Non-Heart Beating Donors and ECMO Brief history of death and

1
Non-Heart Beating Donorsand ECMO
Brief history of death and organ donation A
hypothetical case responses Dr Bailey foster
organ donation Dr Huddle protect
the interests of patients and do no harm

• F. Amos Bailey
• Thomas S. Huddle

2

• 1960s
• Docs grappling with turning off ventilators
• Organ transplantation in its infancy donors in
  short supply
• 1968 Harvard Committee to examine the definition
  of brain death

3

• Pre-1968 death is cardiopulmonary cessation of
  function
• Post-1968 death is
• Cardiopulmonary cessation of function
• or
• Whole brain cessation of function (brainstem and
  cortex)

4

• 1970s 1980s
• Transplantation blossoms
• Many states pass helmet laws
• As time passes, brain-dead donor supply
  diminishes
• Transplant community ponders how to increase
  supply of organs possbilities
• Pvs patients
• Severe neurological injury not meeting brain
  death criteria

5
1992 Pittsburgh protocol for non-heartbeating
organ donation (NHBD)

• Patients family are approached and donation of
  organs is requested
• If family agrees patient is taken to OR and
  prepped for surgery for harvest of organs
• Life sustaining therapy such as ventilation is
  removed
• Palliative treatment for symptoms is provided

6
Non-Heart Beating Donors

• If patients dies within 60 minutes of removing
  life sustaining support the Palliative Care
  Physician Certifies death 2-5 minutes after
  asystole occurs
• The family is escorted from the room and
  immediate surgery to harvest organs is undertaken

7
Recent twist in NHBD ECMO

• Because the patient is allowed to proceed from
  dying to dead before the harvest of the organs,
  the viability of the organs for transplant is
  negatively impacted
• In some protocols, ECMO catheters are inserted
  before the removal of life sustaining therapies
  and ECMO is begun 2-5 minutes after asystole to
  maintain organ perfusion until harvest can be
  completed

8
Case

• Mr. GH in a Peruvian fit of pique due to Mr. THs
  continual blockheadedness, raps him on the head a
  little too hard and an aneurismal lesion bursts
  open. After extensive neurological testing it is
  determined that TH has severe and unremitting
  neurological injury and not just blockheadedness.
  He is not however, officially Brain Dead

9
Case

• Fortunately TH has appointed wise Dr. AB to be
  his surrogate. Dr. AB in substituted judgment
  decides to withdraw life sustaining treatment and
  allow poor dying TH to pass on to his reward.
• Dr AB also magnanimously agrees to hook TH up to
  ECMO so that his organs can be used for the
  benefit of others.
• Dr AB is detained by police

10
Why do we blame AB when there still arent enough
organs!Sources

• Organs harvested from patients who are declared
  Brain Dead and family agrees with donation
• Organs harvested from living donors
• Bone Marrow -very limited danger to donor
• Organ such as Kidney, Lung, Liver - part of the
  organ capacity of the donor is removed and
  donors risk of surgery and potential debility
  due to lost organ capacity

11
Non-Heart Beating Donorstoo few of these
patients donate

• Many patients have severe and ultimately terminal
  conditions
• Traumatic Brain Injury
• Brain Hemorrhage or Strokes
• Anoxic Brain Injury
• In which the severity of injury does not rise to
  the level of severity to meet Brain Death
  criteria, but is severe, irreversible and the
  decision is often made to withdraw life support
  and allow death to occur.

