The general public is ready for transparency about organ donation at
the end of life
Bruce et al conducted an opinion survey using a convenience sample
in the emergency department (ED) and concluded that patients and relatives
are not averse to organ donation being "discussed shortly after ED death"
and that "organ preservation procedures [prior to donation consent] are
acceptable to many" [1]. We outline 3 main concerns regarding the validity
of the conclusions drawn by Bruce et al from the survey.
First, the medical criterion of death determination by the
circulatory criterion (ie, mechanical asystole or cardiac arrest for 2- 10
minutes) without simultaneously confirming that brain death has occurred
is scientifically flawed [2-4]. The use of a faulty "accepted medical
standard" potentially leads to high error rates of determining donor
death, which would then inevitably be underreported because of the
terminality of surgical procurement. At least 6% of donors determined dead
for organ donation purposes were successfully resuscitated and surgical
procurement had to be aborted [5]. The public is uninformed of the
scientific uncertainty of declaring death in donors in either planned
(controlled) or unplanned (uncontrolled) cardiac arrest [4, 6-8].
Therefore, medical scholars from Canada and the United States have pleaded
for "a call for a moratorium pending full public disclosure and fully
informed consent" [3].
Bruce et al state that the survey results show that "organ
preservation procedures are acceptable to many." However, none of the
subjects prior to participating in the survey received information on the
types of procedures involved, how and when they are performed on donors,
and their potential risks. The authors state when consent to donation had
yet to be obtained, "the majority [of survey participants] felt [that]
commencement and continuation of these procedures would be acceptable if
there was as little invasion to their relatives' bodies as possible" [1].
Practically, several highly invasive procedures are necessary to preserve
organs for transplantation after unplanned cardiac arrest in eligible
donors. They include but are not limited to:
1) Mechanical external cardiac compression, positive pressure
ventilation through endotracheal tubes and administration of resuscitation
drugs are continued until organs are surgically procured [5].
2) Catheters are inserted into the abdomen to irrigate the peritoneal
cavity with ice-cold saline solution and cool rapidly internal organs.
Rapid cooling preserves the internal organs for transplantation until
donors are transported to medical facilities for surgical procurement [9].
3) Vascular catheters are inserted in the femoral vessels to
recirculate oxygenated blood in the systemic circulation with heart-lung
machines ie, extracorporeal membrane oxygenation (ECMO) [10, 11]. ECMO
preserves organs until the surgical team can start organ removal. ECMO can
resuscitate donors during organ procurement [2, 12]. ECMO is also
performed at specialized centers to resuscitate patients after refractory
cardiac arrest or failed traditional cardiopulmonary resuscitation.
Survivors can recover fully with minimal neurological disabilities after
ECMO-CPR intervention [13]. However, administering preservative fluids to
donors is lethal and obliterates any possible chances of survival if they
are successfully resuscitated on ECMO.
4) Surgical procurement is accomplished through midline
laparotomy/sternotomy and enbloc removal of organs [14].
Second, the UK community consists of different ethnic groups and
religious affiliations. The survey was not representative of these groups.
Decision-making at the end of life is informed by personal values,
beliefs, preferences, cultures and religious affiliations [15].
Sensitivity to and respect for cultural diversity in the care of dying in
pluralistic societies is a basic human right that warrants respect. These
considerations have been overlooked.
Finally, determining what ought to be considered ethical or morally
acceptable in society should not be grounded in public opinion surveys
[16]. As has been argued elsewhere:
"If ethics was determined by mere public opinion, our moral standards
would be rendered hopelessly and unacceptably changeable, making it
difficult to be certain about what is the morally right thing to do.... On
a philosophical level, it violates a necessary requirement for sound moral
judgements, notably the requirement for internal consistency.... On a more
pragmatic level, there is also the troubling possibility that public
opinion might be mistaken or wrong or misguided, particularly where it has
been manipulated by pressure groups, politicians or by the media" [16].
This contention is pertinent to Bruce et al claims. What should a
person expect as the minimal standard of disclosed information that is
reasonable to ensure an informed decision/consent? Utilitarian
bioethicists may justify certain life-ending medical practices to
facilitate recovery of transplantable organs. For others, such life-ending
medical practices constitute a violation of the moral obligation to
preserve human life and dignity. In light of the cultural complexities at
issue, deciding these issues requires a stronger moral foundation.
