A recent article in the Wall Street Journal by Dick Teresi says much of what I have been saying for a long time about organ transplant. Here are some relevant quotes. If you didn't know this before, wake up and pay attention now (emphasis added):
The exam for brain death is simple. A doctor splashes ice water in your ears (to look for shivering in the eyes), pokes your eyes with a cotton swab and checks for any gag reflex, among other rudimentary tests. It takes less time than a standard eye exam. Finally, in what's called the apnea test, the ventilator is disconnected to see if you can breathe unassisted. If not, you are brain dead. (Some or all of the above tests are repeated hours later for confirmation.)
Here's the weird part.
If you fail the apnea test, your respirator is reconnected. You will begin to breathe again, your heart pumping blood, keeping the organs fresh. Doctors like to say that, at this point, the "person" has departed the body. You will now be called a BHC, or beating-heart cadaver.
Still, you will have more in common biologically with a living person than with a person whose heart has stopped. Your vital organs will function, you'll maintain your body temperature, and your wounds will continue to heal. You can still get bedsores, have heart attacks and get fever from infections.
"I like my dead people cold, stiff, gray and not breathing," says Dr. Michael A. DeVita of the University of Pittsburgh Medical Center. "The brain dead are warm, pink and breathing."
But BHCs—who don't receive anesthetics during an organ harvest operation—react to the scalpel like inadequately anesthetized live patients, exhibiting high blood pressure and sometimes soaring heart rates.
And now here comes another kicker, a reference to a 1999 article that I had somehow missed until now:
In a 1999 article in the peer-reviewed journal Anesthesiology, Gail A. Van Norman, a professor of anesthesiology at the University of Washington, reported a case in which a 30-year-old patient with severe head trauma began breathing spontaneously after being declared brain dead. The physicians said that, because there was no chance of recovery, he could still be considered dead. The harvest proceeded over the objections of the anesthesiologist, who saw the donor move, and then react to the scalpel with hypertension.
And, indeed, that is exactly what Gail van Norman reports. I have now downloaded the article, available here.
The case to which Teresi alludes is the one van Norman labels "Case 2." She describes it like this:
During an educational course for anesthesiologists, a participant described a case (not independently verified by the author) in which a 30-yr-old patient was admitted to a level 1 trauma center with severe head trauma. A computed tomography scan demonstrated diffuse cerebral damage and blood in the fourth ventricle. The patient was declared brain dead by two physicians, and preparations were made to obtain vital organs for transplantation. Liver transplantation was planned for a level 1 recipient: an otherwise healthy 19-yr-old with hepatic dysfunction of unknown origin.
The on-call anesthesiologist noted that the donor was intubated but
breathing spontaneously with a tidal volume of 800 cm3 and a respiratory
rate of 20 breaths/min. When the anesthesiologist questioned
the diagnosis of brain death, one of the declaring physicians reportedly
stated that because the donor was not going to recover, he/she could
be declared brain dead, and that in any case the liver recipient would
die imminently without transplantation. Vital organ collection proceeded
over the protests of the anesthesiologist, who ohserved donor
movement and hypertension with skin incision that required treatment
with thiopental and a muscle relaxant. The liver recipient died in
another operating room of acute hemorrhage before liver collection
was complete. The liver went untransplanted.
So, if we take this report at face value, this patient was breathing on his own at the time his organs were to be taken. Over the objections of the anesthesiologist, he was directly killed by the harvesting of his organs, the argument given being that he could not recover and therefore could be regarded as dead. Oh, and the recipient really needed the organ, so there. Hint: That wasn't what "whole brain death" was supposed to be. At all. Then, because the devil never plays fair, the recipient died anyway. Murder for nothin'.
Van Norman's other two case studies are scarcely less horrifying. Here is Case 1:
An anesthesiologist questioned his colleagues on the Internet about
whether strict brain death criteria are relevant when the organ donor
is not expected to survive his or her injuries. He reported a case in
which, while caring for a multiple organ donor who had been declared
brain dead after an intracranial hemorrhage, he administered a dose of
neostigmine to treat an episode of tachycardia. The donor began to
breathe spontaneously just as the surgeon announced that the vena
cavae were ligated and the liver had been removed. Upon subsequent
review of the patient’s chart, the anesthesiologist learned that the
donor had gasped at the end of an apnea test, but a neurosurgeon had
certified that brain death criteria had been met.
Now, if I understand this correctly, this was also a case in which the patient was killed by organ removal. He began breathing spontaneously only after (oops! too late!) his liver had been completely removed.
