The Advancing Slippery Slope of Organ Donation and Euthanasia

The timing of organ donation relative to death of the donor is critical to the survivability and future functioning of the donated organs in the transplant recipient. With cardiovascular death, circulation ceases in the donor causing his or her death, making it legally and ethically permissible to retrieve the organs for donation. Unfortunately, cardiovascular death also means that the donated organs have also lost circulation at the moment of death and begin to suffer local tissue destruction, affecting the very health of the donor organs and success of transplantation. If the donor has sustained severe brain damage but without cardiovascular death, he or she may be considered dead secondary to whole brain death criteria. This allows transplant surgeons to begin harvesting the organs from the donor while the organs are still enjoying a normal oxygen supply, maximizing their survivability for the future transplant recipient. These organs are far more viable than those from donors who had cardiovascular death, similar to the situation of a healthy living organ donor voluntarily donating one of her two kidneys. Crudely, the less dead you are when you donate your organs, the better chance of success of the organ transplantation for the recipient. Knowing the exact moment when the donor dies maximizes the timing and therefore the success of the transplant process.

Enter euthanasia, in particular the growing acceptance of medical aid in dying (MAID) or physician assisted suicide (PAS), where a physician is directly controlling the dying process. The union of MAID/PAS and organ donation would seem to be a marriage made in transplant heaven. By controlling the time of death of the donor, the subsequent immediate harvesting of the donated organs would theoretically maximize their viability. What could be better?

Euthanasia via organ donation, of course.

The NEJM offered a recent Perspective entitled “Altruism in Extremis – The Evolving Ethics of Organ Donation” by Dr. Lisa Rosenbaum. The article is behind a subscription firewall that does offer limited free access with registration. In short, Dr. Rosenbaum explores many of these ethical issues in organ transplantation as she describes the case of a man who was dying of amyotrophic lateral sclerosis (ALS or Lou Gehrig’s Disease) and wanted to donate his organs in the process of his MAID/PAS (hence her title “Altruism in Extremis“). In his case, the plan was to donate one kidney, then be taken back to the intensive care unit and extubated, technically allowing the ALS respiratory muscle weakness to cause his death, and the remainder of his organs harvested immediately thereafter. The hospital ethics committee approved the plan but the hospital attorneys warned the doctors they might be “charged with murder or acceleration of the patient’s death” (facts not apparently obvious to the doctors). In the end, the patient died in hospice care, unable to donate his organs.

An interesting sidebar discussion of a similar case involving “live donation prior to planned withdrawal” (LD-PPW – that is, removing the organs before withdrawal of life support – what I have labelled Euthanasia via Organ Donation) was considered ethically permissible but politically problematic, the concern being LD-PPW might reduce the number of willing donors who saw the “surgeons as ‘vultures’ stealing organs from those not quite dead”.

What struck me was the obvious slippery slope on which we find ourselves. The question as to whether the patient in Dr. Rosenbaum’s article should proceed with MAID/PAS given his terminal ALS was NOT the ethical debate but rather how to ethically marry MAID/PAS (perhaps ideally with LD-PPW) with his desire for organ transplantation. Labeling this type of organ donation as obviously altruistic will undoubtedly place further pressure on some presently terminally-ill patients to get on with their deaths to make their organs available for the rest of us who apparently have an unspecified ethically superior claim to their use. Organ donation from a living donor is itself a supererogatory act – additionally encouraging the donor’s suicide (and labelling it altruistic) just to improve the success of the transplant is calling evil good. Why is one more minute of life-giving use of my heart or liver by me necessarily less ethical than 1 year of life-giving use of those organs in another?

P.S. Frankly, I thought the vulture metaphor failed as even vultures normally wait for their prey to be dead before enjoying their harvest.

Vouchers for Kidneys

An innovative voucher program has begun at the UCLA Medical Center to increase the number of live kidney donations. The program allows for an individual to donate his or her kidney in exchange for a voucher that allows the donor’s specified voucher recipient to receive a kidney in the future. See HERE for the details.

Presently the number of people needing a kidney donation far exceeds the number of available kidneys. Historically, kidneys were obtained upon the death of an individual via the United Network for Organ Sharing (UNOS) and were (and still are) dispensed via a transparent process matching donors and recipients based upon disease severity and tissue-type matching. More recently, it has become possible for a living person to donate one of their two kidneys to another individual that the donor specifies (usually a close family member). The process is managed by several organizations, such as the National Kidney Registry. The process is regulated such that donor kidneys may not be bought or sold. There are real health risks to the donor in a live kidney donation but the actual risk of death is low. Despite the addition of live kidney donations to the pool from UNOS, the number of people awaiting a kidney donation far outpaces the number of available kidneys – approximately 13 people die every day awaiting a kidney transplant.

Trusty Wikipedia defines a voucher as “a bond of the redeemable transaction type which is worth a certain monetary value and which may be spent only for specific reasons or on specific goods”. Is this voucher system going to lead to a “cash for kidneys” situation? Presently, there appear to be some good safeguards in place. The UCLA voucher is not transferable to anyone other than the five people listed on the voucher, and only the first person within the list needing a kidney can redeem that voucher. Recipients are also identified by specific tissue typing and blood typing, making it virtually impossible to transfer the voucher to a random person. As long as these restrictions remain in place, these vouchers should have no market value for anyone not listed on the voucher.

But the voucher program does abstract the act of donating a kidney, storing the value of the act in paper format, allowing its redemption (in this case, the receiving of a kidney) at some future time. Effectively, the voucher program monetizes the kidney donation. Kidneys perish and vouchers do not. This is effectively one of the benefits of using money over bartering as a basis for expanding trade. UCLA hopes the voucher program results in such an expansion of the supply of kidneys and that expansion of supply is a good thing.

However, this monetization of the kidney donation program demands we remain ever more ethically vigilant to avoid heading down the slippery slope of “cash for kidneys”.