Recovery of transplantable organs after cardiac or circulatory death: the end justifying the means.

To the Editor: DuBois and DeVita (1) argue that every health policy group or professional association that has studied donation after cardiac or circulatory death (DCD) has come out in favor of the procedure. They should also inform readers that the different study groups—including the Institute of Medicine (IOM)—shared medical and ethics advisors charged with DCD implementation in the United States and therefore have consistently reached the same favorable conclusions. The IOM reports provided the pivotal thrust for legal, ethical, and medical justification for DCD (1). Federal regulations were introduced to enforce DCD in U.S. hospitals (2, 3). In September 2006, the President’s Council on Bioethics appointed an independent group to reanalyze and provide comprehensive and balanced interpretation of the DCD issues (4). The Council paper reached conclusions different from those of DuBois and DeVita (1). The Council noted conflicting evidence for the original assumptions for DCD and expressed ethical, legal, and moral uncertainty of the acceptability of DCD in the medical community and society at large. First assumption: Organ procurement is not the act causing the donor’s death (i.e., “the dead donor rule”). Dubois and DeVita claimed that “those concerned that the patient may not be dead may be uninformed of the near consensus in the literature on death determination” (1). The IOM endorsement of 5 mins of loss of cardiorespiratory activity for DCD death criteria was based on incomplete literature analysis (5). The DCD death criteria did not fulfill the irreversibility requirement for the Uniform Determination of Death Act (5). The IOM overlooked delayed spontaneous autoresuscitation with neurologic recovery in humans (called the Lazarus phenomenon) even though the Maastricht DCD protocol (University of Zurich, Switzerland) had acknowledged that phenomenon and required 10 mins after death before organ procurement (5–8). Also, the IOM expanded DCD to neurologically intact individuals after cardiorespiratory death (1, 9). Artificial circulatory and ventilatory support performed upon death to maintain organ viability for procurement could initiate spontaneous cardiac and neurologic activities and occasionally survival to discharge from hospital (5). In the DCD donors, reanimation or return of life would be actively suppressed by mechanical and pharmacologic interventions during the procurement process (10). The legal importance of being dead during the procurement process has been emphasized so that DCD would not become an act of “homicide” (5). Second assumption: The act of donation does not influence the donor’s medical or end-of-life (EOL) care. The variability of EOL practice raises the possibility of conflicted decision making on medical futility within institutions with transplant programs (11). The pressure to recover transplantable organs from DCD candidates can influence healthcare professionals’ decisions on medical futility and EOL (11). The deleterious consequences of donor management critical pathways on the quality of EOL care also have been downplayed and thus misinformed donors and their families on the trade-off in DCD (4, 9). Third assumption: A person’s right to donate is congruent with respect for autonomy and protected through an informed consent. Organ procurement organizations or affiliates are the designated entities to obtain consent; they also have administrative and financial interests to increase organ recovery rate (2). The organ procurement organizations’ conflict of interest and self-serving bias become apparent as they obtain donation consent, reinforcing the motivation to consent, while avoiding the discussion on the trade-off in EOL care (12). The information imbalance invalidates the notion that donation consent is truly based on complete and unbiased disclosure (4). Fourth assumption: Euthanasia is not permitted for the recovery of transplantable organs. To successfully procure organs in DCD, the warm ischemia time must be kept to a minimum and surgical recovery must begin within 60–90 mins after withdrawal of life support. The inaccuracy of predicting the time of death can be overcome by the use of large doses of opiates and sedatives to shorten the warm ischemia interval and fulfill the necessary criteria to begin the procurement process in a timely manner (9). Many healthcare providers who are directly involved with DCD have expressed euthanasia as a major concern and cause for moral distress toward such practice (1). In spite of the fallibility of DCD assumptions, its supporters, on behalf of the entire medical community and the public, have declared its ethical acceptability beyond any further debate because of its altruistic notion: It saves lives. The unilateral decision to invoke DCD, without widespread public awareness, impedes informed societal debate and participation (13). The absence of societal consensus can lead to a backlash re-igniting public distrust and jeopardizing the integrity of the entire process of deceased organ donation. The authors have not disclosed any affiliation or financial involvement with organizations or entities with a direct financial interest in the subject matter or materials discussed in the manuscript.