Organ Donors are Alive
#1
Finally, some common sense, and from a prestigious medical journal to boot. Thanks be to God that this ghoulish practice is finally being exposed for what it is:

<a target="_blank" href="http://content.nejm.org/cgi/content/full/359/7/674?query=TOC">LINK</a> <table class="MsoNormalTable" style="width: 100%;" border="0" cellpadding="0" cellspacing="0" width="100%"> <tbody><tr style=""> <td style="padding: 0in;"> <p class="MsoNormal" style="margin-bottom: 0.0001pt; text-align: center; line-height: normal;" align="center"><a target="_blank" href="http://content.nejm.org/"><span style="">
</span></a>
</td> </tr> </tbody></table> <p class="MsoNormal" style="margin-bottom: 0.0001pt; line-height: normal;">
<table class="MsoNormalTable" style="width: 100%;" border="0" cellpadding="0" cellspacing="0" width="100%"> <tbody><tr style=""> </tr> </tbody></table> <p class="MsoNormal" style="margin-bottom: 0.0001pt; line-height: normal;">
<table class="MsoNormalTable" style="width: 100%;" border="0" cellpadding="0" cellspacing="0" width="100%"> <tbody><tr style=""> <td style="padding: 0in; background: rgb(255, 51, 0) none repeat scroll 0% 50%; -moz-background-clip: -moz-initial; -moz-background-origin: -moz-initial; -moz-background-inline-policy: -moz-initial;" valign="top"> <p class="MsoNormal" style="margin-bottom: 0.0001pt; text-align: center; line-height: normal;" align="center"><!--[if gte vml 1]> <![endif]<!--[if !vml][img]file:///C:%5CUsers%5CKathy%5CAppData%5CLocal%5CTemp%5Cmsohtmlclip1%5C01%5Cclip_image003.gif[/img]<!--[endif]
</td> </tr> <tr style=""> <td style="padding: 0in;"> <p class="MsoNormal" style="margin-bottom: 0.0001pt; line-height: normal;">
</td> </tr> <tr style=""> <td style="padding: 0in;" align="center"><a target="_blank" href="http://content.nejm.org/">[Image: v2_title_large.gif]</a></td> </tr> <tr style=""> <td style="padding: 0in;"> <p class="MsoNormal" style="margin-bottom: 0.0001pt; line-height: normal;">
</td> </tr> </tbody></table> <p class="MsoNormal" style="border: medium none ; padding: 0in; margin-bottom: 0.0001pt; text-align: center; line-height: normal;" align="center">

<table class="MsoNormalTable" style="width: 480pt;" border="0" cellpadding="0" cellspacing="0" width="640"> <tbody><tr style=""> <td style="padding: 0in;" valign="top"> <p class="MsoNormal" style="margin-bottom: 0.0001pt; text-align: center; line-height: normal;" align="center"><!--[if gte vml 1]> <![endif]<!--[if !vml][img]file:///C:%5CUsers%5CKathy%5CAppData%5CLocal%5CTemp%5Cmsohtmlclip1%5C01%5Cclip_image005.gif[/img]<!--[endif]
<div align="center"> <table class="MsoNormalTable" style="width: 480pt;" border="0" cellpadding="0" cellspacing="0" width="640"> <tbody><tr style=""> <td style="padding: 0in;" nowrap="nowrap" valign="top">
</td> <td style="padding: 0in;" valign="top"> <div align="center"> <table class="MsoNormalTable" style="" border="0" cellpadding="0" cellspacing="0"> <tbody><tr style=""> <td style="padding: 0in;" nowrap="nowrap" valign="top"> <p class="MsoNormal" style="margin-bottom: 0.0001pt; text-align: right; line-height: normal;" align="right"><b>Volume 359:674-675
</b>
</td> <td style="padding: 0in;" nowrap="nowrap"> <p class="MsoNormal" style="margin-bottom: 0.0001pt; line-height: normal;"><!--[if gte vml 1]> <![endif]<!--[if !vml][img]file:///C:%5CUsers%5CKathy%5CAppData%5CLocal%5CTemp%5Cmsohtmlclip1%5C01%5Cclip_image006.gif[/img]<!--[endif]
</td> <td style="padding: 0in;" nowrap="nowrap" valign="top"> <p class="MsoNormal" style="margin-bottom: 0.0001pt; text-align: center; line-height: normal;" align="center"><b><a target="_blank" href="http://content.nejm.org/content/vol359/issue7/index.shtml">August 14, 2008
</a></b><a target="_blank" href="http://content.nejm.org/content/vol359/issue7/index.shtml">

</a>
</td> <td style="padding: 0in;" nowrap="nowrap"> <p class="MsoNormal" style="margin-bottom: 0.0001pt; line-height: normal;"><!--[if gte vml 1]> <![endif]<!--[if !vml]<!--[endif]
</td> <td style="padding: 0in;" nowrap="nowrap" valign="top"> <p class="MsoNormal" style="margin-bottom: 0.0001pt; line-height: normal;"><b> Number 7</b>
