Non-heart-beating organ donation: personal and institutional conflicts of interest

While procurement of organs from donors who are not "brain dead" does not appear to pose insurmountable moral obstacles, the social practice may raise questions of conflict of interest. Non-heart-beating organ donation opens the door for pressure on patients or families to forgo possibly beneficial treatment to provide organs to save others. The combined effects of non-heart-beating donation and organ shortages at major transplant centers brought about by the 1991 United Network for Organ Sharing (UNOS) local-use organ allocation policy created potential conflicts, including the fact that candidates for organs become potential donors far more frequently than previously. Hospitals with a major emphasis on transplantation have economic and academic interests that may have been hurt by the relative organ shortage. Some may view non-heart-beating organ donation as a way to restore weakened programs and thus unconsciously compromise recognition of problems associated with non-heart-beating donation.     

Procuring organs from a non-heart-beating cadaver: commentary on a case report

Procurement of organs from non-heart-beating cadaver donors raises concerns. Standards for optimal patient care during withdrawal of life-sustaining therapy are evolving and continue to be debated and studied. Consensus on specific procedures and methods has not been attained, however, and protocols for the procurement of organs from patients following the withdrawal of life-sustaining therapies may compromise the evolving standards and harm the patient and the attendant family. In addition, there is little evidence to suggest that such protocols will significantly increase the number of organs procured. "Non-heart-beating cadaver" protocols that do not give comprehensive attention to optimal patient/family care at the time of withdrawal of life-sustaining therapy ought not to be endorsed.     

Conflict of interest in the procurement of organs from cadavers following withdrawal of life support

The University of Pittsburgh policy for procuring organs from non-heart-beating cadaver donors recognizes the potential for conflicts of interest between caring for a "hopelessly ill" patient who has forgone life-sustaining treatment and caring for a potential organ donor. The policy calls for a separation between those medical personnel who care for the gravely ill patient and those involved with the care of transplant recipients. While such a separation is possible in theory, it is difficult or impossible to attain in practice. However, such a separation of duties would be unnecessary if an arbitrator were appointed to monitor the proceedings as they take place on a case-by-case basis. In this way, the biases--real or potential--of the individuals involved could be identified, and the harmful effects of the unavoidable conflicts of interest could be minimized.     

History of organ donation by patients with cardiac death

When successful solid organ transplantation was initiated almost 40 years ago, its current success rate was not anticipated. But continuous efforts were undertaken to overcome the two major obstacles to success: injury caused by interrupting nutrient supply to the organ and rejection of the implanted organ by normal host defense mechanisms. Solutions have resulted from technologic medical advances, but also from using organs from different sources. Each potential solution has raised ethical concerns and has variably resulted in societal acclaim, censure, and apathy. Transplant surgery is now well accepted, and the list of transplant candidates has grown far quicker than the availability of organs. More than 30,000 patients were awaiting organs for transplantation at the end of March 1993. While most organs came from donors declared dead by brain criteria, the increasing shortage of donated organs has prompted a reexamination of prior restrictions of donor groups. Recently, organ procurement from donors with cardiac death has been reintroduced in the United States. This practice has been mostly abandoned by the U.S. and some, though not all, other countries. Transplantation has been more successful using organs procured from heart-beating, "brain dead" cadavers than organs from non-heart-beating cadavers. However, recent advances have led to success rates with organs from non-heart-beating donors that may portend large increases in organ donation and procurement from this source.     

Non-heart-beating organ donation: a reply to Campbell and Weber.

In the preceding commentary, Campbell and Weber raise two valid and important issues concerning non-heart-beating organ donation (NHBOD). First, because the procedure links withdrawal of life support and the potential for subsequent organ donation, the desire for organs may create a situation in which care of the dying individual has relatively less importance and the dying may receive suboptimal care. Second, even if concerns about care of the dying were dealt with adequately, there will not be enough non-heart-beating donors to significantly decrease the organ shortage that exists, making the procedure not worth the risk. We agree that attention to the important details of caring for the dying are, and must be, the primary concern of all health care workers caring for those individuals. Ensuring the patients' comfort, dignity, and autonomy, and providing for family and social support are the mainstays of this care. All policies for NHBOD should clearly support and mandate these concepts. Regarding the second concern, we agree that NHBOD is currently rare; however, evidence is increasing that this type of donation has great potential. Continued growth of the practice in this country will depend largely on public acceptance, which we believe will be directly influenced by whether the public perceives that care of the dying is not compromised by this procedure.     

