2003 Voices: Update on Non-Heart-Beating Organ Donation

Voices Online Edition
Vol. XVIII No. 4 Christmastide 2003 – Epiphany 2004
Update on Non-Heart-Beating Organ Donation
Archdiocese of St. Louis Calls for
Immediate Moratorium on Non-Heart-Beating Organ Donation

by Nancy Valko, RN

On May 23, 2003, the St. Louis Review, the newspaper of the Archdiocese of St. Louis, published an editorial stating that “the NHBD (non-heart-beating organ donation) protocol is cruel and dangerous and does not meet standards of respect for human life” and called for an immediate moratorium on the practice at all St. Louis hospitals “until such time as clearer, objective moral standards of determination of death are enacted” (See article below)

Reaction was swift and critical. In a page one article on the controversy1, the St. Louis Post-Dispatch cited transplant surgeons and others who defended NHBD as a way to increase organ donations by taking organs from patients who “have little brain activity and are in a vegetative state with no hope of recovery” and whose families decide to discontinue life support. Michael Panicola, vice president of ethics for the Catholic SSM Healthcare System, called NHBD “an opportunity for people to give the gift of life when they don’t meet brain death criteria”, the much-publicized previous requirement for organ donation.
A few days later the Post-Dispatch published a letter from James DuBois, PhD, a Catholic ethicist with St. Louis University’s Center for Health Care Ethics, and a commentary from Ronald Munson, an ethicist with the University of Missouri-St. Louis.

DuBois, who has written several articles defending NHBD, argued that NHBD donors die of their underlying condition, not from the withdrawal of treatment or the organ donation itself. He also cited the “safety measure” of waiting “a full five minutes after death is declared before beginning organ procurement”.

Ronald Munson, in his commentary, portrayed NHBD donors as “hospitalized, critically ill people who have expressed the wish to become donors when they die”. Explaining the motive for dispensing with the previous brain death standard in organ donation, Munson admitted that “Waiting longer (than 5 minutes after the person’s heart stops) — to determine if the donors also satisfy brain-death criteria — would result in the organs’ deteriorating and becoming useless”.

But suddenly, this important issue was quickly dropped.

This logically leads to the question: Are there some things about NHBD that the media or organ transplant organizations don’t want you to know?

BRAIN DEATH AND NHBD
For the past several years, a little-known but disturbing revolution has been occurring in organ donation. In the understandable but sometimes alarming zeal to obtain more organs, the procedure called non-heart-beating organ donation has been quietly added to brain death organ donation in more and more hospitals all over the country.

Although “brain dead” is a term many people erroneously associate with a coma-like condition or use to humorously describe an ignorant person, brain death is a legal and medical term that describes the irreversible loss of total brain function, even when the body can be kept going for a while using technology such as a ventilator. Since 1970, every state has added brain death to the legal and more familiar definition of death as the irreversible end of breathing and heartbeat. The addition of brain death as a legal definition of death revolutionized organ transplantation, because waiting until a person died naturally to harvest organs often resulted in organs too damaged for successful transplant. With brain death, organs could be taken before breathing and heartbeat stopped, and organ transplantation became commonplace. But when brain death did not meet the demand for organs, NHBD was invented in the 1990s as a way to obtain more organs.

NHBD is very different from brain death organ donation. While brain death organ donation means the person is legally dead but still has a heartbeat when organs are harvested, the potential NHBD patient is alive but termed “hopeless” or “vegetative” by a doctor, usually soon after suffering a devastating condition like a severe stroke or trauma and while still needing a ventilator to breathe. Because of the legal acceptance of the so-called “right to die”, families or patients can then agree to have the ventilator turned off, a “do not resuscitate” order written and the organs harvested if or when the person’s breathing and heartbeat stops.

In NHBD, the ventilator is usually stopped in an operating room while a doctor watches for up to one hour until the heartbeat and breathing stops. After an interval of usually just two to five minutes, the patient is declared dead and the transplant team takes over to harvest the organs. A determination of brain death is considered unnecessary even though Dr. Michael DeVita, one of the inventors of the NHBD protocol, has admitted, “the possibility of (brain function) recovery exists for at least 15 minutes”. Nonetheless, Dr. Devita defends waiting only two minutes before harvesting the organs because, as he writes, “the 2-minute time span probably fits with the layperson’s conception of how death ought to be determined”2 (emphasis added).

