Elective ventilation for organ donation: law, policy and public ethics

John Coggon

doi:10.1136/medethics-2012-100992

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Elective ventilation

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Elective ventilation for organ donation: law, policy and public ethics

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Re:"Ahsan v University Hospitals Leicester NHS Trust" does not legitimize antemortem organ preservation in end-of-life care.
John Coggon
Published on: 22 February 2013
"Ahsan v University Hospitals Leicester NHS Trust" does not legitimize antemortem organ preservation in end-of-life care.
Mohamed Y Rady
Published on: 14 January 2013

Published on: 22 February 2013
Re:"Ahsan v University Hospitals Leicester NHS Trust" does not legitimize antemortem organ preservation in end-of-life care.
- John Coggon, Academic
I am grateful for the response to my paper.
For clarity's sake, however, I would like to point out in reply that I do not cite Ahsan to 'legitimize' any claim. Rather I present it as legal authority for a claim about legal principle. The principle is clear, though the respondents to my paper seem not to understand it quite.
I would therefore emphasise that the idea of best interests applies to patients...
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I am grateful for the response to my paper.
For clarity's sake, however, I would like to point out in reply that I do not cite Ahsan to 'legitimize' any claim. Rather I present it as legal authority for a claim about legal principle. The principle is clear, though the respondents to my paper seem not to understand it quite.
I would therefore emphasise that the idea of best interests applies to patients individually, and thus necessarily varies from patient to patient. I do not for a moment consider that best interests supports the measures discussed in the paper for all patients; rather I suggest that it does so in some cases.
The respondents to my paper seem to suggest that a preponderance of relgious opinion renders my interpretation of the law impossible.
Their argument rests on a fundamental failure to appreciate that the law respects a plurality of distinct values. Many systems of beliefs are respected.
It would not be true that it would be in everyone's best interests, as that idea is understood in English law, to become organ donors. But it is wrong to suggest that this means that it can be in no-one's best interests.
Conflict of Interest:
None declared
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Conflict of Interest:
None declared.
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Published on: 14 January 2013
"Ahsan v University Hospitals Leicester NHS Trust" does not legitimize antemortem organ preservation in end-of-life care.
- Mohamed Y Rady, Consultant
- Other Contributors:
  Joseph L. Verheijde
"Ahsan v University Hospitals Leicester NHS Trust" does not legitimize antemortem organ preservation in end-of-life care.
Coggon cited Ahsan v University Hospitals Leicester NHS Trust to legitimize elective mechanical ventilation and preservation of organs in dying patients for transplantation [1]. Elective mechanical ventilation alone does not preserve organs in donors for transplantation without performing ad...
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"Ahsan v University Hospitals Leicester NHS Trust" does not legitimize antemortem organ preservation in end-of-life care.
Coggon cited Ahsan v University Hospitals Leicester NHS Trust to legitimize elective mechanical ventilation and preservation of organs in dying patients for transplantation [1]. Elective mechanical ventilation alone does not preserve organs in donors for transplantation without performing additional medical procedures. We have discussed elsewhere several antemortem medical procedures for organ preservation that included, but not limited to,: 1) endotracheal intubation, 2) invasive positive pressure ventilation, 3) pharmacological and/or mechanical support of the circulation, 4) invasive instrumentation of blood vessels and body cavities, and 5) use of antemortem preservative drugs such as anticoagulants and vasodilators [2,3]. Coggon cited Ahsan v University Hospitals Leicester NHS Trust to argue in favor of the permissibility of elective mechanical ventilation in end-of-life care of dying patients for the specific purpose of organ preservation and donation [1]. We disagree with Coggon's interpretation of the 2 standards applied in Ahsan case: (1) patient's best interests; and (2) reasonableness of the proposed care regime.
(1) The standard of patient's best interests
