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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.
Notes:
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.
5 Ibid.
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. **Women for Faith &
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