Does Donation After Cardiac Death (DCD) Break the Dead Donor Rule?
Alex Tang wrote me a question in my "My Opinion is.." ethics Google Knol which I subsequently answered. Specifically with regard to "donation after cardiac death" (DCD), I thought that his concern that "doctors are allowing the patient to die so that organ harvesting can take place" needs to be responded to. I feel visitors to this bioethics blog should also read Alex's concern and my answer, so I have copied the texts below. In addition, I have included the following link to the New England Journal of Medicine Video Round Table discussion of the issue regarding organ donation after cardiac death with Atul Gawande as moderator and discussants, ethicists George Annas, Arthur Caplan and Robert Truog. ..Maurice.
Here is the question:
Cardiac Death and Organ Harvesting
The normal procedure for organ harvesting is from patients who has been certified brain death. In the United States, the Uniform Determination of Death Act (UDDA) set two criteria for death; (1) sustained irreversible of circulatory and respiratory function, and (2) all function of the brain including the brain stem is considered non-existent.
In recent years, there is a movement to harvest organs when the heart stops but brain function is still present. This is usually in patients that are severely ill and are going to die. This is termed "Non-Heart-Beating" or "Cardiac Death" organ donation. The University of Pittsburgh Medical Centre allocated 2 minutes after the heart stops before organ harvesting can begin. There is some uncertainty about this and the Institute of Medicine (IOM) extended the time to 5 minutes. However there have been documented cases of "autoresuscitation" i.e. the heart restarts after 10 minutes of no heart beats. The University of Zurich allows 10 minutes. This is a scary development because doctors are allowing patients to die so that organ harvesting can take place.
Dr Mark M Boucek reported the first heart transplants in three children after cardiac failure rather than brain death in August 14, 2008 issue of the New England Journal of Medicine. The transplants were done in Denver's Children Hospital in Denver. The time between the heart stops and organ harvesting is...75 seconds.
This is a scary development because the ends has justified the means. While it cannot be denied that there is a need for human organs, these organs must be harvested from patients who are already brain dead, not those allowed to die.
What do you think? Alex Tang
Here is my answer:
The moment of death for legal purposes has always been pronounced by a person who has the legal responsibility and capacity to pronounce death. It should be the same (and is the same) whether organs are to be procured or not. The pronouncement of death of a patient in whom no attempt will be made for cardio-vascular-pulmonary resuscitation should occur when it is known by clinical experience that full return of non-assisted cardio-vacular-pulmonary system function spontaneously is unlikely or if it should occur the period of anoxia of the brain would be long enough to cause brain function to meet brain death criteria. The pronouncement of death can also be made in a patient who may still have cardio-vascular system function but meets the clinical criteria for brain death. The pronouncement of death, if not by neurologic criteria, was made not because the heart was "dead" but because of the permanent pathophysiologic failure of the cardio-vascular-pulmonary system, no longer providing oxygen or other substances to the brain and the other body organs and with no intention to attempt artificial resusitation. I believe it should be clarified that The Dead Donor Rule (that the patient should be dead at the time the organs are removed) is satisfied by a legal pronouncement of death, There is no other way to define death since it is known that the cells throughout the human body don't all die at the same instant. There is nothing inconsistent with the Dead Donor Rule that the donated heart has resumed beating in the recipient. This event is not pertinent to the pronouncement of death of the donor since it was the entire cardio-vascular-pulmonary physiologic system that "died" and not the heart.. Patients have the ethical and legal right to voluntarily withdraw unwanted life support and the legal right to give permission for their organs to be removed for donation when the patient is pronounced dead. I would disagree that "doctors are allowing patients to die so that organ harvesting can take place" since the physicians, supported by the law and ethics, are following the requests of the patient. As long as society maintains strict attention regarding the validity of these patient permissions, the act of organ procurement for transplant is an ethical and humanistic procedure. ..Maurice.