Section 4(6) of the UK Mental Capacity Act of 2005 states that in determining what is in a person's best interests one "must consider, so far as is reasonably ascertainable-- (a) the person's past and present wishes and feelings (and, in particular, any relevant written statement made by him when he had capacity), (b) the beliefs and values that would be likely to influence his decision if he had capacity, and (c) the other factors that he would be likely to consider if he were able to do so". Furthermore, section 4(7) (b) of the Act affirms that one "must take into account, if it is practicable and appropriate to consult them, the views of-- anyone engaged in caring for the person or interested in his welfare" [4].
In Ahsan v University Hospitals Leicester NHS Trust 2006 [5], familial, cultural and religious considerations were significant factors in determining the patient's best interest regarding what, where, when and how to provide end-of-life care in the event of mental incapacity. Although medical experts made the case "to disregard any familial, social, cultural, religious or spiritual considerations in addressing" an incapacitated person's best interests, Judge Hegarty QC came to a different conclusion. Judge Hegarty QC stated in the final ruling: "[o]n the contrary, I would have thought that most reasonable people would expect, in the event of some catastrophe of that kind, that they would be cared for, as far as practicable, in such a way as to ensure that they were treated with due regard for their personal dignity and with proper respect for their religious beliefs" [5]. In accordance with the UK Mental Capacity Act of 2005, cultural and religious values and beliefs must be considered and respected in end-of-life care. In the case of Ahsan, a Sunni Muslim, the values, beliefs and rituals of the Islamic faith determined the "best interests" in end-of-life care.
Coggon extrapolated from the Ahsan case, to argue that the person's (donor) "best interest" in end-of-life care should include supplying transplantable organs to a third party (recipient). However, if the preparation and execution of procurement of transplantable organs directly collide with the values, beliefs and rituals of a person's faith about end -of-life care, then Coggon's argument is bound to fail. Indeed, most world religions would nullify first-person consent to become an organ donor if the process of donating transplantable organs is believed to constitute a violation of enshrined faith-based values and beliefs about caring for dying individuals [6-10].
(2)The standard of reasonableness of the proposed care regime
There are several practical deficiencies in Coggon's claim that elective mechanical ventilation meets the standard of "reasonableness of the proposed care regime"[5]. The proposed elective mechanical ventilation is only one step of multiple sequential medical procedures that must be performed successfully to preserve organs for transplantation. Cardiovascular support is essential following elective mechanical ventilation to perfuse and preserve transplantable organs. Acute resuscitation and stabilization of both cardiac and circulatory functions are generally required after invasive positive pressure ventilation [11]. If elective mechanical ventilation induces an acute cardiovascular collapse in dying patients, that is refractory to cardiopulmonary resuscitation, extracorporal membrane oxygenation (artificial heart-lung machine) will have to be introduced so as to preserve organs for transplantation [2].
Following elective mechanical ventilation, most donors who are dying from neurological injuries fail to progress to the neurological criterion of death to enable heart-beating organ donation [12]. In this situation, elective withdrawal of mechanical ventilation is medically required to induce arterial pulselessness (cardiac mechanical asystole) and meet the circulatory criterion of death in controlled non-heart-beating organ donation [13]. Almost 50% of potential donors, however, fail to progress to arterial pulselessness within 60 minutes after withdrawing mechanical ventilation [14,15]. Organs procured after 60 minutes generally sustain warm ischemic injury and recipients are likely to develop primary nonfunction or delayed function of the transplanted allografts [16]. This raises additional practical questions about the end-of-life care of potential donors who undergo elective ventilation. If they fail to die within the required time to donate transplantable organs, what happen to the still living but dying patients? Furthermore, considering that potential donors should be transferred to the intensive care unit for elective mechanical ventilation and antemortem organ preservation, should this scarce resource be prioritized to potential donors rather than to critically ill patients who are in need of life-support? Alternatively, should potential donors be transferred to separate procurement units especially designed for elective mechanical ventilation and antemortem organ preservation?
