The Ethics of Organ Transplantation

Every year in the United States more than 11,000 people die while waiting for transplantable organs. Although efforts have been made to transplant genetically modified pig organs into humans, the practice is not yet widespread nor are outcomes magnificent. To save human lives, then, we need human organs.

But here’s the catch: Organs don’t grow on trees. And since the Dead Donor Rule says we cannot kill people for their organs, donors must be dead. So how do we know when someone is dead enough that we can take their organs?

Organ donation after the heart stops

Since the beginning of time, all human beings have recognized that when the heart stops irreversibly—known as cardiac death—a person is dead. We say irreversibly, because sometimes the heart stops and then starts again, a phenomenon known as auto-resuscitation. Auto-resuscitation rarely occurs after the heart has been stopped for 5 minutes or more.

Most of us who sign up at the DMV to serve as organ donors imagine scenarios in which we’re in devastating motor vehicle accidents. We say, “Well, if I have no quality of life anyway, you might as well take my organs.” When I signed up as a teenager, I didn’t realize the process by which this happens. Nor does the DMV explain how organs are retrieved.

If you want to be an organ donor after cardiac or “circulatory” death (DCD), this is what transpires. Let’s say you’re in that terrible car accident and end up in the hospital, on a breathing machine, with severe brain damage. You’re not brain dead, but you’re unlikely ever to live outside of a nursing facility, where you will be hooked up to a breathing machine and a feeding tube for the rest of your life. Your family knows you’d never want to live this way and discusses removing the breathing machine.

According to many medical ethicists, as well as the US Supreme Court in Cruzan v. Director, Missouri Department of Health, removing life-sustaining technology is not considered the same act as killing a person. Sometimes we remove life support and patients don’t die. We don’t then kill those patients, because our intent is only to remove impediments to a natural death and allow nature to take its course.

Patients who are willing to donate their organs after withdrawal of life support must do so in an operating room. In many hospitals, loved ones may accompany the patient to the operating room where the mechanical ventilator is withdrawn, and the medical team waits for the heart to stop beating. After 5 minutes of no heartbeat, the patient is declared dead, the family is escorted from the operating room, and organ retrieval begins. The process must begin promptly to minimize the length of time the organs lack blood flow.

The problem with DCD is that it doesn't provide enough organs to begin to meet the demand.

Organ donation after brain death

In 1968, a new definition of death was created to augment the supply of organs. The Ad Hoc Committee of Harvard Medical School to Examine the Definition of Brain Death proposed that severely compromised (but still living) patients be classified as dead. If these patients are considered dead, then they could serve as organ donors.

Although these early conversations conflated severe brain damage with total brain death, the two were subsequently teased apart. Patients with severe brain damage were still alive, but patients with total brain death were legally dead. Although the two both depended on life support to maintain the body's vital functions, only the latter could become organ donors. This gave rise to a new and much more reliable source of organs—donation after brain death (DBD).

In contrast to DCD, in which life support is removed in the operating room and the heart is allowed to stop, now surgeons could remove organs directly from the brain-dead body, while it is still connected to machines. The logic was simple: if the body is already dead, there is no reason to remove the machines. Life support technology ensures that all the organs continue to receive good blood flow and thus are as optimized as possible.

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Still, around the world there is an insufficient organ supply to meet the need. Physicians and researchers began to look for a new way to obtain organs.

A third way to obtain organs

In the late 1990s, a new method of obtaining organs was developed. At least two variations exist, but in the interest of space, I will highlight the most controversial, called donation after circulatory death—normothermic regional perfusion (DCD-NRP). “NRP” was found to improve the quality of organs, especially hearts, that are particularly susceptible to damage from a lack of blood flow.

DCD-NRP follows the usual method of DCD—the still-living-but-terminal patient is wheeled to the operating room, where life support is removed. Once the heart stops and 5 minutes passes, death is declared by circulatory criteria. Then, instead of proceeding with organ removal, doctors cut off blood flow to the brain and restart the heart on the most sophisticated life support available, called ECMO. The patient is not considered alive, because blood flow to the brain was occluded during the 5 minutes the patient was “dead.” The assumption is that the patient whose heart is beating on ECMO is no longer “dead” by circulatory criteria but by brain death criteria—brain death induced by one of the doctors. As a student said to me, “You’re saying you remove life support, let the heart stop, shoot them in the head, and then resuscitate them?”

Ethical questions

DCD-NRP of course raises all kinds of interesting questions. If you intend to resuscitate, why declare death in the first place? If you declare death because the heart has stopped, is it permissible to do what you want to a body while it is “dead”? If you cut off blood flow to the brain to ensure brain death, must you assess for brain death to make sure you don’t kill the patient by removing organs? Do the ends justify the means?

When the New York Times covered NRP last November, it quoted renowned Harvard bioethicist Dr. Robert Truog who worried that “among some transplant professionals there is a little bit of gaslighting going on here with the public.”

This of course leads to 2 more questions: When is a patient dead enough to donate organs? And does the public need to know?