If you think the next president will have a hard job, try being a transplant surgeon. You can't tell parents of a dying kid when to pull the plug, but you have to be there, ready, the minute he expires. You have to wait till he's dead but not so long that his organs become useless. You can give him drugs to keep his organs healthy, but you mustn't technically revive him. And you can't remove and restart his heart till it's been declared kaput.
Pick up the New England Journal of Medicine, and you'll see the far edge of this tortured world. In the journal, doctors at the Denver Children's Hospital describe how they removed hearts from infants 75 seconds after their hearts stopped. The infants were declared dead of heart failure even as their hearts, in new bodies, resume ticking. The federal government funded the procedure; other hospitals are looking to adopt it.
Is it wrong? If only the question were that simple. We like to think moral lines are fixed and clear: My heart is mine, not yours, and you can't have it till I'm dead. But in medicine, lines move. Dead means irreversibly stopped, and stoppages are increasingly reversible. Meanwhile, thanks to transplantation, entitlement to organs is becoming socialized. When life support ends, says one bioethicist, "not using viable organs wastes precious life-saving resources" and "costs the lives of other babies." Failure to take and reuse body parts looks like lethal negligence.
How can we get more organs? By redefining death. First we coined "brain death," which let us take organs from people on ventilators. Then we proposed to allow organ retrieval even if nonconscious brain functions persisted. That goal has now been realized through "donation after cardiac death," the rule applied in Denver, which permits harvesting based on heart, rather than brain, stoppage.
Stoppage is complicated. There's no "moment" of death. Some transplant surgeons wait five minutes after the last heartbeat. Others wait two. The Denver team waited 75 seconds, reasoning that no heart is known to have self-restarted after 60 seconds. That's pretty dicey. Why push the envelope? Because every second counts. Mark Boucek, the doctor who led the Denver team, says waiting even 75 seconds makes organs less useful.
Actually, doctors don't wait for the donor's death. They arrange it. Not the illness or injury, of course, but the timing of demise. The Denver team calls this "anticipated" death, with donation as part of an "end-of-life care plan." Robert Truog, an ethicist who supports the Denver protocol, calls it "orchestrated withdrawal of life support," with the patient "monitored" for cardiac arrest and harvesting. The countdown in Denver began at around 20 minutes. Only the last 75 seconds took place after technical death. In the interim, doctors injected drugs to keep the organs viable for transplant.
The problem with some organ-sustaining measures is that they might technically reverse death. Oxygenation, for example, supplies the circulation whose absence was supposed to be the cause of death. To fix this problem, doctors have learned to block blood flow so that only the organs slated for transplant get oxygen. The rest of the patient remains safely dead.
The heart is a trickier problem. It's the one organ that technically has to die when, as in Denver, the donor is cleared for harvesting based on "cardiocirculatory death." How can a heart be certified as irreversibly stopped when the plan is to restart it in a new body?
Boucek offers two answers. One is that even if the heart resumes pumping in a new body, it couldn't have done so in the old one. That used to be true. But today, hearts can be restarted by external stimulation well after two or even five minutes. Second, he says the heart is dead because the baby's parents have decided not to permit resuscitation. In other words, each family decides when its loved one is dead. In a commentary attached to the Denver report, another ethicist proposes to extend this idea, letting each family decide not just whether to resuscitate but also at what point organs can be harvested. Brain death? Cardiac death? Persistent vegetative state? Death is whatever you say it is.
Enough, says Truog. Stop redefining death. Let's accept that we're taking organs from living people and causing death in the process. This is ethical, he argues, as long as the patient has "devastating neurologic injury" and has provided, through advance directive or a surrogate, informed consent to be terminated this way. We already let surrogates authorize removal of life support, he notes. Why not treat donations similarly? Traditional safeguards, such as the separation of the transplant team from the patient's medical team, will prevent abuse. And the public will accept the new policy, since surveys suggest we're not hung up on whether the donor is dead.
But down that road lies even greater uncertainty. How devastating does the injury have to be? If death is vulnerable to redefinition, isn't "devastating" even more so? The same can be asked of "futility," the standard used by the Denver team to select donors. Is it safe to base lethal decisions on the ebb and flow of public opinion, particularly when, as Hastings Center President Thomas Murray points out, the same surveys show confusion about death standards? And can termination decisions really be insulated from pressure to donate? Even if each family makes its own choice, aren't we loosening standards for termination precisely to get more organs?
Modern medicine has brought us tremendous power. With that power comes responsibility. Boundaries such as death, heart stoppage, and ownership of organs have guided our moral thinking because they seemed fixed in nature. Now we've unmoored them. I'm a registered donor because I believe in the gift of life, and the job of providing organs falls to each of us. So does the job of deciding when and how we can rightly take them.