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By Sandeep Jauhar, Snehal Patel and Deane Smith
Dr. Jauhar is a cardiologist at Northwell Health in New York, where Dr. Patel and Dr. Smith are the directors of the center for heart failure and transplant.
People die in many ways, but in medicine there are only two reasons a person can be declared dead: Either the heart has stopped or the brain has ceased to function, even if the heart is still beating.
A person may serve as an organ donor only after being declared dead. (Until then, transplant surgeons are not allowed even to interact with a dying patient.) This common-sensical rule underpins organ donation in the United States and many other countries.
Most donor organs today are obtained after brain death, defined by most state laws as a condition of permanent unconsciousness with no spontaneous breathing, no response to pain and no primitive reflexes — in other words, devastation of the whole brain. Organs obtained this way are often relatively healthy, because brain-dead patients can continue to circulate blood and oxygen.
Brain death is rare, though. In New York State, with a population of 20 million, there are on average fewer than 500 cases suitable for organ procurement and transplantation each year.
Far more often, people die because their heart has permanently stopped beating, which is known as circulatory death. However, precisely because the blood has stopped circulating, organs from people who die this way are often damaged and unsuited for transplantation.
The need for donor organs is urgent. An estimated 15 people die in this country every day waiting for a transplant. We need to figure out how to obtain more healthy organs from donors while maintaining strict ethical standards.
New technologies can help. But the best solution, we believe, is legal: We need to broaden the definition of death.
Consider how things currently work. In the procedure known as donation after circulatory death, a typical donor is in an irreversible coma from, say, a drug overdose or a massive cerebral hemorrhage, and the heart is beating only because of life support. The donor is still not legally brain-dead; he or she might have, say, a gag reflex or other primitive functions.
In such cases, with the blessing of the family, a donor is brought into an operating room and life support is carefully withdrawn. If, as is expected, the removal of life support results in stoppage of the heart, surgeons will wait long enough to determine that the stoppage is permanent — to be confident of death — but not so long that vital organs get damaged. This period is typically about five minutes. Then the surgeons remove the organs.
But even a few minutes of a stopped heart often results in damage to the organs. This deprives potential recipients of healthy organs and thwarts the wishes of donors to have their organs used to help others.
Fortunately, there is a relatively new method that can improve the efficacy of donation after circulatory death. In this procedure, which is called normothermic regional perfusion, doctors take an irreversibly comatose donor off life support long enough to determine that the heart has stopped beating permanently — but then the donor is placed on a machine that circulates oxygen-rich blood through the body to preserve organ function. Donor organs obtained through this procedure, which is used widely in Europe and increasingly in the United States, tend to be much healthier.
But by artificially circulating blood and oxygen, the procedure can reanimate a lifeless heart. Some doctors and ethicists find the procedure objectionable because, in reversing the stoppage of the heart, it seems to nullify the reason the donor was declared dead in the first place. Is the donor no longer dead, they wonder?
Proponents of the procedure reply that the resumption of the heartbeat should not be considered resuscitation; the donor still has no independent functioning, nor is there any hope of it. They say that it is not the donor but rather regions of the body that have been revived.
How to resolve this debate? The solution, we believe, is to broaden the definition of brain death to include irreversibly comatose patients on life support. Using this definition, these patients would be legally dead regardless of whether a machine restored the beating of their heart.
So long as the patient had given informed consent for organ donation, removal would proceed without delay. The ethical debate about normothermic regional perfusion would be moot. And we would have more organs available for transplantation.
Apart from increased organ availability, there is also a philosophical reason for wanting to broaden the definition of brain death. The brain functions that matter most to life are those such as consciousness, memory, intention and desire. Once those higher brain functions are irreversibly gone, is it not fair to say that a person (as opposed to a body) has ceased to exist?
Understandably, some will worry that doctors will prematurely pronounce a patient irreversibly comatose when in fact the patient is not or there is genuine hope for recovery. This is rare, but it can happen (as recently documented by The Times), and when it does, it is a catastrophe.
That sort of concern, however, is about practicalities such as whether doctors are following protocol properly and whether external pressures are creating perverse incentives for doctors and other medical workers to be careless. These are critical issues, to be sure. But it remains possible (and common) to responsibly determine whether someone is irreversibly comatose, and in such cases a judgment of brain death is merited, as the law should be revised to reflect.
In 1968, a committee of doctors and ethicists at Harvard came up with a definition of brain death — the same basic definition most states use today. In its initial report the committee noted that “there is great need for the tissues and organs of the hopelessly comatose in order to restore to health those who are still salvageable.”
This frank assessment was edited out of the final report because of a reviewer’s objection. But it is one that should guide death and organ policy today.
