Medical ethics in action: heart donation after cardiac death
The last few posts have been about medical ethics, both practical issues and more abstract ones. A recent symposium in The New England Journal of Medicine is an excellent place for you to read and ponder a major ethical conundrum. The symposium consists of three editorials (here, here, and here), as well as a live round table discussion, which you can watch here. The editorials are brief, easy to read for non-physicians, and the video of the round table lasts 17 minutes. The issue at hand is what is called cardiac donation after cardiac death.
I’ve written before about how the demand for organs to transplant far exceeds the supply of available organs, and thus many patients waiting on a transplant list will die on a transplant list, still waiting. This is particularly the case for a small subgroup of those patients — very small children needing heart transplants. The symposium is centered around a scientific report in the same issue of the journal, in which three infants received successful heart transplants. To understand the ethical issue you need to know how organ transplantation is done.
The ethical cornerstone of the practice seems simple and obvious — an organ donor must be dead before he can donate organs. But that means we must all agree upon what “dead” is. Until several decades ago the standard definition of death was irreversible cessation of cardiac function — the heart stops and cannot be restarted. Since then we have added a definition of brain death to that — irreversible cessation of all brain function, including what we call the brain stem. Nearly all organ donors are declared dead by brain death criteria.
The infants in this case series, however, did not receive their new hearts from brain-dead persons. All three organ donors were devastated and dying, but they did not fulfill brain death criteria. Their families had made the heart-wrenching decision to withdraw life-support, a perfectly ethical decision. Once that was decided, the donors’ hearts stopped, were removed three minutes later for one patient and seventy-five seconds later for the other two, and then transplanted in the needy infants. The problem some see with this protocol is that a heart that is removed from one person and then placed in another, and which restarts there, has clearly not lost “irreversible function.”
The core issue, I think, is that when we die the organs within us die in stages, not all at once. At what point are we dead? Any line we draw is arbitrary until all our organs and the cells within them are dead. By that time, of course, they are useless to save anyone else’s life by transplantation. One of the writers in the symposium believes donation of a heart by this protocol is unethical because, by definition, the donor isn’t dead. Another writer points out the historical arbitrariness of our definition of the precise moment of death.
For myself, I participate in donation after cardiac death protocols and believe them to be ethical. But I also acknowledge the complexity of the issue. I highly recommend you watch the video round table. If you are interested in really delving into how complicated problems in medical ethics are worked out, I also recommend the brief articles. It is an emotional and difficult topic, but I know of no better way to illustrate for you how the PICU can highlight some of our most difficult ethical issues.