12
Non-Heart Beating Donorstoo few of these
patients donate

• If the patient does not have asystole in the 60
  minutes after removal of life-sustaining
  treatment then the patient is returned to the
  floor for continued palliative care
• Organ donation is not possible due to prolonged
  hypo-perfusion and hypoxia leading to organ
  deterioration

13
Present norms regulating organ donation are
incorrect

• Numbers of patients who might benefit from organ
  donation increases each year
• Numbers of organs available for donation has been
  fairly stable
• More patients on transplant list die waiting for
  organs

14
Proposal for extending the reach of organ donation

• Present state of medical technology ? 3 States
  (rather than 2)
• Living
• We allow donation if the donor will probably
  not be injured permanently
• Dead
• Really completely indubitable dead
• AND

15
3 States

• arrested dying
• Patients that are Brain Dead (not really dead
  but are in an arrested state of dying that we
  maintain until the organ harvest can occur)
• Irreversible neurological injury w/out brain
  death (ECMO is a way to maintain the arrested
  dying in patients who do not meet Brain Death
  criteria but are dying and will have the
  impediments that have arrested their dying
  removed)
• These patients may or may not be donors based on
  their surrogate decision makers choices

16

• Present constraint on extending organ donation is
  the dead donor rule
• Our present situation (in which significant
  numbers of patients are best characterized as in
  a state of arrested dying) has rendered the
  dead donor rule obsolete.
• Let the dying donate!!

17
Proposal

• candidacy to be an organ donor (and hence for
  continued intensive support until donation)
  should be extended to those in a state of
  arrested dying
• We already do this for those who are brain dead
• Why not for those who are irreversibly injured
  who happen not to meet brain death criteria?

18
Non-Heart Beating Donors

• Why not turn on the ECMO before removing the
  life-sustaining treatment so that the viability
  of organs for transplant is maximized?
• After all, we do not turn off Mechanical
  Ventilation for the Brain Dead patient until
  after the organ harvest is completed
• If one Brain Dead donation is ethical then ECMO
  with NHBD should be too

19
Case in light of proposal

• Rather than being detained by police, AB is feted
  by THs family, the transplant surgeons, and the
  public he goes on to win the Presidential
  Citizens Medal unfortunately the excitement of
  the ceremony leads to a fall from which he
  sustains head trauma, but he goes on to become an
  organ donor and his remains end up in the UAB
  anatomy lab. All is well.

20
Dr Baileys position

• Dead donor rule
• Potential donors must be dead before donation of
  vital organs
• Living will not be killed for their organs
• Losing the dead donor rule for organ donation
  from
• Donors must be dead
• to
• Donors may be living

21
Concepts of Life and death

• Dichotomous
• Non-overlapping
• Jointly exhaustive
• the word for Amoss 3rd state alive

22
Dr Baileys position

• Harvesting from the soon-to-die means we
  (physicians) kill them for their organs.
• vs
• Traditional medical ethics physicians dont kill
  patients
• Hippocratic Oath I will neither give a deadly
  drug to anybody if asked for it, nor will I make
  a suggestion to this effect.
• as to diseases, make a habit of two thingsto
  help, or, at least, to do no harm

Hippocrates, Epidemics
23
Traditional medical ethics

• Human life is special
• sanctity or specialness
• Innocent human life must not be taken (except
  perhaps insofar as soldiers in war are innocent)

24
Ways to get to its ok to kill the innocent
(sometimes)

• Nhbd donors have lost their specialness
• What makes our lives special is consciousness or
  rationality or capacity for decision-making
• ? move for higher brain criteria for brain
  death
• Personhood theory dualism theres no one home
  anymore
• To be a person is to have
• Minimal awareness or capability of anticipating
  the future or being able to value existence etc

25
Ways to get to its ok to kill the innocent
(sometimes)

• Nhbd donors are fully human but killing them is
• in their interests via ending suffering
• There are circumstances (often a product of
  medical technology) in which it is in the
  patients interest to die.
• E.g. severe neurological injury not meeting brain
  death criteria
• In such situations, killing is not harming
• Furthers their dignity (vs death without dignity)
• is what they would have chosen ahead of time

26
Killing the fully human can be ok

• For purposes of motivating physician action
• Suffering trumps human being/existence (or may do
  so)
• Choice trumps human being/existence
• Dignity (or lack of dignity) may trump it

27

• Existence
• Consciousness, rationality, experience (of high
  quality)
• Human existence is for the sake of these latter,
  is not of itself a good (or is a lesser good than
  these latter)

28

• We dont operate by valuing consciousness/rational
  ity/enjoyment as the ends to which human
  being/existence is the means if we did
• Moral worth would vary by degree of possession of
  those characteristics
• Some humans would be worth more than others
• Some animals would be worth more than some humans
  (infants)

29

• We accord moral value to persons in themselves
  (as human beings),
• apart from how much consciousness, or rationality
  they may have, or
• whether their experience is pleasurable/painful.
  