</td> </tr> </tbody></table> </td> <td style="padding: 0in;" nowrap="nowrap" valign="top">
</td> </tr> </tbody></table> </div> </td> </tr> </tbody></table> </div> <p class="MsoNormal" style="margin-bottom: 0.0001pt; text-align: center; line-height: normal;" align="center"><b>The Dead Donor Rule and Organ Transplantation</b>
<p class="MsoNormal" style="margin-bottom: 0.0001pt; text-align: center; line-height: normal;" align="center"><i>Robert D. Truog, M.D., and Franklin G. Miller, Ph.D. </i>In this issue of the <i>Journal,</i> Boucek et al. (pages 709–714)<sup> </sup>report on three cases of heart transplantation from infants<sup> </sup>who were pronounced dead on the basis of cardiac criteria. The<sup> </sup>three Perspective articles and a video roundtable discussion<sup> </sup>at www.nejm.org address key ethical aspects of organ donation<sup> </sup>after cardiac death. Bernat and Veatch comment on the cases<sup> </sup>described by Boucek et al.; Truog and Miller raise a fundamental<sup> </sup>question about the dead donor rule. In a related Perspective<sup> </sup>roundtable, moderator Atul Gawande, of Harvard Medical School,<sup> </sup>is joined by George Annas, of the Boston University School of<sup> </sup>Public Health; Arthur Caplan, of the University of Pennsylvania;<sup> </sup>and Robert Truog. Watch the <a target="_blank" href="http://content.nejm.org/cgi/content/full/359/7/674/DC1">roundtable
</a> online at www.nejm.org.
<p class="MsoNormal" style="line-height: normal;">Since its inception, organ transplantation has been guided by<sup> </sup>the overarching ethical requirement known as the dead donor<sup> </sup>rule, which simply states that patients must be declared dead<sup> </sup>before the removal of any vital organs for transplantation.<sup> </sup>Before the development of modern critical care, the diagnosis<sup> </sup>of death was relatively straightforward: patients were dead<sup> </sup>when they were cold, blue, and stiff. Unfortunately, organs<sup> </sup>from these traditional cadavers cannot be used for transplantation.<sup> </sup>Forty years ago, an ad hoc committee at Harvard Medical School,<sup> </sup>chaired by Henry Beecher, suggested revising the definition<sup> </sup>of death in a way that would make some patients with devastating<sup> </sup>neurologic injury suitable for organ transplantation under the<sup> </sup>dead donor rule.<a target="_blank" href="http://content.nejm.org/cgi/content/full/359/7/674?query=TOC#R1"><sup>1
</sup></a><sup> </sup>
<p class="MsoNormal" style="line-height: normal;">The concept of brain death has served us well and has been the<sup> </sup>ethical and legal justification for thousands of lifesaving<sup> </sup>donations and transplantations. Even so, there have been persistent<sup> </sup>questions about whether patients with massive brain injury,<sup> </sup>apnea, and loss of brain-stem reflexes are really dead. After<sup> </sup>all, when the injury is entirely intracranial, these patients<sup> </sup>look very much alive: they are warm and pink; they digest and<sup> </sup>metabolize food, excrete waste, undergo sexual maturation, and<sup> </sup>can even reproduce. To a casual observer, they look just like<sup> </sup>patients who are receiving long-term artificial ventilation<sup> </sup>and are asleep.<sup> </sup>
<p class="MsoNormal" style="line-height: normal;">The arguments about why these patients should be considered<sup> </sup>dead have never been fully convincing. The definition of brain<sup> </sup>death requires the complete absence of all functions of the<sup> </sup>entire brain, yet many of these patients retain essential neurologic<sup> </sup>function, such as the regulated secretion of hypothalamic hormones.<a target="_blank" href="http://content.nejm.org/cgi/content/full/359/7/674?query=TOC#R2"><sup>2