Just as disturbing, sometimes the NHBD patient will unexpectedly continue to breathe for longer than the one hour time limit for NHBD. The transplant is then cancelled but, rather than resuming care, the patient is just returned to his or her room to eventually die without treatment.

A RECENT EXAMPLE
The recent case of Jason Childress3 illustrates the lethal problems with this non-treatment plan. Jason is a young man who was severely brain-injured in a car accident and became the center of a “right to die” case in which the judge ordered the removal of his ventilator two months after his accident.

Against all predictions and because his tube feedings were not also stopped, Jason continued to breathe on his own. He is now showing signs of improvement and is receiving treatment. Ominously, the doctors’ initial recommendation to withdraw the ventilator two days after his accident could have made him a prime candidate for NHBD, since it is possible he would have been too injured to breathe on his own so soon after his accident.

As I wrote in an article last year on the ethical implications of NHBD, the rush to declare patients “hopeless” or “vegetative” soon after illness or injury can deprive at least some patients of the chance of survival or even recovery.

Shockingly, NHBD protocols do not even necessarily require that the donor be mentally impaired at all. For example, one ethicist wrote about the case of a fully conscious man with ALS (“Lou Gehrig’s disease”) who decided to check himself into a hospital, have his ventilator removed and donate his organs under NHBD criteria. The ethicist wrote, “An operating room nurse reported feeling that the procedure was ‘Kevorkian-like.'”4

PRESSURE FOR ORGANS OPENS PANDORA’S BOX
Even more pressure to increase the use of NHBD is apparently coming, even though the public has been kept largely in the dark about this new method of obtaining organs.

For example, last November, an advisory committee to the US Department of Health and Human Services recommended that, in the future, all hospitals should establish policies and procedures to “manage and maximize” NHBD and also be required to “notify organ procurement organizations prior to the withdrawal of life support to a patient, so as to determine that patient’s potential for organ donation”5 (emphasis added).

Unknown to most of the public, hospitals are now already required to report every death to the local transplant organization even when tissue or organ donation is refused. If enacted, this new proposal could put further pressure on distraught families.

Ironically at the same time, new information is coming forward about these so-called “hopeless” patients who are considered potential NHBD candidates.

A September 2003 article in The New York Times featured Dr. Joseph T. Giacino and others who work with people who have had severe brain damage but who are now showing signs of “complex mental activity” — even after months or years with little sign of consciousness.6 And, of course, there are many reported cases, even in the media, of brain-injured people who improve or even recover long after the doctors declared them hopeless.

Yet even this may not be enough for some ethicists, like Dr. Robert Truog, who recently proposed that “individuals who desire to donate their organs and who are either neurologically devastated or imminently dying should be allowed to donate their organs, without first being declared dead”.7 In other words, Dr. Truog wants to eliminate even the controversial NHBD protocol in favor of just taking organs from incapacitated or dying patients while they are still very much alive.

Linking the so-called “right to die” with organ donation — as NHBD does — has truly opened Pandora’s box. While organ donation can be a gift of life and a worthy goal, we must not allow the deaths of some people to be manipulated to obtain organs for others. The position of Cardinal-designate Justin Rigali and the Archdiocese of St. Louis regarding an immediate moratorium and re-evaluation of NHBD is eminently sensible and should be replicated nationwide.
1 “Archdiocese criticizes some organ retrievals” by Deborah L. Shelton. St. Louis Post-Dispatch, June 10, 2003
2 “The Death Watch: Certifying Death Using Cardiac Criteria” by Michael A. DeVita, MD, University of Pittsburgh Medical Center, Pittsburgh, Pa. Prog Transplant 11(1):58-66, 2001. © 2001 North American Transplant Coordinators Organization
3 “Jason Childress Still Breathing, Receives Proper Medical Care” by Steve Ertelt, LifeNews.com editor, September 25, 2003. Available online at: http://www.lifenews.com/bio58.html
4 “A Primer for Health Care Ethics” by Kevin O’Rourke, O.P., Georgetown Press, 2000. p. 182
5 US Department of Health and Human Services Advisory Committee on Organ Transplantation, Recommendations to the Secretary, November 2002. Available online at: http://www.organdonor.gov/acotrecsbrief.html
6 “What if There is Something Going On in There?” by Carl Zimmer. The New York Times, 9/28/03.
7 “Role of brain death and the dead-donor rule in the ethics of organ transplantation” by Robert D. Truog, MD, FCCM; Walter M. Robinson, MD, MPH. Critical Care Medicine Journal, September, 2003. Critical Care Medicine 2003; 31(9):2391-2396

EDITORIAL
Organ donation and the definition of death

The following editorial appeared in the May 23, 2003 edition of the St. Louis Review, the newspaper of the Archdiocese of St. Louis. It is reprinted here with the kind permission of the St. Louis Review.

