Human Nature: Science, Technology, and Life.

Organs, Haste, and Culpability

We have a verdict in the premature-organ-harvesting case.

Let's go to the Los Angeles Times for a summary of the case. Two years ago, the patient, Ruben Navarro, lay close to death after a heart attack.

His mother had given permission for organ donation, and a team that included [Dr. Hootan] Roozrokh flew in from San Francisco on behalf of a regional transplant network.  Roozrokh ... was to supervise a donation after cardiac death ... In most transplants, the removal of organs occurs only after a patient is declared brain-dead. In donations after cardiac death, a patient's brain is irreversibly damaged but still functioning minimally. With a family's consent, the patient is removed from life support and, once the heart has stopped, the patient is declared dead, and organs may be removed minutes later. Many experts say, however, that organs are usable only if they can be retrieved within 30 minutes after the machines are turned off.
According to prosecutors, Roozrokh ordered up excessive doses of the painkiller morphine and Ativan, an anti-anxiety drug, so that Navarro would die within that crucial half-hour. As it turned out, he died eight hours later and Roozrokh did not remove any organs.

So the basic problem was that Navarro's medical care was being directed by a guy sent to the hospital to get his organs—and that the doctor's actions may have helped the organs but not the patient. The doctor was looking at a felony charge, dependent adult abuse, with a possible sentence of four years.

Verdict: Not guilty. But the jury also issued this statement (handwritten PDF here):

Ruben's case has identified that Donation by Cardiac Death (DCD) is in desperate need for further identification of prescribed policy in order to continue successfully as a viable option for organ donation in this country. Refining the nationwide protocol of DCD organ procurements will be an important part of Ruben's legacy...

In other words, Roozrokh may have crossed the line, but the jury blames the system, or lack thereof, for failing to draw the line clearly in the first place. I think the jury did the right thing. Most of us are selectively pious. We like to single out villains when bad things are done. It's harder to admit that the bad things are extensions of good ideas and that the people behind those ideas include us. What happened to Navarro wasn't a bad doctor. It was a system that has increasingly pushed boundaries to get organs that save lives. As Art Caplan puts it in the Times story:

There's a growing waiting list; there are more centers competing for donors; and it's a very lucrative procedure for hospitals. It's against that backdrop that the story of a doctor being sent out to come back with organs unfolds.

The pressure has reached the point where doctors at one hospital, as noted here,

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.

It's a discomfiting new trend of treating people as bags of organs. But the driving force behind this trend isn't Hootan Roozrokh. It's all of us.

Meat Wagons

If you're old enough to imagine your dead body being carted away, you're probably old enough to remember "Meat Wagon Action Set," the sidesplitting (oops—wrong metaphor!) parody ad that first aired on Saturday Night Live in 1977. It looked like an ordinary commercial for a kids' race-car set until one car crashed and burst into flames. That's when the flagship vehicle arrived: an ambulance that picked up the bodies and hauled them away. In the background, you could hear the manly jingle, "Meat Wagon ..."

Back then, "meat wagon" was just slang for ambulance. No more. It's about to become quite real. Here's the skinny (oops—bad metaphor again!) from Rob Stein of the Washington Post. Backed by a three-year federal grant,

New York City is working on a plan to deploy a special ambulance to collect the bodies of people who have died suddenly from heart attacks, accidents and other emergencies and try to preserve their organs. If the "rapid-organ-recovery ambulance" succeeds, officials would like to expand the unique pilot program citywide with a fleet of ambulances and eventually duplicate it in other cities.

Stein explains how the plan would work:

Once all hope for resuscitation was gone, and as long as no family members objected, the victims' bodies would be transferred to the organ ambulance team, even if the victims' willingness to be organ donors was unclear. The crew could then perform measures on the body to prevent the organs from deteriorating, including chest compressions with an automated device and pumping oxygen into the lungs through a tracheal tube to keep blood and oxygen flowing. The crew might also administer the blood-thinning drug heparin to prevent clots while speeding to Bellevue. At the hospital, doctors could take additional steps, such as inserting a plastic tube known as a cannula into an artery, usually in the groin, to infuse the body with fluids to cool and preserve the organs. Organ bank workers would then assess whether the person was a suitable donor, determine whether they had an organ donor card or were listed on an organ donor registry, and try to locate a family member to give consent.

As you can imagine, the plan is freaking some people out. One bioethicist calls it "disgusting." But let's step back and understand what's going on here: Medicine is becoming ever more efficient and rational. Thanks to improving technology, organs that were previously useful only to their owners are now useful to other people, too. This has created pressure on doctors to think about dying people as resources, not just as patients. This pressure, in turn, has driven a movement to loosen organ-collection rules so that people who aren't yet brain-dead can be prepped for harvesting.

Meat wagons are the next step. They advance the rationalization of organ harvesting from the hospital to the street. Instead of letting perfectly good innards go to waste, they go out and get them.

If this creeps you out, you're not alone. But remember Human Nature's first law: In technology, bad things don't happen because they're bad. They happen because they're good. Nearly 100,000 Americans are officially waiting for organ transplants. Just yesterday, a friend of mine disclosed that her kidneys are failing, and she needs a donor. When you think about all these people, it seems crazy that healthy organs are being routinely thrown away with their owners. Stein reports:

Currently, New York City paramedics try for about 30 minutes to revive patients whose hearts have stopped before declaring them dead, while a doctor monitors their efforts remotely. The bodies are then taken to a funeral home, morgue or medical examiner's office.

The meat-wagon plan would end this presumption of nondonation. But the shift of presumption wouldn't start at death. It would start beforehand. Things you would never do to a hopelessly dying loved one—automated chest compressions, oxygen pumping, and injections of blood thinners of preservatives—make perfect sense when you start to think of that person as a failing organ bank. Nature doesn't give you the luxury of waiting for total, irreversible death. She starts ruining organs well before that. If you want them, you have to move fast.

Meat wagons won't be the last step in the movement toward efficient organ harvesting. The next steps are already underway. As Stein points out, the compressions and injections would begin on board the meat wagon "even if the victims' willingness to be organ donors was unclear," in order to keep open the harvesting option while organ collectors hustle to locate family members and lobby them for consent.

The next barrier to go will be the five-minute rule. Under the current plan, Stein reports, "The organ team would wait five minutes after EMTs give up on resuscitation, to create a clear demarcation between efforts to save lives and those to preserve organs." But in those five minutes, lots of organs will spoil. Once we've accepted the idea that dying people are also organ banks, it's hard to see why we'll tolerate this delay. We'll probably shorten it a minute at a time.

We'll also dispense with the distinction between ambulances and meat wagons. For now, officials are determined to keep these functions in separate vehicles, so families and neighbors don't freak out when the ambulance shows up. But in the long run, it makes no sense to have a vehicle on the scene that can do only half the job. I can't imagine cities assembling, staffing, and dispatching fleets of meat wagons when they already have fleets of ambulances ready to be dually equipped.

Until then, fear not the meat-wagon siren. As long as you can hear it, it wails not for thee. At least, not yet.