The Thin Flat Line: Redefining Who Is Legally Dead in Organ Donation After Cardiac Death
46 Pages Posted: 23 Feb 2009 Last revised: 26 Feb 2009
Date Written: February 17, 2009
Solid organ transplantation has become the standard of care for end-stage organ disease. Most cadaveric organs are recovered from donors who meet brain death criteria. There is, however, a growing imbalance between the number of brain-dead donors and the demand for transplantable organs. To increase the supply of organs, the transplant community has turned to donation after cardiac death (DCD). In DCD, death is declared two to five minutes after the cessation of cardiac and respiratory functions in donors who are not brain-dead. Once a diagnosis of death is made, transplant surgeons begin the process of organ retrieval. The Uniform Determination of Death Act requires an "irreversible" cessation of cardiopulmonary functions for death to be declared under cardiac criteria and the question is whether a few minutes of heart stoppage is sufficient for the patient to be considered legally dead.
In the United States, DCD has been primarily used in severely ill, hospitalized donors who do not meet the criteria for brain death but who have decided to withdraw life-sustaining medical care. The debate over DCD, which has been confined primarily to academic journals, has focused almost exclusively on this small subset of organ donors. During the past few years, however, there has been a movement to expand DCD to other potential donors. For example, in March 2008, New York City announced that it was studying whether "rapid organ recovery ambulances" should trail emergency responders and begin DCD in victims of sudden cardiac arrest outside the hospital. In July 2008, there was a widely circulated account of three heart transplants from infant donors, two of whom were declared dead only seventy-five seconds after their hearts stopped. These reports generated considerable controversy in both medical journals and the media.
This article addresses the history of DCD, proposals for its expansion, and whether, in the pursuit of new sources of organs, medicine has gone too far in tinkering with the definition of death. Without wider public debate on what it means to be "dead enough" for organ donation, DCD should not be expanded to situations that present new legal and ethical challenges.
Keywords: bioethics, health law, definition of death, transplant, organs, cardiac death, controlled donor, uncontrolled donor
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