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"We can't imagine..."

A friend drew my attention to this article in The Atlantic, pushing for loosened criteria for organ donation. I mean, really loosened.

But I want to start by jumping to a would-be reassuring paragraph in the middle of the article. We'll find out what "such a model" means as we go along.

Some may argue that such a model could compromise doctors' care of critically ill patients....In practice, though, a donor's doctors have little connection to those involved with organ recovery, precisely so as to avoid any conflict of interest. We can't imagine a scenario in which doctors would give a patient inferior care so that her [sic] organs could be procured. (emphasis added)

They can't imagine! So let's look at their proposals.

Let's start with the proposal that makes that paragraph only somewhat of a lie.

The authors, transplant physicians Joshua Mezrich and Joseph Scalea, are much concerned with a patient they name W.B. who has ALS (Lou Gehrig's Disease). W.B. very much wants to be a live donor of one of his kidneys, but he doesn't qualify as a donor. The article is explicit about why.

In his weakened state, will he tolerate the anesthesia and surgery? Or will they hasten his death? If he survives the surgery, will he ever leave the hospital?

Now, at a minimum, the authors definitely want W.B. to be able to donate one of his kidneys as a live donor.

[W]e are not as courageous as he is. Maybe we will yet find a way to honor his dying wish--or if not his entire wish, then part of it. If we were to help W.B. donate a single kidney, and he survived, the experience might add some real value to his remaining days.

So what the authors are saying (this is just one part of what they are saying) is that W.B. should be a live kidney donor of one kidney even though the surgery might kill him and even though, in his weakened state, he is not normally considered a candidate to be a donor. But they say that they can't imagine any scenario in which a patient would get "inferior care" so that his organs could be procured! And they insist that there is complete independence between the patient's doctors and organ procurement doctors.

Yet this is all manifestly untrue in their proposal concerning W.B.! They are positively recommending that W.B. be subject to a severe risk that might kill him, so that he can be an organ donor. This would presumably require the cooperation of his own doctors. You know, his actual doctors. The ones who treat and care for him as an ALS patient and would have to deal with him after the attempt to donate a kidney. And it would mean necessarily that W.B. would be receiving inferior care as a vulnerable ALS patient, because he would be subjected to the rigors of kidney donation surgery which (they fully admit) his body is ill-equipped to tolerate.

So the statement that they "can't imagine a scenario" in which the patient would be treated in an inferior fashion so as to be a donor is a lie, even when we just consider the proposal that W.B. should be a live donor of a single kidney.

But it gets much, much, much worse.

The bulk of the article considers a much more radical proposal. Here it is, in their own words:

A more useful ethical standard [than whole-brain death] could involve the idea of "imminent death." Once a person with a terminal disease reaches a point when only extraordinary measures will delay death; when use (or continued use) of these measures is incompatible with what he considers a reasonable quality of life; and when he therefore decides to stop aggressive care, knowing that this will, in relatively short order, mean the end of his life, we might say that death is "imminent." If medical guidelines could be revised to let people facing imminent death donate vital organs under general anesthesia, we could provide patients and families a middle ground--a way of avoiding futile medical care, while also honoring life by preventing the deaths of other critically ill people. (emphasis added)

So the end-game here is to throw out the dead donor rule altogether and to take vital organs--presumably, as many as you can get--under general anesthesia from unambiguously alive people. At the end of such a "surgery" (surgical murder), the patient would have been turned into a heartless, kidney-less, lungless, etc., corpse instead of a patient.

That's the plan. That's the proposal. But Mezrich and Scalea can't imagine a scenario in which a patient would receive "inferior care so that [his] organs could be procured."

This is bald-faced. The authors are openly proposing that unambiguously living patients be directly killed by organ procurement under anesthesia, yet they "can't imagine a scenario" in which prospective donors would be given "inferior care"!! I guess this means that they'd receive the best care available, until, you know, they are taken into the operating room to be killed by having their vital organs taken out! I think that counts as "inferior care," don't you?

The article contains some useful information, and I suggest that anyone interested in the subject read it. The authors confirm what I have said before about the near impossibility of doing a "slow glide" into death in a natural fashion and still donating organs. They talk about "donation after circulatory death," also known as the Pittsburgh Protocol, in which patients are taken off a ventilator, their hearts stop naturally, and then they are rushed off to have their organs taken within just a couple of minutes. (The authors don't mention the particularly gruesome aspect of the DCD protocol, which is that oxygenation has to be started back up again for the sake of the organs, which, because of the speed with which the patient was whisked away after his heart stopped, might revive him. This possibility is prevented both by chemical and physical means.) In any event, the problem with the DCD protocol is that, the authors say again and again, the patient sometimes doesn't die fast enough. Then, because of the slow glide, the organs often have been compromised. "The donor typically needs to die within an hour or two of being taken off life support..." "Even when DCD organ donors do die in the allotted time, we tend to recover fewer organs from them..." "...to everyone's distress, he didn't die quickly enough to allow for the transplantation of his organs. This came as a particularly terrible blow to his parents,..."

