The “dead donor rule” is the cement that binds the public’s trust in organ transplant medicine. Under the DDR (other than in living donations, such as of one kidney) organs cannot be procured unless donors, in the words of the Munchkins, are not be merely dead but really most sincerely dead.
There are two means of declaring death. Let’s call the first “heart death,” that is an irreversible cessation of all cardio/pulmonary function. The other is popularly known as “brain death,” (death declared by neurological criteria) in which function in the whole brain and each of its constituent parts have irreversibly ceased. The key word in both means of declaring death is “irreversible.”
But something appears to have gone badly off the rails in the field of procuring organs after heart death. A long New York Times expose found cases of patients who were clearly alive when organ procurement began. At the same time, a very disturbing report by the Department of Health and Human Services contained similar findings.
First, the NYT. From “A Push for More Organ Transplants Is Putting Donors at Risk”:
This system works only if the absence of physiological signs of life are accurately identified. But the push for organs has apparently grown so intense that corners may be being cut, endangering still-living patients and treating them as so many organ farms:
HHS has also issued a harrowing report about the same seeming crisis involving one OPO. The Health Resources and Services Administration (HRSA) revealed disturbing lapses — apparently including cases of inaccurately determined brain death. From the press release, “HHS Finds Systematic Disregard for Sanctity of Human Life in Organ Transplant Medicine:”
HHS is demanding that the OPO reform its practices:
This isn’t the first such warning about the potential perils of the Pittsburgh Protocol. For example, I posted this piece issuing a similar alarm in 2009.
I have worried often that there is a temptation to treat organ donor patients — who are subjects as long as they are alive — as objects once they are seen as dying, toward the perceived greater good of saving the lives of people who need organs. That can’t be allowed to happen. It is not only wrong, but from a purely utilitarian perspective, if people lose faith in the donation system, the number of available organs will decline as fewer people sign up to donate. In such a circumstance, recipients will become the primary victims of popular distrust.
There are two means of declaring death. Let’s call the first “heart death,” that is an irreversible cessation of all cardio/pulmonary function. The other is popularly known as “brain death,” (death declared by neurological criteria) in which function in the whole brain and each of its constituent parts have irreversibly ceased. The key word in both means of declaring death is “irreversible.”
But something appears to have gone badly off the rails in the field of procuring organs after heart death. A long New York Times expose found cases of patients who were clearly alive when organ procurement began. At the same time, a very disturbing report by the Department of Health and Human Services contained similar findings.
Last spring at a small Alabama hospital, a team of transplant surgeons prepared to cut into Misty Hawkins. . . . Days earlier, she had been a vibrant 42-year-old with a playful sense of humor and a love for the Thunder Beach Motorcycle Rally. But after Ms. Hawkins choked while eating and fell into a coma, her mother decided to take her off life support and donate her organs. She was removed from a ventilator and, after 103 minutes, declared dead.The horror! Why are such awful things happening?
A surgeon made an incision in her chest and sawed through her breastbone. That’s when the doctors discovered her heart was beating. She appeared to be breathing. They were slicing into Ms. Hawkins while she was alive.
In recent years, as the system has pushed to increase transplants, a growing number of patients have endured premature or bungled attempts to retrieve their organs. Though Ms. Hawkins’s case is an extreme example of what can go wrong, a New York Times examination revealed a pattern of rushed decision-making that has prioritized the need for more organs over the safety of potential donors.These examples are cases of procurement after planned “heart death” under an approach known as the Pittsburgh Protocol. First, life support is removed. After the patient’s heart stops, there is supposed to be a waiting period to ensure irreversibility — three or five minutes. Only then can the procurement begin. If the patient does not die, he or she is returned to the ward.
In New Mexico, a woman was subjected to days of preparation for donation, even after her family said that she seemed to be regaining consciousness, which she eventually did. In Florida, a man cried and bit on his breathing tube but was still withdrawn from life support. In West Virginia, doctors were appalled when coordinators asked a paralyzed man coming off sedatives in an operating room for consent to remove his organs.
This system works only if the absence of physiological signs of life are accurately identified. But the push for organs has apparently grown so intense that corners may be being cut, endangering still-living patients and treating them as so many organ farms:
The Times found that some organ procurement organizations [OPO] — the nonprofits in each state that have federal contracts to coordinate transplants — are aggressively pursuing circulatory death donors and pushing families and doctors toward surgery. Hospitals are responsible for patients up to the moment of death, but some are allowing procurement organizations to influence treatment decisions.Hastening death is strictly forbidden by the dead donor rule. Any such advocacy should result in job terminations, and if actually done, criminal prosecutions.
Fifty-five medical workers in 19 states told The Times they had witnessed at least one disturbing case of donation after circulatory death.
Workers in several states said they had seen coordinators persuading hospital clinicians to administer morphine, propofol and other drugs to hasten the death of potential donors.
HHS has also issued a harrowing report about the same seeming crisis involving one OPO. The Health Resources and Services Administration (HRSA) revealed disturbing lapses — apparently including cases of inaccurately determined brain death. From the press release, “HHS Finds Systematic Disregard for Sanctity of Human Life in Organ Transplant Medicine:”
HRSA examined 351 cases where organ donation was authorized, but ultimately not completed. It found:
- 103 cases (29.3%) showed concerning features, including 73 patients with neurological signs incompatible with organ donation.
- At least 28 patients may not have been deceased at the time organ procurement was initiated—raising serious ethical and legal questions.
Yikes!
- Evidence pointed to poor neurologic assessments, lack of coordination with medical teams, questionable consent practices, and misclassification of causes of death, particularly in overdose cases.
HHS is demanding that the OPO reform its practices:
Vulnerabilities were highest in smaller and rural hospitals, indicating systemic gaps in oversight and accountability. In response to these findings, HRSA has mandated strict corrective actions for the OPO, and system-level changes to safeguard potential organ donors nationally. The OPO must conduct a full root cause analysis of its failure to follow internal protocols—including noncompliance with the five-minute observation rule after the patient’s death—and develop clear, enforceable policies to define donor eligibility criteria. Additionally, it must adopt a formal procedure allowing any staff member to halt a donation process if patient safety concerns arise.Indeed. Uniformity of medical approach — both in heart- and brain-death cases — is often lacking. Time for that to change all across the country!
This isn’t the first such warning about the potential perils of the Pittsburgh Protocol. For example, I posted this piece issuing a similar alarm in 2009.
I have worried often that there is a temptation to treat organ donor patients — who are subjects as long as they are alive — as objects once they are seen as dying, toward the perceived greater good of saving the lives of people who need organs. That can’t be allowed to happen. It is not only wrong, but from a purely utilitarian perspective, if people lose faith in the donation system, the number of available organs will decline as fewer people sign up to donate. In such a circumstance, recipients will become the primary victims of popular distrust.
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