Stepping on "Various Traditional Social Taboos"

"The greatest fear the public has when it comes to organ donation is their loved one will not receive aggressive treatment and will wind up having their death hastened because of the zeal people have to get organs," said Arthur Caplan, a University of Pennsylvania bioethicist. "You create a tremendous fear on the part of the public whenever any crossing of that line takes place."
     Washington Post, September 13, 2007

The headline on the front page story in today's Washington Post is "New Zeal in Organ Procurement Raises Fears." The 1,697-word-long story, written by Rob Stein, raises the profoundly disturbing possibility that ever-more aggressive teams searching for organs are cutting a number of ethical corners.

Stein's account is very evenhanded. "Even the critics agree that most organ-donation advocates are acutely sensitive to ethical concerns, help save many lives and enable families to find solace in their losses," he writes. "But they worry that disturbing lapses may be increasingly common."

He uses one example of a "disturbing lapse" to start the story--that of Ramon Navarro. Last July prosecutors in California charged a surgeon "with trying to hasten Navarro's death, marking the first time a surgeon has faced criminal charges in a transplant case." (The surgeon's attorney denied that his client did anything to hasten Navarro's death.)

While a much more aggressive campaign to secure organs "has increased the number of organ donations," Stein writes, "some doctors and nurses say the shift has been accompanied by a discomfiting rise in both subtle and overt pressure."

I think it's fair to conclude from Stein's very thoughtful article that two factors have brought the question of improper pressure to, if not a boil, at least to a simmer. They go hand in hand.

The first is a federal campaign known as the Breakthrough Collaborative, launched by the Department of Health and Human Services, which is  "designed to boost the number of organs retrieved by the nation's 58 organ-procurement organizations, or OPOs," Stein writes. "These private, nonprofit government-authorized entities deploy nurses, social workers and other specialists to identify potential donors, obtain consent from families, and work with doctors and nurses to recover as many organs as possible."

The other factor (which is not discussed until deep into the story) is the push by organ donor advocates for a highly controversial practice known as "donation after cardiac death" (DCD.) As Stein explained in a related article written for the Post last March, "Under the procedure, surgeons are removing organs within minutes after the heart stops beating and doctors declare a patient dead. Since the 1970s, most organs have been removed only after doctors declared a patient brain dead."

With respect to the behavior of OPOs, critics point to a number of questionable practices by some organ procurement teams, according to Stein's account this morning. They include (1) pressing doctors to "declare a patient brain-dead before the appropriate tests had been done"; routinely "comb[ing] through patients' records looking for potential donors"; and (3) when interacting with loved ones, some OPO representatives are "either initially letting families assume they are part of the hospital staff or being vague, saying only that they are 'end-of-life' or 'grief' counselors."

The practice of DCD presents its own problems. "The person is not dead yet," Jerry A. Menikoff, an associate professor of law, ethics and medicine at the University of Kansas, told Stein for Stein's March story. "They are going to be dead, but we should be honest and say that we're starting to remove the organs a few minutes before they meet the legal definition of death."

How long doctors wait after the heart stops beating to pronounce the patient dead varies widely--from five minutes at some hospitals to "three minutes, others two," Stein writes. "In Denver, surgeons at Children's Hospital wait 75 seconds before starting to remove hearts from infants, to maximize the chances that the organs will be useable."

Stein quotes Gail A. Van Norman, an anesthesiologist and bioethicist at the University of Washington in Seattle, who says, "A lot of us are not particularly happy about cutting that line particularly close."

Others are less troubled. "It's an example of pushing the envelope to get more organs," Stuart J. Youngner, a bioethicist at Case Western Reserve University, told Stein. "Whenever we do that, we tend to step on various traditional social taboos."

Please send your comments to Dave Andrusko at daveandrusko@hotmail.com.