It always pains me to have to disagree with Wesley J. Smith, who is such an important and stalwart spokesman for the cause of human exceptionalism, but this time, I have to do so.
Smith is positively inclined toward this proposal to institute "organ preservation" measures on patients who "die unexpectedly" when they or their relatives have not yet agreed to organ donation. The actual proposal is to ask relatives only to agree to these "preservation" measures at first, to give them time to process the patient's death, and then after some unspecified period of time (I cannot see how it would be more than a few days, maximum) to try to obtain their agreement to actual organ donation. Wall, et. al. (the JAMA article authors) sound like they would actually prefer a European system in which organ preservation is begun immediately on all patients whether or not relatives consent, but they realize that people in the U.S. will balk at this and suggest this alternative as (it appears to me) a halfway house sop to U.S. sensibilities.
I think their proposal is a very bad idea.
First, although the article characterizes the proposal as initiating "organ preservation" (meaning, among other things, artificial means of guaranteeing blood flow and oxygenation in the body) only after death, one complaint it is designed to answer is this one:
During controlled donation after circulatory determination of death (CDCDD), the time from cessation of life support to circulatory arrest often exceeds 60 minutes. Prolonged hypotension leads to irreparable organ damage, thus limiting the effect of CDCDD on organ supply.
Notice that this complaint concerns the fact that the patient was allowed to suffer circulatory death after the removal of life support. This might, say the authors, be a long, slow glide into natural death, which would mean that circulation to some organs desired for transplant might be compromised before the patient ever was declared dead in the first place. Insofar as their proposal is meant to be an alternative, then, it must be proposing that patients in such scenarios not be taken off of life support and permitted to die a natural death! This would mean that this way of regarding the patient as a potential donor would have to affect decisions made before the patient was even declared dead. In order to avoid prolonged low blood pressure (of an hour or more) while the patient was being permitted to die naturally after being taken off life support, the relatives would apparently be asked to agree to keep the patient on life support. It seems to me that this would have to mean that some other means of declaring death would be used rather than circulatory death, if the concern is that allowing the patient to die after coming off life support would take too long. It is unclear precisely what the authors have in mind here as a "better" alternative (from the perspective of maintaining organ condition in a dying patient). Perhaps they are envisaging keeping the patient on life support and eventually declaring death by neurological criteria (so-called "whole brain death") when that becomes possible, but they do not say so. The article is unclear at this point, but what is clear is that their proposal would affect the treatment of patients even before they were deemed dead by the medical profession. Hence, this would mean that families who wanted to have, say, a ventilator discontinued and to allow the patient to die naturally afterwards would be asked to agree to some other death process for the sake of organ maintenance. This is undesirable interference in the dying process for the sake of conceiving the still-living patient as a means to an end.
Second, they are clearly envisaging in other cases taking a patient who has been declared dead by circulatory criteria (perhaps a patient whose heart stopped outside of an ICU context) and swiftly restarting his circulation and oxygenation before warm ischemia can take place:
UDCDD requires initiation of organ preservation soon after death. If the warm ischemic time, which represents the time organs receive inadequate circulation to sustain cellular function, exceeds an organ-specific threshold, organs are not viable. [snip] We propose a 2-step authorization process following unexpected death to better support grieving family members while increasing opportunities for donation through UDCDD.
The first step, permission for preservation, seeks permission to maintain the body for possible organ donation after unexpected death. This step requires only that families and other authorized persons are able to indicate a choice to begin organ preservation, not a full authorization for donation.
Since they have already made it clear that even one hour would be too long (and this is true), this request for permission is going to have to be extremely swift. In fact, it's difficult to see how this program could possibly work. Only kidneys of the vital organs can endure even a moderate period of warm ischemia. For a heart, lung, or liver the tolerance is no more than five minutes! I assume that they are envisaging attempting to increase the supply of kidneys by these means, but even so, the request for preservation is going to have to go out to the family with incredible swiftness if the kidneys are going to be saved. And if the idea is to get any more vital organs, the family is going to have to agree to restarting the heart, etc., after no more than five minutes! In neither case does this allow the grieving families any decent amount of time to understand and think about what is being requested, especially in a case of truly sudden and unexpected death. As I have pointed out repeatedly, the picture of vital organ donation as taking place from stone cold, unambiguous corpses is a misguided one and is simply scientifically and medically incorrect. Vital organs are more delicate than that, and everyone in the transplant community knows this and would consider it unethical to transfer organs from a corpse that had been allowed to "sit around" for any significant period of time.
So at a minimum, even if only kidneys are in view, we are talking about rushing relatives to agree very quickly to this "organ preservation," and this is undesirable. See here, as well:
The US organ donation system is neglecting the much larger pool of potential donors who could provide organs following unexpected death outside an intensive care unit.