Organ donation is quickly becoming a very troublesome affair. In theory, it’s a wonderful act of charity. In practice, it just might be your worst nightmare.

There are some 80,000 persons in the United States today awaiting a vital organ from a donor in order that they might live. It is widely held that the donation of organs after death is a noble and meritorious act. The “Catechism of the Catholic Church” makes clear that organ donation is to be encouraged as an expression of solidarity (No. 2296). Pope John Paul II has said this on numerous occasions.

The desirability for exercising charity and encouraging organ donation in solidarity with one another, however, cannot obliterate the “dead donor rule” where vital organs are concerned. Procuring organs for donation should not cause the donor’s death.

The donation of an organ to save another’s life does not make killing the donor morally admissible. In the words of the Pope, “There is a real possibility that the life whose continuation is made unsustainable by the removal of a vital organ might be that of a living person, and the respect due to human life absolutely prohibits the direct and positive sacrifice of that life.”

Most of us would see the dead donor rule as simple, clear and morally mandated. But, there is a problem. When is a life over? How does one determine death? Again, many people have come to accept the definition of death based upon so-called “brain death,” or the irreversible cessation of all brain and nervous system function. The Pope has condoned the reasonable use of the criteria associated with this definition as a way of establishing death. However, there are no established criteria for death in authentic magisterial teaching. That is something left to the scientists.

Uncertainty about the moment of death has resulted in a hotly debated organ donation protocol known as Non-Heart-Beating Organ Donation (NHBD). Transplant services operating in the St. Louis region and around the country have adopted NHBD as a means of procuring organs from patients who are not brain dead by any set of criteria. Rather, in this procedure, the pronouncement of death is based upon the cessation of circulatory and respiratory function for 2 to 5 minutes after being removed from a ventilator. This “death watch” could take place in the operating room as the patient is prepared to become a donor with the transplant team in wait nearby.

In NHBD procedures, the determination to remove the patient from the ventilator is founded upon the medical team’s prognosis that the patient is hopeless even though brain function continues. It is even possible that the patient could experience recovery of circulatory and respiratory function, consciousness, and, moreover, significant recovery if enough care was given. However, because of the protocol, some patients will never have this opportunity.

In NHBD some patients will be pronounced dead because their hearts did not begin to beat on their own or they were not given CPR within the 2 to 5 minutes determined by the protocol. A do not resuscitate order or a living will to that effect will prevent the CPR, of course. But because there is no sure bet that the patient’s heart will stop after removal from the machine, the “death watch” begins — a process that is aborted after 60 minutes if, indeed, the blood pressure and pulse continue. This means, of course, that the patient who was abandoned to death an hour earlier by the attending physician was, in fact, quite alive.

According to the protocol, in this scenario the patient will be returned to the room to die “naturally” with no treatment given. What will the team tell the family when the patient finally does die? Hours or days after the patient had been declared dead and then returned to the room, the family will learn that the organs will probably be of no use for donation purposes.

The NHBD protocol is cruel and dangerous and does not meet standards of respect for human life. Even the action of removal of the ventilator from a patient destined to become a donor could constitute a grave injustice against human life if the intention in doing so is to cause or hasten death. All hospitals should impose an immediate moratorium upon the procedure until such time as clearer, objective moral standards of determination of death are enacted. The conscience rights of all medical personnel who object to these procedures should be respected and protected.
**Women for Faith & Family operates solely on your generous donations!
WFF is a registered 501(c)(3) non-profit organization. Donations are tax deductible.

Voices copyright © 1999-Present Women for Faith & Family. All rights reserved.
Nancy Valko, a registered nurse, is president of Missouri Nurses for Life, a spokesperson for the National Association of Pro-life Nurses and a Voices contributing editor.
**Women for Faith & Family operates solely on your generous donations!
WFF is a registered 501(c)(3) non-profit organization. Donations are tax deductible.

Voices copyright © 1999-Present Women for Faith & Family. All rights reserved.

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