Mohamed Y Rady, BChir, MB (Cantab), MA, MD (Cantab), FRCS (Edin.
& Eng.), FRCP (UK), FCCM
Professor, College of Medicine, Mayo Clinic
Consultant, Department of Critical Care Medicine,
Hospital, Mayo Clinic,
Phoenix, Arizona, USA
Joseph Verheijde, MBA, PhD, PT
Associate Professor,
Department of Physical Medicine and Rehabilitation,
Mayo Clinic, Phoenix, Arizona, USA
Megan-Jane Johnstone, RN, PhD, FRCNA, FCN
Professor, Chair in Nursing and Associate Head of School (Research),
School of Nursing and Midwifery, Faculty of Health,
Deakin University,
Melbourne, Victoria 3125, Australia
References
1. Bruce CM, Reed MJ, MacDougall M. Are the public ready for organ
donation after out of hospital cardiac arrest? Em Med J. 2012:Published
Online First: 13 April 2012 doi:2010.1136/emermed-2012-201135.
2. Rady MY, Verheijde JL, McGregor JL. Scientific, legal, and ethical
challenges of end-of-life organ procurement in emergency medicine.
Resuscitation. 2010;81(9):1069-1078.
3. Joffe A, Carcillo J, Anton N, et al. Donation after
cardiocirculatory death: a call for a moratorium pending full public
disclosure and fully informed consent. Philos Ethics Humanit Med.
2011;6(1):17. http://www.peh-med.com/content/6/1/17.
4. Rady MY, Verheijde JL. Autoresuscitation and determining
circulatory-respiratory death in clinical practice for organ donation.
Crit Care Med. 2012;40(5):1665-1656.
5. Mateos-Rodriguez A, Pardillos-Ferrer L, Navalpotro-Pascual JM,
Barba-Alonso C, Martin-Maldonado ME, Andr?s-Belmonte A. Kidney transplant
function using organs from non-heart-beating donors maintained by
mechanical chest compressions.Resuscitation. 2010;81(7):904-907.
6. Dhanani S, Ward R, Hornby L, et al. Survey of determination of
death after cardiac arrest by intensive care physicians. Crit Care Med.
2012;40(5):1449-1455.
7. Stiegler P, Sereinigg M, Puntschart A, et al. A 10 min "no-touch"
time - is it enough in DCD? A DCD Animal Study. Transpl Int.
2012;25(4):481-492.
8. Rodriguez-Arias D, Tortosa J, Burant C, Aubert P, Aulisio M,
Youngner S. One or two types of death? Attitudes of health professionals
towards brain death and donation after circulatory death in three
countries. Med Health Care Philos. 2011:Online First, 2 December 2011.DOI:
2010.1007/s11019-11011-19369-11011.
9. DuBois JM, Waterman AD, Iltis A, Anderson J. Is Rapid Organ
Recovery a Good Idea? An Exploratory Study of the Public's Knowledge and
Attitudes. Am J Transplant. 2009;9(10): 2392 - 2399.
10. Rodriguez-Arias D, Deballon IO. Protocols for uncontrolled
donation after circulatory death. Lancet. 2012;379(9823):1275-1276.
11. Fondevila C, Hessheimer AJ, Flores E, et al. Applicability and
Results of Maastricht Type 2 Donation After Cardiac Death Liver
Transplantation. Am J Transplant. 2012;12(1):162-170.
12. Dejohn C, Zwischenberger JB. Ethical implications of
extracorporeal interval support for organ retrieval (EISOR). ASAIO J.
2006;52(2):119-122.
13. Shin TG, Choi J-H, Jo IJ, et al. Extracorporeal cardiopulmonary
resuscitation in patients with inhospital cardiac arrest: A comparison
with conventional cardiopulmonary resuscitation. Crit Care Med.
2011;39(1):1-7.
14. Perera MTPR. The super-rapid technique in Maastricht category III
donors: has it developed enough for marginal liver grafts from donors
after cardiac death? Current Opinion in Organ Transplantation.
2012;17(2):131-136.
15. Johnstone M-J, Kanitsaki O. Ethics and Advance Care Planning in a
Culturally Diverse Society. J. Transcult. Nurs. 2009;20(4):405-416.