By Sandeep Jauhar, Snehal Patel and Deane Smith
Dr. Jauhar is a cardiologist at Northwell Health in New York, where Dr. Patel and Dr. Smith are the directors of the center for heart failure and transplant.
People die in many ways, but in medicine there are only two reasons a person can be declared dead: Either the heart has stopped or the brain has ceased to function, even if the heart is still beating.
A person may serve as an organ donor only after being declared dead. (Until then, transplant surgeons are not allowed even to interact with a dying patient.) This common-sensical rule underpins organ donation in the United States and many other countries.
Most donor organs today are obtained after brain death, defined by most state laws as a condition of permanent unconsciousness with no spontaneous breathing, no response to pain and no primitive reflexes — in other words, devastation of the whole brain. Organs obtained this way are often relatively healthy, because brain-dead patients can continue to circulate blood and oxygen.
Brain death is rare, though. In New York State, with a population of 20 million, there are on average fewer than 500 cases suitable for organ procurement and transplantation each year.
Far more often, people die because their heart has permanently stopped beating, which is known as circulatory death. However, precisely because the blood has stopped circulating, organs from people who die this way are often damaged and unsuited for transplantation.
The need for donor organs is urgent. An estimated 15 people die in this country every day waiting for a transplant. We need to figure out how to obtain more healthy organs from donors while maintaining strict ethical standards.
New technologies can help. But the best solution, we believe, is legal: We need to broaden the definition of death.
Consider how things currently work. In the procedure known as donation after circulatory death, a typical donor is in an irreversible coma from, say, a drug overdose or a massive cerebral hemorrhage, and the heart is beating only because of life support. The donor is still not legally brain-dead; he or she might have, say, a gag reflex or other primitive functions.
In such cases, with the blessing of the family, a donor is brought into an operating room and life support is carefully withdrawn. If, as is expected, the removal of life support results in stoppage of the heart, surgeons will wait long enough to determine that the stoppage is permanent — to be confident of death — but not so long that vital organs get damaged. This period is typically about five minutes. Then the surgeons remove the organs.
But even a few minutes of a stopped heart often results in damage to the organs. This deprives potential recipients of healthy organs and thwarts the wishes of donors to have their organs used to help others.
Fortunately, there is a relatively new method that can improve the efficacy of donation after circulatory death. In this procedure, which is called normothermic regional perfusion, doctors take an irreversibly comatose donor off life support long enough to determine that the heart has stopped beating permanently — but then the donor is placed on a machine that circulates oxygen-rich blood through the body to preserve organ function. Donor organs obtained through this procedure, which is used widely in Europe and increasingly in the United States, tend to be much healthier.
But by artificially circulating blood and oxygen, the procedure can reanimate a lifeless heart. Some doctors and ethicists find the procedure objectionable because, in reversing the stoppage of the heart, it seems to nullify the reason the donor was declared dead in the first place. Is the donor no longer dead, they wonder?
Proponents of the procedure reply that the resumption of the heartbeat should not be considered resuscitation; the donor still has no independent functioning, nor is there any hope of it. They say that it is not the donor but rather regions of the body that have been revived.
How to resolve this debate? The solution, we believe, is to broaden the definition of brain death to include irreversibly comatose patients on life support. Using this definition, these patients would be legally dead regardless of whether a machine restored the beating of their heart.
So long as the patient had given informed consent for organ donation, removal would proceed without delay. The ethical debate about normothermic regional perfusion would be moot. And we would have more organs available for transplantation.
Apart from increased organ availability, there is also a philosophical reason for wanting to broaden the definition of brain death. The brain functions that matter most to life are those such as consciousness, memory, intention and desire. Once those higher brain functions are irreversibly gone, is it not fair to say that a person (as opposed to a body) has ceased to exist?
Understandably, some will worry that doctors will prematurely pronounce a patient irreversibly comatose when in fact the patient is not or there is genuine hope for recovery. This is rare, but it can happen (as recently documented by The Times), and when it does, it is a catastrophe.
That sort of concern, however, is about practicalities such as whether doctors are following protocol properly and whether external pressures are creating perverse incentives for doctors and other medical workers to be careless. These are critical issues, to be sure. But it remains possible (and common) to responsibly determine whether someone is irreversibly comatose, and in such cases a judgment of brain death is merited, as the law should be revised to reflect.
In 1968, a committee of doctors and ethicists at Harvard came up with a definition of brain death — the same basic definition most states use today. In its initial report the committee noted that “there is great need for the tissues and organs of the hopelessly comatose in order to restore to health those who are still salvageable.”
This frank assessment was edited out of the final report because of a reviewer’s objection. But it is one that should guide death and organ policy today.