So they are talking about jumping on relatives of people who die outside of an ICU. In fact, this proposal is much like the vulture proposal momentarily considered in New York, with only the difference that what the vultures rush to get your permission for is "organ preservation" rather than (yet) actually taking the organs. I'm surprised that Smith doesn't realize the similarity and raise objections for that reason.
Third, and most troubling of all, is what is involved in the so-called "preservation" if begun after a declaration of death on circulatory grounds. I have quoted this before, but it needs to be reemphasized.
Artificial support of circulation with cardiopulmonary bypass and reintubation for lung ventilation are required for organ viability in donors. The donation-related procedures can resuscitate (reanimate) organ donors during procurement, which requires pharmacological agents (chlorpromazine and lidocaine) and/or occlusion of coronary and cerebral circulation for suppression...
That quotation is from this article, "Organ Procurement After Cardiocirculatory Death: A Critical Analysis."
Focus for a moment on that last quotation. What it is saying is this: What they have to do to create circulation for organ donation is to engage in aggressive, artificial measures to restart circulation throughout the relevant parts of the body and to make the lungs breathe. If these procedures are started very quickly after the patient has been declared dead on circulatory and respiratory criteria (declared dead because he isn't breathing and has no heartbeat), it can happen that the so-called "preservation" procedures actually revive the patient. To prevent this, when these procedures are done (especially if whole brain death has not been declared and there is therefore more fear of the patient's reviving), the transplanters will either physically block off the circulation to the brain or give strong drugs to prevent the patient from reviving! This is ghoulish and completely unethical. It should be shouted from the housetops and should, in fact, bring about a complete moratorium on (at a minimum) any organ donation from patients who are not found to have suffered whole-brain death. All organ procurement after the mere declaration of circulatory death should be halted because of these considerations--namely, that the restart of circulation in a possibly revivable patient is so quick that the patient may be, in essence, simultaneously revived by the "preservation" procedures and actively murdered by deliberate occlusion of circulation to the brain! (Yet the whole-brain death criterion has its own problems, so yes, it may be that there is no ethical way to get vital organs. If so, so be it.)
Now, as far as I can see, this is exactly the sort of thing that Wall, et. al., must have in mind when they talk about "organ preservation." These aggressive measures are required for organ preservation and, apparently, if started quickly enough they may revive the patient, so...At a minimum, powerful drugs are given to make sure that no embarrassing incidents take place.
In other words, asking grieving relatives to agree to swift "organ preservation after death" is not an unambiguous, neutral, ethically unproblematic request. What the relatives would be agreeing to is, potentially, an interruption of the process of natural death in their relative, but without the possibility that the relative will be allowed to revive or that resuscitation will be recognized or admitted if it were to occur, since death has already been declared! I would never, under any circumstances, agree to "organ preservation after unexpected death" given what I know.
Wesley Smith has faithfully sounded the alarm in various cases and has even taken much flak for it, and he deserves our great gratitude for all his important work. However, he still believes that diagnosis of death is simple and unproblematic in a great many cases and that organ procurement procedures undertaken after that diagnosis cannot change matters. The medical evidence is otherwise. It may be unproblematic in a sense to declare a person dead because he isn't breathing and his heart isn't beating. That's fine for purposes of putting on the death certificate. But if he can be "brought back" for some period of time thereafter, then you'd darned well better not begin procedures that might bring him back while having set up a situation in which he won't be allowed to revive because his organs are slated for donation or possible donation!
This problem presents, in my opinion, an ethically insuperable obstacle to the proposal of Wall, et. al.
The point here is that "organ preservation" is not really separable from organ procurement in the way that Wall, et. al., imply and that Smith hopes it can be. Many of the ethical problems of organ procurement arise from the very conditions of organ preservation: The patient is deliberately placed into a biologically ambiguous state where legitimate question can arise as to whether the patient is biologically dead. The patient is not simply allowed to die a natural death, without aggressive life support procedures, and his body to assume room temperature, because that renders vital organs unsuitable for transplant. Yet at the same time, this possibly-not-dead patient has been declared dead so that later questions are simply not allowed to arise legally or medically. The Jahi McMath case shows that questions about death can arise for a patient on life support even in a case where whole brain death has been declared by extremely cautious procedures over a long period of time. (To clarify, organ donation was never considered in Jahi McMath's case.) So much the more can such an ambiguity arise when a patient's heart and breathing have stopped unexpectedly, the patient has been declared dead, and the patient has then very quickly been placed on circulatory and respiratory support.
We need to recognize that the problems of vital organ donation are extremely deep and broad. If this raises serious doubt as to whether it can ethically continue, maybe that's exactly how it should be.