Stewards of a Public Trust: Responsible Transplantation Use?

"Time of death . . . 19:47. Thank you all for your efforts." The somber pronouncement marks the anti-climactic conclusion of an unsuccessful resuscitation effort. It is a disquieting feeling, to hear the cardiac monitor "chirp" one last volley, as you cross the threshold to inform a family their loved one has died.

Disquiet or not, there is less ambiguity surrounding the declaration of death than Elysa R. Koppelman (2003) suggests. One is dead when a qualified individual (defined variously in different jurisdictions) declares him/her dead in accordance with accepted standards: the irreversible cessation of either cardio-pulmonary function or the function of the entire brain (including the brain stem). There may be special challenges—for instance, in the declaration of brain death in infants and neonates; there is, however, greater fundamental consensus than Koppelman admits.

Koppelman contends that we should acknowledge the ambiguities surrounding the definition of death and abandon the dead donor rule in favor of her "respect for donor" rule, which would allow organ recovery from individuals in limbo between life and death. As noted by several commentators, such an approach is fraught with difficulties. Much of the ambiguity Koppelman identifies surrounding brain death stems from a lack of precision in how we talk about states of neurologic devastation. We talk about "brain death" in a manner that seems to suggest it is not quite "the real thing." I have often heard people say that brain-dead individuals were being "kept alive" by life- support machines. Perhaps the machines maintain their physiology, but one of the criteria for a declaration of brain death is the demonstration of apnea under controlled physiologic parameters. That is, there is no vital respiratory function in patients who are declared dead based on neurologic criteria, a feature which distinguishes them from others in a persistent vegetative state. Thus, our verbiage is more ambiguous than our criteria. I dare say that Koppelman's proposal, with only an amorphous fence around the suspended states to which she alludes, invokes far greater ambiguity and misgiving than our notion of death defined by neurologic criteria. Further, as Denise M. Dudzinski (2003) notes, those with diminished autonomy (such as neurologically devastated individuals) merit special protections. Taking Koppelman's proposal to its logical extreme offers no solid basis for denying an individual with decision-making capacity the opportunity to commit suicide by donation of vital organs.

Several important themes run through Koppelman's article and its accompanying commentaries, some explicit, others more subtly implied. Respect, for persons and their autonomy, is readily identified as a core value in organ donation. However, the social context of transplantation, distinct from the social construct of "brain death" on which it has been largely dependent, has gone unrecognized. It is a common problem. The "gift exchange" aspect of transplantation is unlike other gifts we might give. We rely on the surgical team(s), at a minimum, to effect the gift. As Eike-Henner Kluge (1989) has noted, the gift exchange cannot be simply a private act between two people. For this reason, the values of the transplant community matter. Transplant teams cannot be compelled to accede to the requests of would-be living donors to have vital organs removed. Because organ donation requires active societal involvement to be complete, it is appropriate that the preferences of the donor be mediated by communal values. Thus, as Laura A. Siminoff (2003) suggests, it is necessary to have a much stronger sense of societal consensus regarding not only the definition of death, but also the acceptable circumstances for organ donation.

The dilemma in transplantation has often been cast as an issue of supply-and-demand. Nevertheless, it is tempting to abstract one from the other. While transplantation initially relied exclusively on living donors, the introduction of effective immunosuppression, coupled with the clinical and legal recognition of "brain death" as a basis for the...