restricted access Chapter Eleven: Are DCD Donors Dead?

From: Potentiality

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Chapter eleven Are DCD Donors Dead? Don Marquis Ever since brain death came to be understood in the 1970s as death of the whole human being, organ transplantation has, for the most part, been closely linked to it. The typical donor has been somebody declared brain dead while on life support and while the heart continues to beat, thereby keeping the organs suffused with oxygen. However, because relatively few healthy people—people with suitable organs—have died in just this way, the number of organs available for transplantation has been much less than the number of people needing them. One strategy for making up the difference has been the introduction of “donation after cardiac death” protocols , which provide for vital organ donation from people declared dead on the basis of cardiac death. The typical DCD case goes like this: The prospective donor, although not brain dead, has suffered extensive neurological damage and is on life support.1 Following a decision from the person’s family, life support is withdrawn and cardiac arrest results . If the heart does not resume beating on its own within two to five minutes, it will never resume beating on its own. In a DCD protocol, after one of these intervals , death is declared. Consent for organ donation has been obtained from the donor or his family, and after death is declared, the donor’s organs are removed for transplantation as quickly as possible. DCD protocols are subject to two major constraints. On the one hand, organ removal must occur as soon as possible after cardiac arrest to prevent organ damage. The point of organ transplantation is to provide the recipient with healthy organs, but because the donor’s circulation has stopped, the donor’s organs are deprived of oxygenated blood. The longer the deprivation, the more likely organ damage will be. On the other hand, the organs must not be removed so soon after cardiac arrest that the donor is not actually known to be dead. A DCD protocol is justified only if, given the former constraint, the latter constraint can be satisfied. Those who defend DCD protocols believe that both constraints can be satisfied. 224 Don Marquis Since DCD protocols have won wide support, these arguments have apparently been persuasive. That does not mean they are sound, however. I shall argue that DCD donors are not known to be dead. Death and Reversibility An article in the August 2008 issue of the New England Journal of Medicine illuminates how the declaration of death in a DCD protocol can be problematic. Mark Boucek and colleagues reported on three successful infant heart transplants performed on the basis of DCD.2 Boucek’s investigational protocol, approved by the ethics committee at his institution, permitted death to be pronounced only seventy-five seconds after cessation of donor cardiac function, much less than the two-minute minimum interval recommended by the Society of Critical Care Medicine.3 The shorter interval can be both defended and criticized. On the one hand, the longest reported period between cardiac arrest and autoresuscitation (that is, the resumption of a heartbeat without external resuscitation) in DCD cases has been sixty seconds, and adopting a shorter interval minimizes damage from warm ischemia , therefore maximizing the likelihood that the transplant will work. On the other hand, one might wonder whether the patients were genuinely dead. To begin with, whether there are now sufficient data to justify the seventy-five second interval and whether the data that presently exist—or will exist—can be extrapolated from adults to infants is arguable.4 This issue can be resolved only after the acquisition of more data, however, and I set it aside, pending the data. Other issues cannot be set aside so easily. The most obvious starts from an observation about the very term “donation after cardiac death.” A “gift of cardiac life” received from someone who has suffered “cardiac death” strongly suggests a contradiction . If the donor’s heart is truly dead, then it would not be able to function in the recipient. If the transplanted heart functions in the recipient, then it was not dead when it was still in the donor. If the donor’s heart was not dead, then the donor should not have been pronounced dead on the basis of cardiac death. If the donor was not dead, then Boucek’s transplant did not accord with the dead donor rule— the axiom of the transplant community that stipulates that vital organs may be taken...