Here is case 3, which is the only one with a better ending:
An anesthesiologist requests that his/her department review the events surrounding a potential organ collection. A young woman receiving intravenous magnesium sulfate for pregnancy-induced hypertension suffered seizures several hours after vaginal delivery. After the seizures, she was unarousable and posturing. She was intubated after intravenous administration of 4 mg pancuronium, and a computed tomography scan showed coning, diffuse edema, and occipital lobe infarcts. A neurologist determined that the patient had suffered a “catastrophic neurologic event.” Intravenous esmolol that was being infused to control blood pressure and heart rate was discontinued, and permission was obtained from the patient’s family for the patient to become a vital organ donor.
On the day of anticipated organ collection, the anesthesiologist
found that the donor had small, reactive pupils, weak corneal reflexes,
and a weak gag reflex. The estnolol infusion was reinstituted. Further
review of the patient’s chart showed the previous administration of
pancuronium, and a serum magnesium level of 5.1 mEq/l, more than
2.5 times normal several hours after the magnesium infusion had been
discontinued. After the anesthesiologist administered edrophonium 10
mg intravenously, the patient coughed, grimaced, and moved all extremities.
Vital organ collection was canceled, and after consultation with a
neurosurgeon, the patient underwent placement of an intracranial
pressure monitor. Intracranial pressure was initially 18 cm H2O and
gradually decreased with therapy to 10 cm H2O. The patient ultimately
regained consciousness and was discharged home. She was alert and
oriented but suffered from significant neurologic deficits.
Three cheers for the alert anesthesiologist. A life spared from the harvesting machine.
Van Norman observes,
Transplantation strains the traditional doctor-patient relationship by presenting a conflict of interest for doctors between the best interest of the potential donor and the needs of a potential recipient.
Indeed. Case 2 illustrates this well, does it not? What is supposed to take care of all of this is the separation between the harvesting team and the patient's doctor while the patient is still regarded as a patient. An independent doctor or set of doctors is supposed to declare death, and only then the harvesting team comes in. Well and good, if the distinction is always observed, but what if, as in case 2, the harvesting team happens to witness incontrovertible evidence that the death-declaring team royally messed up and that the patient is still a patient? See, the problem is that at that point the patient is legally not a patient. He's already been declared dead. He's out of the land of the living. He literally has no rights whatsoever.
Had the doctors in Case 1 and Case 2 reported what they knew, I don't know what would have happened. Perhaps the patients' families would have been able to sue. Perhaps not.
Getting back to Teresi in the WSJ, towards the end he gives us this cynical thought:
It is possible that not being a donor on your license can give you more bargaining power. If you leave instructions with your next of kin, they can perhaps negotiate a better deal. Instead of just the usual icewater-in-the-ears, why not ask for a blood-flow study to make sure your cortex is truly out of commission?
And how about some anesthetic?
Bargaining power? And using that bargaining power to get anesthetics? If you really thought it even remotely plausible that you would find anesthetics useful during the organ procurement process, would you want to be a donor at all? I would hope not. Teresi may be writing tongue-in-cheek, but I suspect he's serious. And that's a scary thought. "Hey, I may not really be dead during organ procurement, but I'll tell my loved ones they can use the bargaining power of my not being an organ donor on my license. They can agree to organ donation, but only after some extra tests, and only with anesthetics for the procurement. Just in case I'm really not dead." What a comforting thought.
Now can we rethink organ donation? From the ground up? In principle? Look, what are we seeing here? What we are seeing here is that one set of people--those deemed hopeless, those who are "good candidates" for being organ donors--are being viewed while they are still alive as sources for the use of another set of people--potential organ recipients. What I would suggest is that there is no way around this. No set of safeguards can change that fact, because it is fundamental to the whole business of vital organ procurement from allegedly dead donors. Vital organ procurement under those circumstances requires that the patient be assessed as a potential candidate while still alive, that a way be found to make him legally dead while maintaining oxygenation of the organs, and that the organs be taken before they are "ruined." From that, all the rest follows. This is all intrinsic to the nature of the process.
Nobody is taking hearts and livers from cadavers that are the way Dr. Michael DeVita prefers dead people to be: "Cold, stiff, gray and not breathing." It isn't happening, because it can't happen that way.
So it is no wonder that the situation we have come to is the ghoulish situation in which we presently find ourselves, as described by Teresi, van Norman, and plenty of others. And it is no wonder that the bioethicists want to take us to the next level and just go ahead and take organs from people who don't even begin to meet the criteria for whole-brain death, people who are breathing on their own but are in a so-called "persistent vegetative state."
The time has come to back up and rethink. Maybe the entire "dead"-donor organ donation industry should just be shut down. Immediately.