By Deepa Malaiyandi, MD
From ECMO to assisted dying, the options for end-of-life care truly span the spectrum of therapeutic intensity. In the age of autonomy, global perspectives from all along this spectrum contribute to medical, ethical and legal opinions of death, dying and organ donation.
The dead donor rule (DDR), which has been an accepted ethical norm since the dawn of transplant medicine, has been interpreted both as a requirement for donors to be dead and/or a prohibition against killing through procurement. The essential goal of the DDR is to prevent the unethical removal of organs from vulnerable individuals.
By the mid-20th century, mechanical ventilation could maintain individuals with no brain or brain stem function. With these advances came the promise of heart transplantation. However, the idea of removing a person’s heart provoked a fear that unconscious patients with a poor prognosis would be killed, in violation of the DDR to harvest this highly valued organ. Both because of these advances and in light of the fear of violating the DDR, a legal standard for determining death based on neurologic criteria was created.
Now, nearly three-quarters of a century after the creation of the DDR, we find ourselves in a familiar place. How do we interpret and apply the DDR in todays’ technologically advanced and socially progressive society? Do newer organ donation and procurement practices comply with the DDR? If a patient is determined to be dead by circulatory criteria and circulation is restarted with ECMO or cold perfusion fluid to improve organ quality, is that patient still dead? Do cold perfusion fluids slow neuronal death to the point that a “hands-off” time of two to five minutes is inadequate to comply with the DDR? Can assisted dying be coupled with organ donation without violating the intent of the DDR? The following three articles address these issues.
Dalle Ave AL and Bernat JL. Donation after brain circulation determination of death. BMC Medical Ethics. 2017. 18:15
This article proposes that the time has come to redefine the donation by circulatory death determination (DCDD) criteria as donation after brain circulation determination of death (DBCDD) to better satisfy the DDR. The authors feel that the advent of the term DBCDD is warranted for advanced technologies, such as ECMO, to be utilized in dead donors without prompting the question of whether or not these donors are still dead. Just as ventilators isolated the function of the lungs, so, too, has ECMO uncoupled the hearts’ circulatory function from brain perfusion.
The proposed “brain circulation determination of death” states, “when systemic circulation ceases, the criterion of death is the permanent cessation of brain circulation. When organ donation is conducted, we call it donation after brain circulation determination of death or DBCDD.”
By rephrasing existing terminology and adhering to the appropriate hands-off time, resuming systemic circulation by means of E-CPR, ECMO or cold perfusion fluids would not negate death declaration as long as cerebral circulation is excluded by means of aortic clamp or balloon.
This new definition of death would simplify the process of organ donation, though there is one important limitation. At this time, there is no test that is able to accurately confirm that cerebral circulation has been completely excluded and that no trace residual cerebral flow exists. Until an accurate test to do this has been developed, any technology that restarts systemic circulation would violate the DDR.
Omelianchuk A. How (not) to think of the “dead-donor” rule. Theor Med Bioeth. 2018. 39:1-25.
This article re-explores the original intent of the DDR and how it is applied today. The author states that the “death requirement” is merely the operational result of a precautionary approach to maintaining compliance with the “do not kill rule,” which he describes as the moral core of the DDR. He argues that the “do not kill rule” is less restrictive as it allows for vital organ procurement in cases where surgery is causally unrelated to death. He makes the case that focusing on when it is acceptable to remove vital organs would provide more useful answers than continuing to debate the criteria defining the precise moment when death has occurred. While this article posits that it is never acceptable to kill, changing societal views regarding assisted dying may help move this discussion forward as exemplified by the next article.
van Dijk G, van Bruchem-Visser R, de Beaufort I. Organ donation after euthanasia, morally acceptable under strict procedural safeguards. Clinical Transplantation. 2018. 32:e13294.
This case report provides an example of how organ donation can be combined with voluntary euthanasia (ODE) in a just and ethical way. In 2015, a middle-aged gentleman in the Netherlands underwent assisted dying five years after a stroke left him dependent for all activities of daily living. Unlike the U.S. Death with Dignity Act, the Netherlands, Luxemburg, Belgium and Canada do not require a prognosis of less than six months in order to qualify for assisted suicide. The patient felt that his life consisted of insurmountable suffering and was devoid of both quality and dignity. He requested assistance with dying and the opportunity to donate his organs. It was the first such request encountered by his medical team. The article describes the process they followed to ensure that the desire to donate was distinct from the intent to die. Patients with progression of severely debilitating neurologic disorders, such as end stage MS or ALS, are often cited as potential candidates for ODE, but the rarity of these disease processes would contribute little to the growing need. This case of an individual with ischemic stroke, a common disease worldwide, suggests that ODE represents a potential for a sizable source of donor organs where voluntary euthanasia is practiced. More importantly, it demonstrates how ODE can satisfy the DDR and combine respect for persons, autonomy, compassionate end-of-life care and altruism to save lives.
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