Organ Donation: Who, How,Why and also What are the Ethics? (4)

The organ donation, procurement and transplant process is fairly well established in the United States. The UNOS (United Network for Organ Sharing) has representative organizations in all parts of the country to actually make the contact to donors and find the appropriate recipients. There are numerous policies to keep the process fair and just. However, there are some areas of ethical concern that remain. In the process of getting consent for the donation of organs, great care is taken by all institutions that conflict of interest is avoided. Specifically, that means that the patient’s physicians and other hospital caregivers avoid talking with family about organ donation of their family member who by procurement criteria might be a potential candidate. A representative of the organ procurement organization, who has no responsibility for patient care, talks to the family about possible donation. In this way, there is less chance that it would appear that the patient’s medical team is involved in the procurement and therefore might be attending to the interest of obtaining an organ and not the interest of the patient. It is the patient’s physician or representative who pronounces death and not the procurement team. The costs of procurement are borne by the procurement organization.

With regard to consent, response of the family may at times be very conflicting. This particularly occurs when there is a written directive by the patient to donate organs after death and the family then refuses to follow the directive. In this case, often the family’s decision against donation trumps the patient’s request and the procurement organization will tend to obey the family. This decision by the organization may be related to legal concerns regarding the family’s legal authority over the body of the deceased. Though written statements of the patient’s property is carefully followed by legal process, the patient’s body and what is done with it appears to be the responsibility of the family. This creates an ethical concern regarding the autonomy of patient requests. It is very important that people who wish to donate organs after death make their wishes very clear by, in addition, communicating this directly to their families rather than solely depending on some written document or check off on a drivers license.

Whereas, some years ago, in an attempt to be sure that the vital organs were going to get adequate oxygenated blood flow during the period between termination of life-support and death, procedures were carried out which could have been interpreted as actively hastening the patient’s death. This was an ethical “no-no” since it was felt that if the patient was to die it should be due to the underlying illness and not because of something done to better the organ survival. The policy is that nothing be done as part of the procurement process until the patient is pronounced dead. However, in patients who are to be non-heart beating donors (see my first posting on the subject) there is debate as to when death actually occurs. For example, is the patient really dead after 2 minutes of the heart not beating or after 5 or 10 minutes? There is still even some argument by some neurologists and other specialists about whether the patient is really dead after brain death has been pronounced since even with mechanical ventilation support, the heart may continue beating for hours or occasionally longer but eventually will stop. Certain secretions and endocrine and other metabolic activities can be detected for days. However, no patient recovers life. A logical suggestion has been made that the criteria given in these situations regarding whether death has really occurred should be revised to say simply that they meet ethical and legal requirements for organ procurement since there is no recovery of life when the criteria are met.
More later about ethics of organ donation. ..Maurice.