</sup></a><sup> </sup>Some have argued that these patients are dead because they are<sup> </sup>permanently unconscious (which is true), but if this is the<sup> </sup>justification, then patients in a permanent vegetative state,<sup> </sup>who breathe spontaneously, should also be diagnosed as dead,<sup> </sup>a characterization that most regard as implausible. Others have<sup> </sup>claimed that "brain-dead" patients are dead because their brain<sup> </sup>damage has led to the "permanent cessation of functioning of<sup> </sup>the organism as a whole."<a target="_blank" href="http://content.nejm.org/cgi/content/full/359/7/674?query=TOC#R3"><sup>3
</sup></a> Yet evidence shows that if these<sup> </sup>patients are supported beyond the acute phase of their illness<sup> </sup>(which is rarely done), they can survive for many years.<a target="_blank" href="http://content.nejm.org/cgi/content/full/359/7/674?query=TOC#R4"><sup>4
</sup></a> The<sup> </sup>uncomfortable conclusion to be drawn from this literature is<sup> </sup>that although it may be perfectly ethical to remove vital organs<sup> </sup>for transplantation from patients who satisfy the diagnostic<sup> </sup>criteria of brain death, the reason it is ethical cannot be<sup> </sup>that we are convinced they are really dead.<sup> </sup>
<p class="MsoNormal" style="line-height: normal;">Over the past few years, our reliance on the dead donor rule<sup> </sup>has again been challenged, this time by the emergence of donation<sup> </sup>after cardiac death as a pathway for organ donation. Under protocols<sup> </sup>for this type of donation, patients who are not brain-dead but<sup> </sup>who are undergoing an orchestrated withdrawal of life support<sup> </sup>are monitored for the onset of cardiac arrest. In typical protocols,<sup> </sup>patients are pronounced dead 2 to 5 minutes after the onset<sup> </sup>of asystole (on the basis of cardiac criteria), and their organs<sup> </sup>are expeditiously removed for transplantation. Although everyone<sup> </sup>agrees that many patients could be resuscitated after an interval<sup> </sup>of 2 to 5 minutes, advocates of this approach to donation say<sup> </sup>that these patients can be regarded as dead because a decision<sup> </sup>has been made not to attempt resuscitation.<sup> </sup>
<p class="MsoNormal" style="line-height: normal;">This understanding of death is problematic at several levels.<sup> </sup>The cardiac definition of death requires the irreversible cessation<sup> </sup>of cardiac function. Whereas the common understanding of "irreversible"<sup> </sup>is "impossible to reverse," in this context irreversibility<sup> </sup>is interpreted as the result of a choice not to reverse. This<sup> </sup>interpretation creates the paradox that the hearts of patients<sup> </sup>who have been declared dead on the basis of the irreversible<sup> </sup>loss of cardiac function have in fact been transplanted and<sup> </sup>have successfully functioned in the chest of another. Again,<sup> </sup>although it may be ethical to remove vital organs from these<sup> </sup>patients, we believe that the reason it is ethical cannot convincingly<sup> </sup>be that the donors are dead.<sup> </sup>
<p class="MsoNormal" style="line-height: normal;">At the dawn of organ transplantation, the dead donor rule was<sup> </sup>accepted as an ethical premise that did not require reflection<sup> </sup>or justification, presumably because it appeared to be necessary<sup> </sup>as a safeguard against the unethical removal of vital organs<sup> </sup>from vulnerable patients. In retrospect, however, it appears<sup> </sup>that reliance on the dead donor rule has greater potential to<sup> </sup>undermine trust in the transplantation enterprise than to preserve<sup> </sup>it. At worst, this ongoing reliance suggests that the medical<sup> </sup>profession has been gerrymandering the definition of death to<sup> </sup>carefully conform with conditions that are most favorable for<sup> </sup>transplantation. At best, the rule has provided misleading ethical<sup> </sup>cover that cannot withstand careful scrutiny. A better approach<sup> </sup>to procuring vital organs while protecting vulnerable patients<sup> </sup>against abuse would be to emphasize the importance of obtaining<sup> </sup>valid informed consent for organ donation from patients or surrogates<sup> </sup>before the withdrawal of life-sustaining treatment in situations<sup> </sup>of devastating and irreversible neurologic injury.<a target="_blank" href="http://content.nejm.org/cgi/content/full/359/7/674?query=TOC#R5"><sup>5
