This paper examines some of the ethical dilemmas posed to the medical community by the practice of organ donation after cardiac death (DCD) and whether it violates any of the basic ethical principles of medicine. Cardiac death can only be declared on the basis of cardiopulmonary criteria of permanent cessation of circulatory and respiratory function and not on the basis of neurological criteria of irreversible loss of all functions of the entire brain, which is used to declare brain death. In the landmark trial of Dr. Hootan Roozrahk;Dr.
Roozrahk was charged with prescribing unnecessary and inappropriate doses of drugs, in an apparent attempt to quicken the death of a patient slated for organ donation after cardiac death. From this trial new standardization practices were drafted by Organ Procurement and Transplant Network and the United Network for Organ Sharing (OPTN/UNOS) and adopted by all 257 transplant hospitals in the United States. When deciding if organ donation after cardiac death is an ethically acceptable practice, all aspects of biology, medicine, technology, society and culture should be taken into account. The Ethics Organ Donation after Cardiac DeathOrgan donation over the past twenty years has almost more than doubled, but the fact remains that the demand of organs is still dwarfed by the supply. For about 75% of organs that are transplanted, those organs come from deceased donors.
Most recently, the highest increase in organ recovery has come from donors that have suffered cardiac death. Cardiac death is declared on the basis of cardiopulmonary criteria of permanent cessation of circulatory and respiratory function and not on the basis of neurological criteria of irreversible loss of all functions of the entire brain, used to declare brain death (Steinbrook, 2007).According to the ‘dead donor rule’ donation should not cause or quicken death, because of the way donation after cardiac death is practiced, it unavoidably raises more concerns than donation after brain death. Since cardiac death is more complex and the potential donor is not dead at the time life-sustaining measures are removed, it has caused numerous debates as to whether organ donation after cardiac death is an ethically responsible option for retrieval of organs (Institute of Medicine, 2006).
Since the early 1990’s, a new surge in organ donation after cardiac death has occurred. In these cases organs are removed from patients that typically have irreversible and devastating brain or high spinal cord damage, who are on a ventilator. Even though these patients may be very close to death and any further treatment would be unsuccessful in bringing the patient back into consciousness, they are not dead (Steinbrook, 2007).In a first of its kind trial, prosecutors in southern California, charged Dr.
Hootan Roozrokh in February 2008, with prescribing unnecessary and inappropriate doses of drugs, in an apparent attempt to quicken the death of a patient slated for organ donation after cardiac death. In late evening on February 3, 2006, Dr. Hottan Roozrakh flew to Sierra Vista Regional Medical Center on behalf of the Bay Area organ-procurement team to harvest Ruben Navarro’s organs who just days before had suffered massive cardiac and respiratory arrest and had been diagnosed with irreversible brain damage.At this time the decision was made by Ruben’s mother to remove him from life support and donate his organs (Smolowe, 2008). But according to police interviews with a nurse that was present during the procedure, Dr. Roozrakh was in the operating room during the removal of the ventilator; violating protocol for organ removal after cardiac death.
Once removed from the ventilator, in an effort to minimize any suffering Ruben may have had, Dr. Roozrakh ordered several doses of morphine and Ativan.In most cases, the patient will cease to have a heart beat after the termination of life-support, but with Ruben his heart did not immediately stop. In fact, it was not until eight hours later when Ruben’s heart finally gave out. Because of the length of time it ultimately took Ruben’s heat to stop beating in combination with the inexperience and lack of knowledge the Sierra Vista Regional Medical Center staff had in the procedure protocol of procurement of organs after cardiac death, felony charges were brought against Dr.
Roozrahk.At the end of the trial, Dr. Roozrahk was found not guilty on all charges, but federal health officials cited Sierra Vista Regional Medical Center with not following several established protocols in the Ruben Navarro case (McKinley, 2008). Only, a year after the incident involving Ruben Navarro, did the organ-procurement organizations and transplant centers in the United States develop standardized protocols for the recovery of organs in cardiac death (Steinbrook, 2007).According to the Organ Procurement and Transplant Network and the United Network for Organ Sharing (OPTN/UNOS) there are ‘model elements’ that hospitals are required to address in their own policies.
They are: the candidate must be suitable for organ donation and in a non-recoverable and irreversible state of neurological injury requiring dependency on a ventilator but not meeting the established criteria for brain death.Informed consent for organ donation must be acquired from the appropriate persons after the decision to remove the patient from life support is reached. The patient’s end of life care is the responsibility of the patient’s primary care doctor; no member of the transplant team should be involved in the declaration of death. During the withdrawal of life support, ideally in or with the presence of family, operating room and transplant personnel should not be present or visible to the family.The hospital’s own guidelines will dictate the procedure for removal of life support. To declare cardiac death an observation period of at least two minutes must be made by declaring an irreversible cessation of circulatory and repertory functions.
If death does not occur with an hour after life support has been removed, the patient should be reassessed and a decision made as to whether to extend or stop the organ procurement process. Once death is declared, organ recovery by the transplant team should be preformed immediately.The organ procurement organization’s policy should state that no financial burden should be passed on the donor’s family (Department of Health, 20095). Even though rigorous policies have been set in place for organ donation after cardiac death controversy still remains if it is an ethical practice. Critics of organ donation after cardiac death argue that this process of increasing the availability of organs undermines societies trust in the justness of the medical community’s decision making process, thus putting at risk future organ donations (Whetstine, 2002).
Fortunately, because organ donation is so closely regulated though standardized practices that are now in place at all 257 transplant hospitals and because of The Uniform Determination of Death Act specifically state how death can be established; any and all concerns relating to the fairness and justness of the organ donation system can be removed from society (Steinbrook, 2007; Whetstine, 2002).Those that are opposed to donation after cardiac death point to the idea that death is not so much a science but as a culturally constructed time between our lives on earth and what happens to us after we leave. Family members who are given the option to donate organs from a patient, who had not been declared brain dead, may be hastening the time between the natural progression of brain death, in favor of organ donation.Death should not be only seen as a biological definition.
Understanding different cultural perspectives is key in developing policies that respect the diverse society we live in. The fact that there is no standardized wait time after cessation of the final heart beat shows that society has not clearly defined when death has occurred. Ultimately, by drawing the line in different places takes away the justness of organ procurement to the dying patient (Bowman, 2002).