• Physicians (and everyone else) view our lives
  themselves as ends, not merely as means to good
  experience

30

• Human life has moral worth by virtue of our being
  the sort of creatures we are
• Not merely animals but rational animals whose
  place in a moral realm is secured by simply by
  being human.
• True whether or not our distinctively human
  capacities are fully realized
• If so, human life is an end (of itself has moral
  worth), not merely a means (e.g. to experience)

31
TH has an interest in being dead

• Dr Baileys position/many bioethicists
• Morally significant aspects of TH are no longer
  there/gone bad
• What remains of TH is a kind of debris, even if
  not physiologically inert (dualism)
• TH no longer has interests

32
TH has an interest in being dead

• Moral standpoint of traditional medicine
• Contra Bailey, there is no TH separate from his
  human life
• That human life has moral status (even in its
  damaged state)
• TH can only have interests as a live human being
• Positing an interest for TH in being dead is
  incoherent

33
Killing the fully human can be ok

• Suffering trumps human being/existence (or may do
  so)
• Choice trumps human being/existence
• Dignity (or lack of dignity) may trump it

34

• Argument here would be that our choices determine
  our good that autonomy/choice (in any direction)
  is morally to be respected.

35
Autonomy as highest arbiter of the good

• There is a realm where we allow choice a free
  hand
• But on important questions, we value not choice
  per se, but right choices we oppose
• Choices of the evildoer
• Choice for self-enslavement
• Choice for death

36

• Dr Bailey autonomy/choice is the source of our
  human dignity/moral worth
• What we actually believe our dignity and status
  as human beings is what confers our right to be
  autonomous (free of coercion)
• Autonomy is therebye subsidiary to our moral
  status as human beings
• Autonomy exercised in favor of death or
  self-enslavement denies the human moral status
  that authorizes the exercise of autonomy and
  hence is wrong

37

• Appeal to choice as a justification for killing
  the chooser is often a covert appeal to suffering
• Noone argues that anyone/everyone has a right to
  kill themselvesjust those who suffer
  intolerably
• How about the depressed? The disappointed? Anyone
  who makes a rational choice for death?

38
Loss of dignity as justification for being killed

• In what does dignity/specialness of human life
  consist?
• In the degree of rationality/consciousness or
  quality of experience we happen to possess?
• Or
• In our nature as what human beings are rational
  animals inhabiting a sphere of
  innocence/guilt/moral answerability that
  transcends pleasure and pain.

39

• So far view as regards the person to be killed
• What about view as from the standpoint of we
  physicians, the prospective killers

40
Can killing people be a legitimate physician
action?
41
Possible accounts of our profession as physicians

• Physicians are for healing we
• Promote and extend human life (within limits)
• Enhance and augment health, restore natural
  function
• Respect autonomous patient choices (mostly)
  encourage choices favorable to life (within
  limits) and health.
• Or
• Physicians are purveyors of technology/pharmacolog
  y in the service of patient choices (any choices).

42
Prototypical activities

• Physicians are for healing/health promotion
• What you do every day in your practice of
  internal medicine
• Physicians are for furthering patient choices
  unrestrictedly
• Cosmetic surgery
• lifestyle enhancement
• Performance enhancement for e.g. athletes

43
Case in light of rebuttal

• Dr AB is found guilty of murder, but the court is
  merciful. He is forbidden from practicing
  medicine, but finds a job euthanizing stray
  animals and lives happily ever after. Dr GH is
  tried by the courts and has a narrow escape. His
  attorneys mount a successful defense through a
  plea of not guilty by reason of being Peruvian.