The organ transplantation community is continually on the lookout for ways to increase the organ supply.
Sometimes, unethical approaches are proposed–such as killing the cognitively devastated for their organs.
But a new proposal has potential, and I think, could be done ethically. It is called, “Uncontrolled Donation After Cardiac Death.” From the Health Affairs blog:
The general process starts with an individual who suffers a heart attack outside of the hospital setting. Cardiopulmonary resuscitation (CPR) is attempted for at least half an hour and is ultimately declared futile. The individual is then transported to a participating hospital with the continuation of chest compressions, mechanical ventilation, and IV fluids.
Upon arrival, death is declared and there is a mandatory five minute “hands- off” period. Big IV lines are put into the patient’s groin and they are hooked up to a machine that keeps blood circulating (called ECMO).
At this point in the process, the individual’s family is contacted for consent for organ donation. Even though some countries have presumed consent laws for organ donation, it is routine to contact next of kin before proceeding with procurement and to respect refusal even in the absence of express refusal of the potential donor.
The process could also include organ preservation:
In the US, it is clear both legally and ethically that consent is required before organs can be procured from an individual. However, it is not as clear as to what the consent requirements are for organ preservation. Organ preservation in uDCD requires cannulation of the femoral vessels and initiation of ECMO. This needs to be done as quickly as possible in order for organs to be viable for transplantation.
Given the need for expedient intervention, there is generally not time to obtain consent from next of kin or determine the individual’s preferences with respect to donation prior to cannulation.
One proposed theory is that there should be a dual consent process in which next of kin are asked about organ preservation directly following the individual’s death and later asked about organ donation after they have had time to process the death. This approach may not be possible in some situations.
For example, next of kin may not be immediately present when the patient dies or may be unable to make a decision about organ preservation because they are distressed. There should be alternative options for when these situations arise.
I think this could work IF the person who died had consented to donation beforehand–as indicated on his/her driver’s license.
But such proposals do not arise in a vacuum.
We have a distinct and worsening problem of trust to consider. People have noticed the increasing utilitarian bent in bioethics that values the lives of some patients over those of others, pushes medical rationing based on invidious discriminatory categories, and debases the intrinsic dignity of human life.
In such a milieu, many will not consent to being donors out of fear that the intense effort to save their lives would, shall we say, not be enthusiastically pursued.
This proposal has the potential to increase the organ supply in an ethical and life-affirming manner. But it will only work if the general healthcare system is trusted by the people it serves.
That will take a dramatic and pronounced change in the current course pursued in bioethics and among healthcare public policy architects.