16. Johnstone M-J. Public opinion and ethics. Aust Nurs J.
2011;19(1):25-25.
Conflict of Interest:
None declared
The general public is ready for transparency about organ donation at the end of life
Bruce et al conducted an opinion survey using a convenience sample in the emergency department (ED) and concluded that patients and relatives are not averse to organ donation being "discussed shortly after ED death" and that "organ preservation procedures [prior to donation consent] are acceptable to many" [1]. We outline 3 main concerns regarding the validity of the conclusions drawn by Bruce et al from the survey.
First, the medical criterion of death determination by the circulatory criterion (ie, mechanical asystole or cardiac arrest for 2- 10 minutes) without simultaneously confirming that brain death has occurred is scientifically flawed [2-4]. The use of a faulty "accepted medical standard" potentially leads to high error rates of determining donor death, which would then inevitably be underreported because of the terminality of surgical procurement. At least 6% of donors determined dead for organ donation purposes were successfully resuscitated and surgical procurement had to be aborted [5]. The public is uninformed of the scientific uncertainty of declaring death in donors in either planned (controlled) or unplanned (uncontrolled) cardiac arrest [4, 6-8]. Therefore, medical scholars from Canada and the United States have pleaded for "a call for a moratorium pending full public disclosure and fully informed consent" [3].
Bruce et al state that the survey results show that "organ preservation procedures are acceptable to many." However, none of the subjects prior to participating in the survey received information on the types of procedures involved, how and when they are performed on donors, and their potential risks. The authors state when consent to donation had yet to be obtained, "the majority [of survey participants] felt [that] commencement and continuation of these procedures would be acceptable if there was as little invasion to their relatives' bodies as possible" [1]. Practically, several highly invasive procedures are necessary to preserve organs for transplantation after unplanned cardiac arrest in eligible donors. They include but are not limited to:
1) Mechanical external cardiac compression, positive pressure ventilation through endotracheal tubes and administration of resuscitation drugs are continued until organs are surgically procured [5].
2) Catheters are inserted into the abdomen to irrigate the peritoneal cavity with ice-cold saline solution and cool rapidly internal organs. Rapid cooling preserves the internal organs for transplantation until donors are transported to medical facilities for surgical procurement [9].
3) Vascular catheters are inserted in the femoral vessels to recirculate oxygenated blood in the systemic circulation with heart-lung machines ie, extracorporeal membrane oxygenation (ECMO) [10, 11]. ECMO preserves organs until the surgical team can start organ removal. ECMO can resuscitate donors during organ procurement [2, 12]. ECMO is also performed at specialized centers to resuscitate patients after refractory cardiac arrest or failed traditional cardiopulmonary resuscitation. Survivors can recover fully with minimal neurological disabilities after ECMO-CPR intervention [13]. However, administering preservative fluids to donors is lethal and obliterates any possible chances of survival if they are successfully resuscitated on ECMO.
4) Surgical procurement is accomplished through midline laparotomy/sternotomy and enbloc removal of organs [14].
Second, the UK community consists of different ethnic groups and religious affiliations. The survey was not representative of these groups. Decision-making at the end of life is informed by personal values, beliefs, preferences, cultures and religious affiliations [15]. Sensitivity to and respect for cultural diversity in the care of dying in pluralistic societies is a basic human right that warrants respect. These considerations have been overlooked.
Finally, determining what ought to be considered ethical or morally acceptable in society should not be grounded in public opinion surveys [16]. As has been argued elsewhere:
"If ethics was determined by mere public opinion, our moral standards would be rendered hopelessly and unacceptably changeable, making it difficult to be certain about what is the morally right thing to do.... On a philosophical level, it violates a necessary requirement for sound moral judgements, notably the requirement for internal consistency.... On a more pragmatic level, there is also the troubling possibility that public opinion might be mistaken or wrong or misguided, particularly where it has been manipulated by pressure groups, politicians or by the media" [16].
This contention is pertinent to Bruce et al claims. What should a person expect as the minimal standard of disclosed information that is reasonable to ensure an informed decision/consent? Utilitarian bioethicists may justify certain life-ending medical practices to facilitate recovery of transplantable organs. For others, such life-ending medical practices constitute a violation of the moral obligation to preserve human life and dignity. In light of the cultural complexities at issue, deciding these issues requires a stronger moral foundation.
