Using the Newly Dead

As a segue from the last posting on ethics and law in organ donation of the deceased, I want to bring to the attention to my visitors the full picture of the issues involved in the practice of “using the newly dead”. Are my visitors also aware that the newly dead are used for other medical purposes, in addition to organ procurement? Did you know about medical research and medical training to perform procedures?

First, with regard to tissue and/or organ procurement, this is performed on patients who are pronounced dead by classical cardio-respiratory criteria (spontaneous absence of heart beat and respiration), they are also obtained from patients who are pronounced dead by neurologic criteria (absence of whole brain function including brain stem), so-called “brain dead”, and finally from those who are dead by cardio-respiratory criteria but which was the result of the voluntary and intentional turning off of all life-support and awaiting for the heartbeat and respiration to stop. This latter criteria is used for the “donation by cardiac death”(DCD). There is still concern by the public and also by some medical professionals about the ethics of procurement using death by neurologic criteria and the DCD mechanism of producing death. The concerns involved in “brain death” is that the heart is still beating and the patient is being ventilated up to and as the organs are being removed. The patient doesn’t seem “as dead” as with the classical criteria. The concerns about DCD is whether the patient has been observed long enough (usually 5 to 10 minutes) to be sure there is no spontaneous revival of heart function before the organs are removed. Since the intentional turning off of life-support in a patient, as a candidate for DCD. who is terminal or has no chance for any meaningful recovery, is done because of the previous autonomous request of the patient or on the substituted judgment of a legal surrogate or with approval of the family as being in the patient’s best interest, there usually is no controversy about this act itself. But there is concern about the “premature” removal of the organs.

Now we come to another use of the newly dead. For years now, particularly since the advent of ventilator support and the concept of death by neurologic criteria, patients who are “brain dead” are being used for a great variety of research projects in which because the heart and respiration can be maintained for some time, the body can be functionally almost normal despite the absence of brain function. This means that medical research, though various techniques, can be performed on these newly dead which would be unethical or harmful if performed on live volunteers. For more details and examples of this use, you might want to read the Chicago SunTimes article “Ethical Frontier: Research on the Dead” by Jim Ritter in the Jan 3, 2006 issue. There are many ethical issues involve with this use. There have been various ethical guidelines set up by ethics groups to attempt to make sure that the research team follows certain ethical and legal standards. A discussion of the ethical considerations and the presentation of another, more recent, guideline is written in November 2005 issue of Nature Medicine by the multidisciplinary expert Consensus Panel on Research with the Recently Dead.

Respect for the dead is an important moral point.“ Such respect requires that research with the dead abide by the deceased person’s life goals and treats his or her body in a dignified manner.” Other reasons for maintaining the dignity of the person is that “many living people have preferences about the disposition of their bodies after they die; an aversion to disrespectful treatment is commonly among them. Honoring such preferences after death expresses respect for the person who once lived and may prevent emotional distress among the living.” In addition this behavior with regard to honoring preferences may avoid mistrust by the living, without which might generate research opposition. Disrespect may also “cause family and friends anguish and feelings of guilt (for failing to protect a deceased loved one). Some points based on ethical concerns that are covered in the guideline is the need for the research to address an important clinical problem and there should be formal unbiased review by a research board before the research is started. In addition, amongst other points is that prior consent by the patient or surrogates is necessary and there should be confidentiality and an opportunity for health care workers who find the research against their moral values to have an opportunity to opt out.

Finally, another use of the newly dead is that of the use for medical training of students, interns and residents to perform important potentially life-saving procedures such as endotracheal intubation or various other procedures which could cause harm in a living patient if they were performed improperly. To read more about the ethics of this use, go to Virtual Mentor. Prior consent is an ethical requirement, however there is literature which suggests that often prior consent is not obtained. If there is no consent from an advance directive by the patient, an argument that may be offered is that attempting to get such consent from a often distraught and grieving family at the last minute may not be in the family’s best interest.

I hope that this posting gives my visitors some idea of what is being done with the newly dead in medical practice. Since all these uses are clearly done for the benefit of society and we may all have the opportunity to benefit from the results of them, I would be interested to read from my visitors what concerns they may have about the practices involved in organ procurement, medical research and medical training using the newly dead. ..Maurice.