Perish and publish: non-heart-beating organ donation and unduly iterative ethical review

In the expanding repertoire of practices designed to increase the supply of organs for transplantation, non-heart-beating cadaver organ donation has generated an ongoing debate in the literature. The continuing stream of articles is disquieting in part because it documents a troubling "trial-and-error ethics" approach to the formulation of organ procurement policy, and because it raises serious questions about the reasons that the development of this policy is being mediated by published communication. In the light of concerns about the implicit support and credibility that professional publications give to organ procurement policies, restraint in publishing articles about non-heart-beating organ donation as well as in devising such policies is strongly advocated.     

The telltale heart: public policy and the utilization of non-heart-beating donors

The transplant community has quietly initiated efforts to expand the current pool of cadaver organ donors to include those who are dead by cardiac criteria but cannot be pronounced dead using brain-based criteria. There are many reasons for concern about "policy creep" regarding who is defined as a potential organ donor. These reasons include loss of trust in the transplant community because of confusion over the protocols to be used, blurring the line between life and death, stress on family members, and burdens imposed on health care providers when a long-standing policy regarding who can serve as a cadaver organ donor is unilaterally changed. While these concerns are not sufficient reason for abandoning efforts to broaden existing eligibility standards for cadaver donation, they are sufficient reasons for the transplant community to desist in changing existing standards without widespread professional and public discussion.     

Non-heart-beating donors of organs: are the distinctions between direct and indirect effects & between killing and letting die relevant and helpful?

This essay analyzes the principle of double effect and, to a lesser extent, the distinction between killing and letting die in the context of the Pittsburgh protocol for managing patients who may become non-heart-beating donors or sources of organs for transplantation. It notes several ambiguities and unresolved issues in the Pittsburgh protocol but concludes that neither the principle of double effect nor the distinction between killing and letting die (with the prohibition of the former and the allowance of the latter under some circumstances) erects insurmountable obstacles to the implementation of the protocol. Nevertheless, the requirement of the principle of double effect that the intended good effects outweigh the unintended side effects necessitates careful attention to the probable overall impact of the proposed policy on organ procurement, particularly because public mistrust plays such a significant role in limiting the number of organ donations.     

An "opting in" paradigm for kidney transplantation

Almost 60,000 people in the United States with end stage renal disease are waiting for a kidney transplant. Because of the scarcity of organs from deceased donors live kidney donors have become a critical source of organs; in 2001, for the first time in recent decades, the number of live kidney donors exceeded the number of deceased donors. The paradigm used to justify putting live kidney donors at risk includes the low risk to the donor, the favorable risk-benefit ratio, the psychological benefits to the donor, altruism, and autonomy coupled with informed consent; because each of these arguments is flawed we need to lessen our dependence on live kidney donors and increase the number of organs retrieved from deceased donors. An "opting in" paradigm would reward people who agree to donate their kidneys after they die with allocation preference should they need a kidney while they are alive. An "opting in" program should increase the number of kidneys available for transplantation and eliminate the morally troubling problem of"organ takers"who would accept a kidney if they needed one but have made no provision to be an organ donor themselves. People who "opt in" would preferentially get an organ should they need one at the minimal cost of donating their kidneys when they have no use for them; it is a form of organ insurance a rational person should find extremely attractive. An "opting in" paradigm would simulate the reciprocal altruism observed in nature that sociobiologists believe enhances group survival. Although the allocation of organs based on factors other than need might be morally troubling, an "opting in" paradigm compares favorably with other methods of obtaining more organs and accepting the status quo of extreme organ scarcity. Although an "opting in" policy would be based on enlightened self-interest, by demonstrating the utilitarian value of mutual assistance, it would promote the attitude that self-interest sometimes requires the perception that we are all part of a common humanity.     

