Head vs. Heart: The ethics of organ donation
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Transplant medicine is an ever-growing speciality, with the number of successful organ donations often increasing year on year. Despite this, the gap between organ donors and those waiting for a transplant remains a major concern. In the US, UNOS (United Network for Organ Sharing) reports that almost 7000 candidates died in 2016 while on the waiting list. There is a similar story in the UK, with 411 people dying while waiting for a transplant in 2017. However, recent attempts to boost potential donor numbers through legislation changes emphasises that organ donation remains a vital lifeline for many critically ill patients.
While conversations about organ donation continue to be impactful at a societal level, healthcare professionals have to navigate its complexities at a uniquely clinical level. Currently post-mortem organ donation falls into two broad categories, based on the criteria for death determination. When procurement occurs after death determination using neurologic criteria, it is termed ‘donation after brain death’ (DBD). When procurement follows death determined using absence of respiration, circulation, and responsiveness, it is termed ‘donation after cardiac death’ (DCD). Both DBD and DCD contain legal, moral, and ethical issues that must be considered during all stages of donation – from procurement to final transplantation.
DCD can be divided into two further categories: controlled and uncontrolled. Controlled DCD refers to a donation following a death that is anticipated but has not yet occurred, and follows a planned removal of life-sustaining treatment. Uncontrolled DCD refers to donation after a death that occurred suddenly and was not anticipated, typically an unexpected cardiac arrest in an emergency department or ICU. Controlled DCD often raises ethical questions around the provision of end-of-life care. For example, not every hospital allows the family to be present for extubation and/or for declaration of death, as is standard for end-of-life care outside the operating room. Professional and ethical bodies also strongly support the position that controlled DCD only be raised after the decision has been made to withdraw support. There is concern that, with the growing need for organs globally, this important protocol will not be adhered to.
DBD is a common form of procurement, and brain death itself has been the subject of debate and controversy since it was first described in the mid-1950s. Although the concept of brain death has become generally accepted in the medical community, and there are various neurological criteria that must be met before death is determined, its critics argue that the tests may be insufficient, and report patients that have “recovered” after a final diagnosis. It can be difficult for both families and clinicians to understand a person as deceased, when they essentially resemble other (living) patients in the ICU. Their chests rise and fall with each ventilator-assisted breath, and a regular tracing appears on the ECG monitor.
Organ donation can offer great hope, such as enabling a terminally ill patient to return to good health, but it also can be incredibly challenging for healthcare workers and patients alike. It is important to fully realise the wide-ranging complexities associated with end-of-life-care and transplant medicine in order to facilitate a compassionate and adaptable working environment.
This article is based on a chapter from Ethics in Palliative Care: A Complete Guide by Robert C. Macauley