Mohamed Y Rady, BChir, MB (Cantab), MA, MD (Cantab), FRCS (Edin. & Eng.), FRCP (UK), FCCM
Professor, College of Medicine, Mayo Clinic
Consultant, Department of Critical Care Medicine, Hospital, Mayo Clinic, Phoenix, Arizona, USA
Joseph Verheijde, MBA, PhD, PT
Associate Professor, Department of Physical Medicine and Rehabilitation, Mayo Clinic, Phoenix, Arizona, USA
Megan-Jane Johnstone, RN, PhD, FRCNA, FCN
Professor, Chair in Nursing and Associate Head of School (Research), School of Nursing and Midwifery, Faculty of Health, Deakin University, Melbourne, Victoria 3125, Australia
References
1. Bruce CM, Reed MJ, MacDougall M. Are the public ready for organ donation after out of hospital cardiac arrest? Em Med J. 2012:Published Online First: 13 April 2012 doi:2010.1136/emermed-2012-201135.
2. Rady MY, Verheijde JL, McGregor JL. Scientific, legal, and ethical challenges of end-of-life organ procurement in emergency medicine. Resuscitation. 2010;81(9):1069-1078.
3. Joffe A, Carcillo J, Anton N, et al. Donation after cardiocirculatory death: a call for a moratorium pending full public disclosure and fully informed consent. Philos Ethics Humanit Med. 2011;6(1):17. http://www.peh-med.com/content/6/1/17.
4. Rady MY, Verheijde JL. Autoresuscitation and determining circulatory-respiratory death in clinical practice for organ donation. Crit Care Med. 2012;40(5):1665-1656.
5. Mateos-Rodriguez A, Pardillos-Ferrer L, Navalpotro-Pascual JM, Barba-Alonso C, Martin-Maldonado ME, Andr?s-Belmonte A. Kidney transplant function using organs from non-heart-beating donors maintained by mechanical chest compressions.Resuscitation. 2010;81(7):904-907.
6. Dhanani S, Ward R, Hornby L, et al. Survey of determination of death after cardiac arrest by intensive care physicians. Crit Care Med. 2012;40(5):1449-1455.
7. Stiegler P, Sereinigg M, Puntschart A, et al. A 10 min "no-touch" time - is it enough in DCD? A DCD Animal Study. Transpl Int. 2012;25(4):481-492.
8. Rodriguez-Arias D, Tortosa J, Burant C, Aubert P, Aulisio M, Youngner S. One or two types of death? Attitudes of health professionals towards brain death and donation after circulatory death in three countries. Med Health Care Philos. 2011:Online First, 2 December 2011.DOI: 2010.1007/s11019-11011-19369-11011.
9. DuBois JM, Waterman AD, Iltis A, Anderson J. Is Rapid Organ Recovery a Good Idea? An Exploratory Study of the Public's Knowledge and Attitudes. Am J Transplant. 2009;9(10): 2392 - 2399.
10. Rodriguez-Arias D, Deballon IO. Protocols for uncontrolled donation after circulatory death. Lancet. 2012;379(9823):1275-1276.
11. Fondevila C, Hessheimer AJ, Flores E, et al. Applicability and Results of Maastricht Type 2 Donation After Cardiac Death Liver Transplantation. Am J Transplant. 2012;12(1):162-170.
12. Dejohn C, Zwischenberger JB. Ethical implications of extracorporeal interval support for organ retrieval (EISOR). ASAIO J. 2006;52(2):119-122.
13. Shin TG, Choi J-H, Jo IJ, et al. Extracorporeal cardiopulmonary resuscitation in patients with inhospital cardiac arrest: A comparison with conventional cardiopulmonary resuscitation. Crit Care Med. 2011;39(1):1-7.
14. Perera MTPR. The super-rapid technique in Maastricht category III donors: has it developed enough for marginal liver grafts from donors after cardiac death? Current Opinion in Organ Transplantation. 2012;17(2):131-136.
15. Johnstone M-J, Kanitsaki O. Ethics and Advance Care Planning in a Culturally Diverse Society. J. Transcult. Nurs. 2009;20(4):405-416.
16. Johnstone M-J. Public opinion and ethics. Aust Nurs J. 2011;19(1):25-25.
Conflict of Interest:
None declared