Tuesday, May 12, 2015

Death by organ donation

Nair-Collins justifies harvesting organs from living persons, in part, by attacking the legitimacy of the concept of “brain death” that is utilized in some cases to define a person as dead even though some basic life functions remain operative.

“Patients who have been accurately diagnosed with ‘brain death’ according to accepted standards are able to engage in a large variety of integrative, feedback-driven biological functions that work together to maintain the internal physiologic stability for the organism as a whole and can do so over very long periods of time,” Nair-Collins told the Register.

“This includes things like getting a fever in response to an infection, healing wounds, regulating the amount of salt and water in the blood, absorbing nutrients through the gut and generating waste products and exchanging oxygen and carbon dioxide through the lungs,” he added. “Some of these patients also show increased blood pressure and heart rate in response to surgical incision. And, finally, more dramatic examples include sexual maturation in children and gestation of a fetus in pregnant women. ... For these reasons, many scholars, including myself, have concluded that ‘brain-dead’ patients are biologically alive.”

If this scientific criticism of brain-death diagnoses is accurate, then it follows that organ removal causes the biological death of the donor.

“In other words, we do not follow the dead-donor rule in practice now,” Nair-Collins added.
But stopping the procurement of organs from “brain-dead” donors, on the grounds that they are really still alive, would exacerbate the organ shortage for transplant, he said. So, he said, doctors alternatively could “make exceptions to the dead-donor rule ... but to explicitly acknowledge that organ donation causes the biological death of these patients.”...

Truog highlighted problems of the modern definitions of brain and cardiac death, citing instances where people are pronounced dead — “dead enough for skin incision and organ procurement,” for example — and then recovered, on their own or with intervention. Such examples illustrate that the definitions of death are “convoluted” and “torture our commonsense understanding of what it means to be dead.” As well, he added, “Current practices violate the dead-donor rule — they’re perfectly ethical, but not because they’re conforming with the dead-donor rule.”

Widespread acknowledgement of these problems associated with the dead-donor rule “destroy the public’s trust in the organ-transplantation process, and this will lead to the unnecessary death of many patients. But we’ve got to come up with other ways of talking about it because we need to save the lifesaving enterprise of organ transplantation,” Truog said.

“What about procuring organs before death?” he asked. “We’ll call it DPD — donation prior to death.”

Read more: http://www.ncregister.com/daily-news/doctors-push-to-allow-death-by-organ-donation/#ixzz3ZxpFEky1


  1. Abstract
    The dead donor rule (DDR) governs procuring life-prolonging organs. They should be taken only from deceased donors. Miller and Truog have proposed abandoning the rule when patients have decided to forgo life-sustaining treatment and have consented to procurement. Organs could then be procured from living patients, thus killing them by organ procurement. This proposal warrants careful examination. They convincingly argue that current brain or circulatory death pronouncement misidentifies the biologically dead. After arguing convincingly that physicians already cause death by withdrawing treatment, they claim no bright-line differences preclude organ removal from the living. The argument fails for those who accept the double effect doctrine or other grounds for distinguishing forgoing life support from active, intentional killing. If the goal is determining irreversible loss of somatic function, they correctly label current death pronouncement a "legal fiction." Recognizing a second, public policy meaning of the term death provides grounds for maintaining the DDR without jeopardizing procurement.

    Veatch RM. Killing by organ procurement: brain-based death and legal fictions.
    J Med Philos. 2015 Jun;40(3):289-311.

  2. We seek to change the conversation about brain death by highlighting the distinction between brain death as a biological concept versus brain death as a legal status. The fact that brain death does not cohere with any biologically plausible definition of death has been known for decades. Nevertheless, this fact has not threatened the acceptance of brain death as a legal status that permits individuals to be treated as if they are dead. The similarities between “legally dead” and “legally blind” demonstrate how we may legitimately choose bright-line legal definitions that do not cohere with biological reality. Not only does this distinction bring conceptual coherence to the conversation about brain death, but it has practical implications as well. Once brain death is recognized as a social construction not grounded in biological reality, we create the possibility of changing the social construction in ways that may better serve both organ donors and recipients alike.

    See: Truog RD, Miller FG. Changing the conversation about brain death. Am J Bioeth. 2014;14(8):9-14. (also cited in 5/21/15 4:18 pm comment to Brain Death April 12, 2015)

    The scientific evidence is clear—in many cases, brain-dead patients are biologically alive. Nevertheless, there is good reason to maintain the widely accepted policy stance that those with a diagnosis of brain death are legally dead...

    This makes it reasonable to treat a patient who is brain dead as legally dead; the patient is as good as dead. Maintaining life support can be of no value for a person in an irreversible coma; nor can such a person be harmed or wronged by procuring their organs for transplantation, as long as valid consent has been obtained.

    Truog RD, Miller FG. The meaning of brain death: a different view. JAMA Intern
    Med. 2014 Aug;174(8):1215-6 (also cited in 5/22/15 9:35 am comment to Brain Death April 12, 2015)