Ethics of Organ Retrieval : 'Dead Donor Rule'

"There is growing interest in adopting NRP [normothermic regional perfusion] in Canada [for organ transplant retrieval operations]."

"Knowing how stakeholder perspectives on NRP could impact trust in donation will allow for the development of policy that responds to these perspectives."

"Reanimation of the donor's brain may result in harm to the donor should they regain sentience."

Research paper, journal BMJ Open        

"We know that, after about 30 minutes of having someone on an NRP pump, their heart will actually start beating again, spontaneously, to the degree that the pump can be turned off."

"Potentially -- it's pretty unlikely we think -- potentially there could be restoration of brain activity or even brain function."

"And the concern there is, of course, if brain function is restored to the point where someone becomes conscious, they might be capable of experiencing pain, and that obviously would be a serious threat to donor safety."

"I think prudence demands that we start with abdominal."

Dr. Charles Weijer, professor of medicine and philosophy, Western University

"[By restarting circulation, even artificially, NRP undermines the validity of the definition of circulatory death because] the patient is, in fact, successfully resuscitated,"

"The patient is now dead by brain death criteria -- due to actions taken by the physicians procuring the organs."

American College of Physicians

The medial transplant community in Canada is in preparation mode for the 'anticipated adoption' of a new method of collecting organs for transplant involving restoring warm blood flow to vital organs. Including to the point of restarting the heart sheer moments following someone having been declared officially dead. Known as normathermic regional perfusion (NRP), the procedure is legal in some jurisdictions while outlawed in others. Medical ethicists seem split in their opinion whether the process invalidates the declaration of death.

The focus is on whether the procedure violates the widely accepted dead donor role where there must be the assurance that organs only be taken from dead patients. Researchers are scrutinizing the literature on the ethics of using NRP through conducting in-depth interviews and focus groups with organ recipients, deceased organ donors; family members, donation agencies and transplant surgeons, along with other health professionals involved directly in the donation procedure.

Once a prospective donor was declared officially brain-dead, a decision based on loss of any detectable brain activity and function, organs were only then removed. In brain death the body is maintained on life support, heart beating and pushing blood through the organs, until such time that the organs can be retrieved. A process to remove organs from 'controlled circulatory death' donors -- people not brain dead, but without recovery prospects, the decision was made to withdraw life support; a process recognized since 2006.

 

Once the heart stops and the obligatory five-minute 'no touch' period passes to ensure the heart has permanently ceased beating after the removal of life support, organ procurement proceeds. Starved of oxygen and nutrients during the dying process and the mandated wait period, organs can become unsuitable for transplant or may take longer to recover once set within the recipient than "if they'd been getting blood throughout", explained Toronto nephrologist Dr. Jeffrey Schiff, president, Canadian Society of Transplantation.

Following death, with NRP the donor is immediately connected through cannulas placed within large blood vessels, to a machine funneling their blood into a device that adds oxygen and removes carbon dioxide, then pumps it back into the body. During this process major arteries supplying blood to the brain are clamped and tied off in prevention of brain 'reanimation', a process called "regional" perfusion where doctors can restore blood flow to the abdomen only when target organs are abdominal such as kidneys, liver and pancreas. It is thoraco-abdominal NRP which also resuscitates the heart that becomes the problem.

Perfused for about 60 minutes the body is then weaned from the pump when doctors can assess the viability of the heart pumping inside the body. Several ethical concerns are raised, beginning with the post-mortem reversal of what was intended to be recognized as permanent circulatory death. As well the death donor rule is challenged by NRP, where the donor cannot be made dead to obtain their organs; where organ retrieval as well cannot cause death. 

In the article published in BMJ Open, Dr. Weijer and his colleagues explore the uncertainty over whether the surgical techniques used in prevention of brain reperfusion can with absolute confidence rule out collateral blood flow to the brain. Separately, in an earlier article produced by the same team, continuous brain monitoring in critical care and transplant medicine was called for during NRP to exclude "brain reanimation."

In abdominal NRP, flow of oxygenated blood above the diaphragm is far less likely to result, ruling out the heart beginning to once again beat. Jurisdictions look at the use of this technology differently where, for example Australia outlaws NRP while it is pernitted in the United Kingdom and Spain.

Surgical instruments used in a kidney transplant in 2016. The agency that oversees organ allocation, the United Network for Organ Sharing, is under scrutiny after a report documented loss and waste of donated organs, often because of problems transporting the organs. Molly Riley/AP

"During NRP, the deceased body is ethically manipulated using technology to permit organ recovery, but the body remains dead."

New York University bioethicist Arthur Caplan, American Journal of Transplantation