M. D. D. Bell, Non-Heart Beating Organ Donation: Old Procurement Strategy--New Ethical Problems.

• Position: Abstracts

29 J. MED. ETHICS 176 (2003).

The imbalance between supply of organs for transplantation and demand for them is widening. Although the current international drive to re-establish procurement via non-heart beating organ donation/donor is founded on necessity, the process may constitute a desirable outcome for patient and family when progression to brain stem death does not occur and conventional organ retrieval from the beating heart donor is thereby prevented. The literature acknowledges this practice, however, it raises concerns that risk jeopardizing professional and public confidence in the broader transplant program. This article focuses on these clinical, ethical, and legal issues in the context of other approaches aimed at increasing donor numbers. The feasibility of introducing such an initiative will hinge on the ability to reassure patients, families, attendant staff, professional bodies, the wider public law enforcement agencies, and the media that practitioners are working within explicit guidelines which are both ethically and legally defensible.

A fundamental concern revolves around definitions of death and this needs to be placed in the context of debate over the last forty years. The recognition that medical advances could sustain cardiac activity while progression of intra-cranial pathology resulted in whole brain death generated a need to evaluate concepts of death. It may be argued that the redefinition of death to include this product of medical intervention was simply utilitarian, facilitating optimal organ procurement that could not be legitimately conducted on anything other than a cadaver. Aside from this vexed issue, however, the finality of brain death and the futility of ongoing supportive care is understood and accepted by a majority of the civilized world. The redefinition furthermore clearly established the need for death before organ retrieval.

A greater difficulty with definition has been created by cortical death after brain injury whereby spontaneous respiratory effort is retained in conjunction with cardiac activity, and long term survival is possible with nutritional support and general care. While at the extreme end of the spectrum of PVS the patient will display a complete lack of sentience equivalent to the brain dead patient, leading to calls for a further redefinition of death and indeed utilization for organ donation, the very fact that a spectrum of neurological deficit exists, negates the use of...