Development of the University of Pittsburgh Medical Center policy for the care of terminally ill patients who may become organ donors after death following the removal of life support

In the mid 1980s it was apparent that the need for organ donors exceeded those willing to donate. Some University of Pittsburgh Medical Center (UPMC) physicians initiated discussion of possible new organ donor categories including individuals pronounced dead by traditional cardiac criteria. However, they reached no conclusion and dropped the discussion. In the late 1980s and the early 1990s, four cases arose in which dying patients or their families requested organ donation following the elective removal of mechanical ventilation. Controversy surrounding these cases precipitated open discussion of the use of organ donors pronounced dead on the basis of cardiac criteria. Prolonged deliberations by many committees in the absence of precedent ultimately resulted in what is, to our knowledge, the country's first policy for organ donation following elective removal of life support. The policy is intricate and conservative. Care was taken to include as many interested parties as possible in an effort to achieve representative and broad based support. This paper describes the development of the UPMC policy on non-heart-beating organ donation.     

"An ignoble form of cannibalism": reflections on the Pittsburgh protocol for procuring organs from non-heart-beating cadavers

The author discusses the ways in which she finds the University of Pittsburgh Medical Center protocol for procuring organs from "non-heart-beating cadaver donors" medically and morally questionable and irreverent. She also identifies some of the factors that contributed to the composition of this troubling protocol, and to its institutional approval.     

How to Reverse the Organ Shortage

Thousands of lives are lost each year because of a lack of organs available for transplant, but currently, in the UK and many other countries, organs cannot be taken from a deceased donor without explicit consent from the donor or his or her relatives. Switching to an ‘opt‐out’ (or ‘presumed consent’) system for organ donation could substantially increase the supply of organs, and save many lives. However, it has been argued in some quarters that there are serious ethical objections to an opt‐out policy, and that it would be better to adopt a different policy known as the ‘presumptive approach’, that requires explicit consent while also attempting to sway the choices of potential donors and family in the direction of donating, using various persuasive techniques. This article shows how reflection on the impact of a well‐known cognitive bias known as ‘status quo bias’ can explain (i) why moving from the status quo to an opt‐out policy might be effective in increasing organ availability, even without impinging on anyone's autonomous choices, (ii) why we might have overestimated the strength of the objections to an opt‐out policy, and (iii) why the presumptive approach is morally objectionable, while an opt‐out policy is not.     

The Institute of Medicine's report on non-heart-beating organ transplantation

In December 1997, the Institute of Medicine (IOM) released a report on medical and ethical issues in the procurement of non-heart-beating organ donors. This report had been requested in May 1997 by the Department of Health and Human Services (DHHS). We will here describe the genesis of the IOM report, the medical and moral concerns that led the DHHS to sponsor it, the process of producing it, and its conclusions. The analyses, findings, and recommendations of the report are also reviewed, in particular the central issues that led to suggestions for policy changes.     

SELLING SPARE PARTS AND RENTING USEFUL SPACES

In the late summer and fall of 1983 articles appeared in such publications as the New York Times, Fortune Magazine , and Science News telling of attempts to set up an agency for the selling of kidneys from living donors. The shortage of organs, especially of kidneys where the transplantation success has increased quite markedly over the past decade, has become something of a crisis. A situation of increased need and inadequate supply is also becoming a problem for such substances as human bone marrow, for use in the treatment of immune and blood diseases, and large quantities of human plasma for use by hemophiliacs. Obtaining a kidney for a patient in renal failure was difficult in the past because adequate matching is likely only between very close relatives. Now with new immunosuppressant drugs such as cyclosporine, close matches have become less important. Cadaver organs or marrow from unrelated living donors can be used with far greater success. The supply problem is still immense and the literature is filled with suggestions for appropriate and efficient means of organ acquisition. One of the latest suggestions involves a system of salvaging based on implied consent of deceased donors. The organs would be taken without asking directly for permission from family. The relatives would have the right to object to the organ removal, but unless they did so, the organ would be taken when needed.     