</sup></a><sup> </sup>
<p class="MsoNormal" style="line-height: normal;">What has been the cost of our continued dependence on the dead<sup> </sup>donor rule? In addition to fostering conceptual confusion about<sup> </sup>the ethical requirements of organ donation, it has compromised<sup> </sup>the goals of transplantation for donors and recipients alike.<sup> </sup>By requiring organ donors to meet flawed definitions of death<sup> </sup>before organ procurement, we deny patients and their families<sup> </sup>the opportunity to donate organs if the patients have devastating,<sup> </sup>irreversible neurologic injuries that do not meet the technical<sup> </sup>requirements of brain death. In the case of donation after cardiac<sup> </sup>death, the ischemia time inherent in the donation process necessarily<sup> </sup>diminishes the value of the transplants by reducing both the<sup> </sup>quantity and the quality of the organs that can be procured.<sup> </sup>
<p class="MsoNormal" style="line-height: normal;">Many will object that transplantation surgeons cannot legally<sup> </sup>or ethically remove vital organs from patients before death,<sup> </sup>since doing so will cause their death. However, if the critiques<sup> </sup>of the current methods of diagnosing death are correct, then<sup> </sup>such actions are already taking place on a routine basis. Moreover,<sup> </sup>in modern intensive care units, ethically justified decisions<sup> </sup>and actions of physicians are already the proximate cause of<sup> </sup>death for many patients — for instance, when mechanical<sup> </sup>ventilation is withdrawn. Whether death occurs as the result<sup> </sup>of ventilator withdrawal or organ procurement, the ethically<sup> </sup>relevant precondition is valid consent by the patient or surrogate.<sup> </sup>With such consent, there is no harm or wrong done in retrieving<sup> </sup>vital organs before death, provided that anesthesia is administered.<sup> </sup>With proper safeguards, no patient will die from vital organ<sup> </sup>donation who would not otherwise die as a result of the withdrawal<sup> </sup>of life support. Finally, surveys suggest that issues related<sup> </sup>to respect for valid consent and the degree of neurologic injury<sup> </sup>may be more important to the public than concerns about whether<sup> </sup>the patient is already dead at the time the organs are removed.<sup> </sup>
<p class="MsoNormal" style="line-height: normal;">In sum, as an ethical requirement for organ donation, the dead<sup> </sup>donor rule has required unnecessary and unsupportable revisions<sup> </sup>of the definition of death. Characterizing the ethical requirements<sup> </sup>of organ donation in terms of valid informed consent under the<sup> </sup>limited conditions of devastating neurologic injury is ethically<sup> </sup>sound, optimally respects the desires of those who wish to donate<sup> </sup>organs, and has the potential to maximize the number and quality<sup> </sup>of organs available to those in need.<sup> </sup>
<p class="MsoNormal" style="line-height: normal;">No potential conflict of interest relevant to this article was<sup> </sup>reported.<sup> </sup>
<p class="MsoNormal" style="line-height: normal;">The opinions expressed in this article are those of the authors<sup> </sup>and do not necessarily reflect the policy of the National Institutes<sup> </sup>of Health, the Public Health Service, or the Department of Health<sup> </sup>and Human Services.<sup> </sup>
<p class="MsoNormal" style="line-height: normal;">
<b>Source Information</b>
<p class="MsoNormal" style="line-height: normal;">Dr. Truog is a professor of medical ethics and anesthesia (pediatrics) in the Departments of Anesthesia and Social Medicine at Harvard Medical School and the Division of Critical Care Medicine at Children's Hospital Boston — both in Boston. Dr. Miller is a faculty member in the Department of Bioethics, National Institutes of Health, Bethesda, MD.