In conclusion, we disagree with Coggon's interpretation of patient's best interests and reasonableness of the proposed elective mechanical ventilation in end-of-life care for the specific purpose of organ preservation and donation. As other commentators have done earlier [17], Coggon has mistakenly used the decision in Ahsan v University Hospitals Leicester NHS Trust to support his position on the legal permissibility of antemortem organ preservation in controlled heart-beating donation. Others have mistakenly generalized that antemortem organ preservation upholds human dignity and beneficence [18]. We assert that beneficence, compassion, and human dignity in end-of-life care mean upholding and respecting the cultural and religious values of dying patients [19]. We think that the standards of person's best interests and the reasonableness of proposed care invoked in Ahsan case can, instead, be a ground to legitimately, even mandatorily revoke or overrule a prior first-person consent if the process of organ donation is believed to constitute a violation of the religious values and beliefs of the potential donor or the surviving family.
Mohamed Y Rady, B.Chir, M.B (Cantab), M.A , M.D (Cantab), FRCS (Edin. & Eng.), FRCP (UK), FCCM
Professor, College of Medicine, Mayo Clinic
Consultant, Department of Critical Care Medicine, Mayo Clinic Hospital, Phoenix, Arizona, USA
Joseph L. Verheijde, PhD, MBA, PT
Associate Professor, Biomedical Ethics, College of Medicine, Mayo Clinic
Department of Physical Medicine and Rehabilitation, Mayo Clinic, Phoenix, Arizona, USA
References
1. Coggon J. Elective ventilation for organ donation: law, policy and public ethics. J Med Ethics.2012:Published Online First: 7 December 2012 doi:2010.1136/medethics-2012-100992
2. Rady MY, Verheijde JL, Johnstone M-J. The general public is ready for transparency about organ donation at the end of life. Em Med J.2012;29(10):858-859.
3. Rady MY, Verheijde JL, McGregor JL. Scientific, legal, and ethical challenges of end-of-life organ procurement in emergency medicine. Resuscitation.2010;81(9):1069-1078.
4. The National Archives on behalf of HM Government. Mental Capacity Act 2005. http://www.legislation.gov.uk/ukpga/2005/9/contents.
5. The High Court of Justice Queen's Bench Division. Ahsan v University Hospitals Leicester NHS Trust [2006] EWHC 2624 (QB). 2006.
6. The Lancet. Religion, organ transplantation, and the definition of death. Lancet.2011;377(9762):271-271.
7. Rady MY, Verheijde JL. Brain-dead Patients Are Not Cadavers: The Need to Revise the Definition of Death in Muslim Communities. HEC Forum. 2012:Published online: 28 September 2012, DOI: 2010.1007/s10730-10012- 19196-10737. http://dx.doi.org/10.1007/s10730-012-9196-7.
8. Jones DA. Loss of faith in brain death: Catholic controversy over the determination of death by neurological criteria. Clinical Ethics.2012;7(3):133-141.
9. Sanchez GM. Objections to Donation after Cardiac Death. A Violation of Human Dignity. Natl Cathol Bioeth Q.2012;12(1):55- 65.
10. Shewmon DA. You only die once: why brain death is not the death of a human being. A Reply to Nicholas Tonti-Filippini. Communio: International Catholic Review.2012;39(Fall issue):422-494.
11. Watkinson P, McKechnie S, Wilkinson D, Salmon J, Young D. Actively delaying death to increase organ donation. BMJ.2012;344:e1179
12. Kompanje EJO, de Groot YJ, Bakker J. Is Organ Donation From Brain Dead Donors Reaching an Inescapable and Desirable Nadir? Transplantation.2011;91(11):1177-1180
13. Bernat JL, Capron AM, Bleck TP, et al. The circulatory- respiratory determination of death in organ donation. Crit Care Med.2010;38(3):963-970.
14. de Groot YJ, Lingsma HF, Bakker J, Gommers DA, Steyerberg E, Kompanje EJO. External validation of a prognostic model predicting time of death after withdrawal of life support in neurocritical patients. Crit Care Med.2012;40(1):233-238
15. Rabinstein AA, Yee AH, Mandrekar J, et al. Prediction of potential for organ donation after cardiac death in patients in neurocritical state: a prospective observational study. The Lancet Neurology.2012;11(5):414-419.
16. Dominguez-Gil B, Haase-Kromwijk B, Van Leiden H, et al. Current situation of donation after circulatory death in European countries. Transpl Int.2011;24(7):676-686.
17. Price D, Samanta J. Supporting Controlled Non-Heart-Beating Donation. Camb Q Healthc Ethics.2013;22(01):22-32.
18. De Lora P, P?rez Blanco A. Dignifying death and the morality of elective ventilation. J Med Ethics.2013:Published Online First: 8 January 2013 doi:2010.1136/medethics-2012-100995
19. Rady MY, Verheijde JL. Comfort Care, Withdrawal of Life-Support Treatment, and Nonconsensual Euthanasia in the ICU. Crit Care Med.2013:DOI: 10.1097/CCM.1090b1013e31827c31803ac.
Conflict of Interest:
None declared
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Conflict of Interest:
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