An “Opting In” Paradigm for Kidney Transplantation

Almost 60,000 people in the United States with end stage renal disease are waiting for a kidney transplant. Because of the scarcity of organs from deceased donors live kidney donors have become a critical source of organs; in 2001, for the first time in recent decades, the number of live kidney donors exceeded the number of deceased donors. The paradigm used to justify putting live kidney donors at risk includes the low risk to the donor, the favorable risk-benefit ratio, the psychological benefits to the donor, altruism, and autonomy coupled with informed consent; because each of these arguments is flawed we need to lessen our dependence on live kidney donors and increase the number of organs retrieved from deceased donors.

An “opting in” paradigm would reward people who agree to donate their kidneys after they die with allocation preference should they need a kidney while they are alive. An “opting in” program should increase the number of kidneys available for transplantation and eliminate the morally troubling problem of “organ takers” who would accept a kidney if they needed one but have made no provision to be an organ donor themselves. People who “opt in” would preferentially get an organ should they need one at the minimal cost of donating their kidneys when they have no use for them; it is a form of organ insurance a rational person should find extremely attractive.

An “opting in” paradigm would simulate the reciprocal altruism observed in nature that sociobiologists believe enhances group survival. Although the allocation of organs based on factors other than need might be morally troubling, an “opting in” paradigm compares favorably with other methods of obtaining more organs and accepting the status quo of extreme organ scarcity. Although an “opting in” policy would be based on enlightened self-interest, by demonstrating the utilitarian value of mutual assistance, it would promote the attitude that self-interest sometimes requires the perception that we are all part of a common humanity.     

Co-constructed narratives around being “sick”: A minimalist model

The amount of physical damage may have no fixed relation to how much and in what ways a patient's life is disrupted. The authors discuss a model which addresses the bio-psycho-social complexity of a patient's illness and the narrative constructions which the patient, family members, and health care professionals influence to co-create the patient's identification with being sick. This minimalist model invites the reader to consider a variety of interrelated variable lenses through which to view the narratives around a patient's illness. Clinical case examples are used to illustrate the dominant story themes.     

Blood and organ donation: health impact,prevalence, correlates,and interventions

Abstract

Objective: Without a supply of blood, health services could not meet their clinical needs. Similarly, organs for transplantation save and transform lives. Donations are acts of generosity that are traditionally seen as altruistic, and accordingly, interventions to recruit and retain blood and organ donors have focused on altruism. We review the predictors, prevalence and correlates of these two behaviours, how effective interventions have been, and draw common themes.

Design: Narrative review.

Results: We highlight that both recipients and donors benefit, and as such neither blood nor organ donation is purely altruistic. We also highlight health problems associated with both types of donation. In evaluating interventions, we highlight that a move to an opt-out policy for organ donation may not be the simple fix it is believed to be, and propose interventions to enhance the effectiveness of an opt-in policy (e.g. social media updates). We show that incentives, text messaging, feedback and a focus on prosocial emotions (e.g. ‘warm-glow’, ‘gratitude’) may be effective interventions for both blood and organ donation. Interventions designed to reduce fainting (e.g. water pre-loading) are also effective for blood donation.

Conclusions: We conclude that affect is key to understanding both types of donation and in designing effective interventions.     

Operation Blue,ULTRA: DION--the donation inmate organ network

Presently more than 80,000 Americans await an organ transplant, while 10 to 12 people die each day because of the lack of organs. The program proposed here would allow federal inmates additional "time off" for agreeing to become living donors or to provide organs or their bodies upon death. Such a program could add 100 to 170 thousand new organ donors to the pool, with another 10 to 12 thousand added annually. If the program were applied to all state inmates, up to 4 million new donors might be added, with another 10 to 13 thousand added annually. Given the extreme need for more organ donors and the need for more living donors, the current National Transplant Act of 1984 and the Uniform Anatomical Gift Act must be amended, while still retaining control of donation procedures.