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Medical Ethics Unpacked: The Rushed, Rash Donor Transplantations
In this episode, Dominic Sisti and Steve Levine discuss dilemmas surrounding donor transplants, brain death, and cardiac death in organ donations.
Back in July, the New York Times reported the story of a surgeon taking the organs out of Misty Hawkins, who was believed to be dead. She was not. After a surgeon made an incision in the 42-year-old’s chest and sawed through her breastbone, he discovered her beating heart.
The surgeon was cutting her alive.
Although Hawkins was an extreme case, many surgeons rush to get donor donations, leading to rash decision-making. Several donations come from people who are considered circulatory dead—currently alive, but on life support; doctors deem these patients near death. With circulatory death donations, a doctor can withdraw life support if the relatives agree. Once the person is declared dead, surgeons can take the organs.
In this latest episode of Medical Ethics Unpacked, Arthur Caplan, PhD, the founding head of the Division of Medical Ethics at NYU Grossman School of Medicine, joins Dominic Sisti, PhD, from Penn Medicine, and Steve Levine, MD, from COMPASS Pathways, to discuss definitions of brain death, cardiac death, and the ethics surrounding organ transplantations. When are organ transplants ethical?
“People wonder whether we have the right criteria for brain death. Do we know what we're doing? I don't worry about that,” Caplan said. “I think we have very good definitions: totally reversible loss of brain function, no response when you try to breathe on your own.”
Brain death is determined via an apnea test. When people get off the machine and are still not breathing, still have no reflexes, this confirms brain death.
“We know what brain death is,” Caplan continued. “If you’re well-trained, you know what to do.”
What we do not necessarily know is the definition of cardiac death.
“If I wander around the NYU hospital and go floor to floor, and somebody said to me, 'How long do you wait after the heart stops before you declare somebody dead?’ If it's me, an ancient person of maybe less popularity to my colleagues for yelling at them all day long about ethics issues, maybe about 30 seconds,” Caplan said. “If it's a teenager who was just getting into the prime of life, you might try to resuscitate them 6 times, 7 times. If it's a 90-year-old with many comorbidities, and they've already had a resuscitation, you're going to call cardiac death relatively quickly.”
No proper definition of cardiac death creates problems for donations. Some places may wait 2 minutes to see if the heart does anything, while other places may wait 4 minutes.
Caplan added, “Now people are saying, ‘Hey, I think if you froze the body, or cooled the body down and maybe put the heart on a side pump just to keep it oxygenated, you're still dead, because we've called you both cardiac death and brain dead.’ But somebody else is saying, ‘Well, wait a minute, if you got the machine going and the heart is perfused and it's still pumping, then why did you think they were dead?’ The heart still works. And just to make things completely crazy, well, of course, the heart still works. That's why you're going to transplant it.”
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