Thursday, August 14, 2008

Controversial Infant Heart Transplant Redefines Death

Surgeons in Denver are happily announcing a major break-through in infant cardiac transplants: using hearts from infants that have died of cardiac-related deaths. According to the Wall Street Journal,
Until now, it was thought that hearts from those donors were too badly damaged to be transplanted successfully. Only hearts from donors who were brain-dead -- and whose hearts were still functioning after they were declared dead -- have been considered suitable for transplant.

To make the donors' hearts more viable, doctors at Children's Hospital in Denver altered the standards for declaring the patients dead... The Denver researchers narrowed to as little as 75 seconds the time between when the donor was pronounced dead and when the heart was harvested. Current guidelines call for waiting up to five minutes as a way of making certain that the heart does not start beating again on its own. But removing the heart earlier increases the odds of a successful transplant since it limits the damage caused by a lack of oxygen to the organ.

Most professional medical types I know, be they bioethicists, doctors, nurses, etc, agree that there are significant and severe problems with how transplants are handled in this country, and that we need to do something to increase the number of available organs. Many people support Robert Veatch's suggestion that death not be whole-brain death but higher-brain death, opening up a much larger market for available organs; given that he's been advocating this for 35 years, it's not surprising that he's the bioethicist commenting on the NEJM article. Veatch questions whether removal of the heart after such a short period of time is even legal, saying
"If a heart is restarted, the person from whom it was taken cannot have been dead according to cardiac criteria... Removing organs from a patient whose heart not only can be restarted, but also has been or will be restarted in another body, is ending a life by organ removal."
While the law is certainly something to consider, I agree with a former professor of mine who said that the law should be known and acknowledged, but not actually influence consideration of whether or not a practice is ethical.

And so, is it ethical? In the case of the infants who died, the parents had opted to withhold or withdraw life support; all of the infants had severe neurological injuries but were not considered brain dead. So in this very particular, structured situation, parents had agreed to allow their severely injured infants to die - so removing the heart (almost) immediately after cessation doesn't appear to be terribly problematic; even if the heart did restart on its own, they would just allow it to stop again. There is no effort at saving, rather a withdrawal of treatment and then immediate reaction to the intended end result. And I can understand parents wanting to have their child's death mean something positive for someone else; a chance for a bit of their child to live on, a chance for someone else's child to live.

But I worry. I worry about the people who fear that because they are organ donors, they won't be treated the same, that they will be allowed to die so that they can be harvested - people who buy into the very utilitarian idea that one person dying to save many is okay, and that doctors do such calculus on a daily basis. I worry about over-eager doctors realizing that an infant or child will die, and being less willing to perform life-saving medical interventions because they realize it's futile in the long-term, even if it might buy slightly more time in the short term.

Mostly, though, I worry about a redefinition of death that is happening not via committee or discussion, but action. It smacks of asking forgiveness after acting, rather than asking permission. (I should clarify that I am certain the doctors involved followed their ethics and IRB committee's to the letter, and mean more general community discussion.) It seems like an on-the-fly redefinition that actually moves away from the way the discussion was moving - towards refining what it means to be brain dead - and back towards a much more traditional and potentially troubling definition of what it means to die.

-Kelly Hills (who really does remember how to use this thing, honest...)

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