 "Reconsidering the Dead Donor Rule: Is it Important that Organ Donors be Dead?" by Norman Fost. Kennedy Institute Journal of Ethics, September 2004.
6 US Department of Health and Human Services Advisory Committee on Organ Transplantation, Recommendations to the Secretary, November 2002. Available online at: www.organdonor.gov/acotrecsbrief.html
7 "Organ donation proponents try controversial new tack" by Andis Robeznieks. American Medical News, June 16, 2003. Available online at: www.ama-assn.org/amednews/2003/06/ 16/prsd0616.htm
8 Decision: Donation, A School Program That Gives the Gift of Life. Available online at: www.organdonor.gov/student
9 "Role of brain death and the dead-donor rule in the ethics of organ transplantation" by Robert D. Truog, MD, FCCM; Walter M. Robinson, MD, MPH, Critical Care Medicine. 31(9):2391-2396, September 2003. Abstract available online at: www.ccmjournal.com/pt/re/ccm/abstract.00003246-200309000-00019.htm
Nancy Valko, a registered nurse from St. Louis, is president of Missouri Nurses for Life, a spokesperson for the National Association of Pro-Life Nurses and a Voices contributing editor.
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