The authors pass over the whole-brain-death criterion rather quickly, not stating why it doesn't help them to get as many organs as they want. The explanation is this: The whole-brain death criterion, if applied rigorously, requires evidence that the brain stem has ceased to function. Often patients on a ventilator simply do not come to meet this criterion until after their heartbeat has slowed or become irregular (or stopped), which in turn renders their organs unusable for transplant through insufficient oxygenation. The Goldilocks zone for transplant is the patient who tests positive for whole-brain death, including brain stem cessation of function, lack of blood flow to the brain, and so forth, but whose heart continues to beat strongly while ventilator support continues. This, of course, raises all kinds of questions of its own about how good such tests really are, but even aside from that, the authors make it clear that not "enough" patients are falling into that zone or even being said to fall within it. (Despite the fudging and failure of truly rigorous testing that takes place in many hospitals). Hence their desire to abandon the dead-donor rule altogether.

Such baldly heartless (pun intended) articles are useful, for they tell us where the priorities of the organ procurers really lie--getting more organs, if not quite at any cost, at an ethical cost that is unacceptable. Such articles are also useful because they call into question the positive view of organ donation as having no downside, as being an unambiguous win-win (since after all, if you're dead, you don't "need" your organs anymore, right?).

My own prediction is that the U.S. will not soon abandon the dead-donor rule, at least on paper. However, I expect the fudging of death criteria to become so rampant and so blatant as to amount to almost the same thing. We already have evidence of situations in which donors who failed to meet any death criteria, who were even breathing on their own, were treated as potential donors prior to death. And as I reported, the new UK plan to take organs from anencephalic infants after birth seems to imply some approach that will make organ procurement relatively reliable. I hate to say it, but the only approach that will do that reliably would be putting the babies on a ventilator and then fudging on the brain-stem-cessation criterion. Otherwise you're just in the same position with these babies that you would be in with any other patient. That darned dead-donor rule keeps getting in the way of reliable transplant.

My prediction is that once this fudging is sufficiently widespread either in the U.S. or in the UK, this will be revealed and we will be told that, since this is what goes on all the time anyway, it should be legally formalized by the official abandonment of the dead donor rule. Grieving families will usually cooperate because of the sociological dynamics the authors describe in the article I am discussing here--namely, the extremely positive view of vital organ donation as an unequivocally good thing.

I want to suggest that if all of this revolts you, you should probably revise that positive view and be prepared to be a maverick, both for yourself and as an advocate for any family members who are injured and for whose best interests you speak. Educate yourself so that you can speak with confidence, and then just tell the procurers unambiguously that you are uninterested in being a donor and that your relative cannot be a donor. If you have durable power of attorney for healthcare for your relative, that should give you the authority to refuse, especially if your relative was not already on the donor registry. You don't have to argue with them. Just say no and keep on saying no. That, at any rate, is what I intend to do. For now, they have to listen.

Comments (3)


After the excerpt about ALS-stricken W.B., I was thinking about the principle of double effect. I can see how one might say, "Donate the kidney, and if I don't live, I'm not that worried about it." The nature of the act would be good; the agent would intend only the good effect; the good effect could outweigh the bad effect. There may be good arguments against that, but it's at least plausible.

The immanent death argument, however, is devastating. Insane. Not even close.

But even if it were ethically justifiable (which I question) to take a single kidney from W.B., it would still constitute a counterexample to their claim that no one would be treated harmfully (in an "inferior" fashion) in order to be a donor, because obviously if W.B. weren't a donor, he wouldn't have the life-threatening surgery.

The "we can't imagine" paragraph is the kind of boilerplate that gets inserted into these types of articles all the time. It's the equivalent of soothing noises. In this case it's just particularly bizarre, because every single proposal in the article (of course most strikingly the "imminent death" proposal) directly belies their statement that they "can't imagine a scenario" in which a living patient would be harmed in order to be a donor.

I agree with your entire comment, Lydia. My consideration of double effect was independent of the risible claim that nobody would be treated in an inferior fashion to be a donor.

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