Thursday, January 21, 2010

Life, death, and organ transplantation - Part 2 of 2

In health care, rationing occurs when resources (doctors, nurses, hospitals, imaging devices, drugs, and, of course, dollars) are inadequate to meet the real or perceived medical needs of the population. One area of health care in which rationing is absolutely essential is organ transplantation, since the supply of organs is never enough to meet the demand. In my previous post, I described how I felt while presiding over the choreographed death of a potential organ donor several years ago. This memory came back to me after I read a New York Times Magazine article by pediatric cardiologist Darshak Sanghavi that described the ethical challenges of obtaining vital organs, such as the heart, for critically ill patients who would not survive without a transplant. In addition to "brain dead" donors (who are, contrary to what you might see on soap operas or prime time TV, quite rare), there is another option for donors who do not meet the critieria for diagnosing brain death - donation after cardiac death, or D.C.D.

If someone's heart has "died," how can it be transplanted to save the life of another person? In 1997, the Institute of Medicine declared that the passage of five minutes without a heartbeat to be consistent with death, and some hospitals created organ donation protocols for brain-damaged (but not brain-dead) patients similar to the one that I participated in to retrieve organs such as the liver and kidneys. Unfortunately, the lack of oxygen delivery to the heart during this 5-minute waiting period causes the destruction of enough heart muscle to make it impossible to transplant successfully.

Since the supply of brain-dead donors is not enough to meet the need for new hearts of infants born with inoperable heart defects, up to 50 infants in the U.S. each year die while on the waiting list for a heart transplant. So in 2008, pediatric cardiologist Mark Boucek published a controversial paper in the New England Journal of Medicine that detailed 3 case reports of successful infant heart transplanation via a new D.C.D. protocol that shortened the waiting period from 5 minutes to 75 seconds after the donors' hearts stopped, based on the rationale that the longest reported interval of a heart spontaneously re-starting was 65 seconds.

Predictably, many readers reacted unfavorably to the paper, feeling that it had crossed an ethical boundary. Critics of Dr. Boucek and colleagues feared that transplanting a heart so soon after it stopped beating would lead to a public outcry and loss of confidence in the organ donation system. Supporters pointed out that 3 infants were still alive who would most certainly not have been if not for this protocol. As theologians and philosophers have long debated when a human life begins, the transplantation debate revolves around the question of when we can safely say that someone has died, and amid inevitable disagreement, where a line can be drawn that most of us can live with ... no pun intended.