<p class="MsoNormal" style="line-height: normal;"><b>References</b>
<ol start="1" type="1"><li class="MsoNormal" style="line-height: normal;"><a target="_blank" name="R1"></a>A definition of irreversible coma: report of the ad hoc committee of the Harvard Medical School to examine the definition of brain death. JAMA 1968;205:337-340. <a target="_blank" href="http://content.nejm.org/cgi/external_ref?access_num=10.1001/jama.205.6.337&link_type=DOI">[CrossRef]
</a>[Medline]
<a target="_blank" name="R2"></a></li></ol> <ol start="2" type="1"><li class="MsoNormal" style="line-height: normal;">Truog RD. Is it time to abandon brain death? Hastings Cent Rep 1997;27:29-37. [ISI]
[Medline]
<a target="_blank" name="R3"></a></li></ol> <ol start="3" type="1"><li class="MsoNormal" style="line-height: normal;">Bernat JL, Culver CM, Gert B. On the definition and criterion of death. Ann Intern Med 1981;94:389-394. <a target="_blank" href="http://content.nejm.org/cgi/external_ref?access_num=10.1001/archinte.94.3.389&link_type=DOI">[CrossRef]
</a>[ISI]
[Medline]
<a target="_blank" name="R4"></a></li></ol> <ol start="4" type="1"><li class="MsoNormal" style="line-height: normal;">Shewmon DA. Chronic "brain death": meta-analysis and conceptual consequences. Neurology 1998;51:1538-1545. <a target="_blank" href="http://content.nejm.org/cgi/ijlink?linkType=ABST&journalCode=neurology&resid=51/6/1538">[Free Full Text]
</a><a target="_blank" name="R5"></a></li></ol> <ol start="5" type="1"><li class="MsoNormal" style="line-height: normal;">Miller FG, Truog RD. Rethinking the ethics of vital organ donation. Hastings Cent Rep (in press).</li></ol> <p class="MsoNormal" style="line-height: normal;"><a target="_blank" name="otherarticles"></a><b>This article has been cited by other articles:</b>
<ul type="disc"><li class="MsoNormal" style="line-height: normal;">Curfman, G. D., Morrissey, S., Drazen, J. M. (2008). Cardiac Transplantation in Infants. <i>NEJM</i> 359: 749-750 <a target="_blank" href="http://content.nejm.org/cgi/content/full/359/7/749">[Full Text]
</a> </li></ul>
S.A.G. ~ Kathy ~ Sanguine-choleric. Have fun...or else.

Adoramus te, Christe, et benedicimus tibi, quia per sanctam crucem tuam redemisti mundum.
Reply


Messages In This Thread
Organ Donors are Alive - by AdoramusTeChriste - 08-17-2008, 07:40 PM
Organ Donors are Alive - by Historian - 08-17-2008, 09:56 PM
Organ Donors are Alive - by remnant - 08-17-2008, 10:36 PM



Users browsing this thread: 1 Guest(s)