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R Herdman, J Potts. National Academy Press, 1997, £15.95, pp 92. ISBN 0-309-06424-4
- Herdman R, Potts J. Non heart beating organ transplantation
- Medical and ethical issues in procurement
The problem of the supply of organs for transplantation is a major concern in many areas of health care practice and more generally in society. For many conditions organ transplantation remains the treatment of choice and in many situations this necessitates a cadaver donor. The possibility of harvesting organs from patients other than those who meet the criteria for brain death has received less publicity, but raises different ethical and legal questions, compared to the more usual situation of brain dead, ventilated patients. Given the general shortage of donor organs, however, this group of patients may represent a useful source.
This report was commissioned in 1997 by the US Department of Health and Human Services and concerns “the management of cadaver donors who died a cardiopulmonary death, called non-heart-beating-donors (NHBDs)”. In these patients death results from an “irreversible cessation of circulatory and respiratory function”, as opposed to cessation of functions of the brain. Questions had been raised about the medical management of such donors and whether the interventions practised could be said to be in the best interests of the patient or were in fact hastening death. The question considered by the report was: “Given a potential donor in an end-of-life situation, what are the alternative medical approaches that can be used to maximise the availability of organs from that donor without violating prevailing ethical norms regarding the rights and welfare of donors? The Institute will consider the alternative approaches, including the use of anticoagulants or vasodilators, from the scientific as well as the ethical point of view.” The bulk of the report concerns a review of the protocols for NHBDs obtained from 63 organ procurement organisations in the United States.
The report defines four categories of NHBDs and offers an extensive discussion of the problems of supply and demand for organ transplantation in the United States. An executive summary gives a useful synopsis of the report's findings and the appendices include notes of a workshop on medical and ethical issues in maintaining the viability of organs for transplantation.
The general conclusion of the report is that the use of NHBDs is “an important, medically effective, and ethically acceptable approach to reducing the gap that exists . . . between the demand for, and the available supply of, organs for transplantation”. The authors conclude that the ethical questions posed by this approach “require attention, but . . . are . . . not significantly different from those that arise in cadaveric transplantation generally”. The authors summarise six principles or general approaches that apply to all cadaveric donors:
The societal value of enhancing organ donation;
Organ donors must be dead at organ removal;
Absolute prohibition of active euthanasia;
Complete openness about policies and protocols;
Commitment to informed consent, and
Respect for donor and family wishes.
Perhaps surprisingly, in view of the overall conclusion of the report, the authors are reluctant to set out clear criteria for the various procedures involved, but rely heavily on case-by-case decisions (for example, for the use of anticoagulents and vasodilators, and vascular cannulation in preparation for organ perfusion) and “informed family consent” when interventions are required to facilitate organ harvesting, which are not indicated for the treatment of the patient's medical condition. The legal framework is specific to the American situation, and the report talks of consent being obtained either from the competent patient or from “surrogate decision maker(s) for the incompetent patient”.
The ethical focus of the report is the way in which designation as a potential organ donor may lead to changes in the care of the patient in ways that clearly have no therapeutic value for that patient, but which have great potential value for the recipients of any harvested organs. The extent of these changes in care is illustrated by reference to a study of beating heart cadaver donors, which found that almost half the average hospital-stay cost was related to care that was considered futile for the donor patient but “necessary for improved organ procurement rates”. The discussion of these issues is organised under the headings of Policies and oversight; Medical interventions and ethics; Conflicts of interest; Determination of death, and Families. The general view seems to be that, with adequate safeguards, the interventions necessary to improve organ retrieval from NHBDs, although not offering any benefits to the donor patient, can be justified by reference to the greater social good derived from transplantation.
The report, while very much oriented to the American experience, is a useful resource for anyone working in this area. However, it raises, by inference, one or two troubling questions that do not receive any discussion. One concerns the problem of supply and demand. In 1996 the total number of cadaver donors in the USA was 5416. This number represented a 33% increase over a nine-year period. The transplantation waiting list on the last day of 1996 stood at 50 047 people, an increase of 14% on the previous year and of 212% over the previous nine years. These figures are discussed in more detail in the report, but the conclusion is that demand is growing faster than supply. The only discussion of possible reductions in demand concerns narrowing the criteria for eligibility for transplantation. It would appear, however, that a more productive approach might be to look for ways of reducing the number of organ failures, by preventive measures and by more effective early treatment of the conditions that lead to failure. At 1996 levels a 5% increase in cadaver donors will provide an additional 270 donors. A 5% reduction in demand would mean 2502 fewer people on the list. Of course this analysis is too simplistic—for example, each donor cadaver may benefit more than one recipient, a proportion of those on the waiting list are for repeat transplantation—but the arithmetic would still seem to favour attempts at prevention over attempts to raise the numbers of cadaver donors.
A further aspect of preventive medicine concerns the paradox inherent in any general attempt to increase the numbers of cadaver donors. The report discusses possible conflicts of interest in the treatment of specific patients once they have been identified as potential donors, but does not consider the wider conflict of interests faced by the patients waiting for transplants, their carers, and society at large. The availability of cadaver donors results from the death of a patient, a death that, other things being equal we would have preferred not to have occurred. As long as we rely so heavily on transplantation as the main element of treatment we have a perverse incentive not to reduce rates of neurological or cardiopulmonary death. To put it less controversially, every advance in the prevention of such deaths represents a setback to the transplant programme.
Finally, in the context of supply and demand, the report touches briefly on the impact of managed care. This approach to the management of health services may, on the one hand, slow demand by imposing “stricter indications for medical treatments”, while on the other hand it may diminish supply “by less often carrying the care of seriously injured or ill patients to the point of potential donation using life support and other critical care interventions”. Again, the ethical implications of these trends are not discussed.