Presumed consent for organ preservation in uncontrolled donation after cardiac death in the United States: a public policy with serious consequences

Abstract

Organ donation after cessation of circulation and respiration, both controlled and uncontrolled, has been proposed by the Institute of Medicine as a way to increase opportunities for organ procurement. Despite claims to the contrary, both forms of controlled and uncontrolled donation after cardiac death raise significant ethical and legal issues. Identified causes for concern include absence of agreement on criteria for the declaration of death, nonexistence of universal guidelines for duration before stopping resuscitation efforts and techniques, and assumption of presumed intent to donate for the purpose of initiating temporary organ-preservation interventions when no expressed consent to donate is present. From a legal point of view, not having scientifically valid criteria of cessation of circulation and respiration for declaring death could lead to a conclusion that organ procurement itself is the proximate cause of death. Although the revised Uniform Anatomical Gift Act of 2006 provides broad immunity to those involved in organ-procurement activities, courts have yet to provide an opinion on whether persons can be held liable for injuries arising from the determination of death itself. Preserving organs in uncontrolled donation after cardiac death requires the administration of life-support systems such as extracorporeal membrane oxygenation. These life-support systems can lead to return of signs of life that, in turn, have to be deliberately suppressed by the administration of pharmacological agents. Finally, allowing temporary organ-preservation interventions without expressed consent is inherently a violation of the principle of respect for a person's autonomy. Proponents of organ donation from uncontrolled donation after cardiac death, on the other hand, claim that these nonconsensual interventions enhance respect for autonomy by allowing people, through surrogate decision making, to execute their right to donate organs. However, the lack of transparency and the absence of protection of individual autonomy, for the sake of maximizing procurement opportunities, have placed the current organ-donation system of opting-in in great jeopardy. Equally as important, current policies enabling and enhancing organ procurement practices, pose challenges to the constitutional rights of individuals in a pluralistic society as these policies are founded on flawed medical standards for declaring death.

Figure 1

Organ-donation-related procedures for temporary organ preservation in donation after cardiac death. The Health Resources and Services Administration of the Department of Health and Human Services and the Organ Procurement and Transplantation Network bylaws include extracorporeal membrane oxygenation with a cardiopulmonary bypass machine (artificial heart-lung apparatus), as well as bronchoscopy, as donation-related procedures for organ preservation in donation after cardiac death [20]. The use of a cardiopulmonary bypass machine (artificial heart-lung apparatus) is initiated for the artificial circulation of oxygenated blood necessary for organ preservation, which reverses the circulatory criterion of death. Tracheal intubation and lung insufflations are required for bronchoscopy (permission to reproduce the figure was obtained from Springer Science and Business Media [21]).