Who decides when death begins? A wake-up call for organ donation ethics - Striking a Chord…

When death and life hang in the balance, who has the final say?

By now, many of you have likely heard the harrowing story of Anthony Thomas Hoover II, who was declared brain dead and scheduled to have his organs removed, but then showed signs of life. He woke up while medical staff were bathing his body in surgical solution and preparing to cut into him to remove his organs. “Even though the man cried, pulled his legs to his chest and shook his head, officials still tried to move forward,” Brian Rosenthal reported for The New York Times.

Hoover appeared to react to stimuli earlier that day, by making eye contact and shaking his head, but the doctor declared him brain dead anyway. That was what led to him lying in the operating room, about to be removed from life support so his organs could be harvested.

Thankfully, in this case, an operating room doctor intervened and refused to remove Hoover from life support.

Hoover was rescued from a nearly tragic fate, but it caused a lot of questions about the safety and integrity of the entire organ donation system. The organization preparing to remove Hoover’s organs, Network for Hope, is a federally-funded “organ procurement organization” (OPO) that operates in Kentucky, Ohio, and West Virginia. A recent federal investigation found that Network for Hope staff ignored signs of growing alertness not only in Hoover but dozens of other potential organ donors, Rosenthal reported.

The investigation examined about 350 cases in Kentucky over the past four years in which plans to remove organs were ultimately canceled. More than 100 had “concerning features, including 73 patients with neurological signs incompatible with organ donation,” the Department of Health and Human Services (HHS) said in a press release July 22. Furthermore, at least 28 cases involved patients who may not have been deceased at the time the organ procurement process began, raising “serious ethical and legal questions.”

In response, HHS has launched “a major initiative to begin reforming the organ transplant system,” being pushed by HHS Secretary Robert F. Kennedy Jr.

Network for Hope told CNN that after reviewing the case, it “remains confident that accepted practices and approved protocols were followed.”

This story is particularly jarring because the system that Americans have, by and large, come to trust (more than half of all Americans have registered as an organ donor) is now being seriously called into question.

Dr. Raymond Lynch of HHS, who spoke on Allie Beth Stuckey’s Relatable podcast, said that the organ donation system has been subject to congressional review for a number of years now, but in 2023 a decision was made that allowed for even more oversight, which is allowing some of these findings to come to light. HRSA (the Health Resources and Services Administration, the body that oversees HHS) has issued a corrective action plan, so that’s encouraging.

Lynch also said the vast majority of medical staff and others involved in organ procurement want to do the right thing ethically. He didn’t think what happened in the Hoover case or others like it was intentional, but rather an example of incompetence perhaps due to a lack of training. He said one big factor is medical staff not being properly trained in how to identify whether a person is unresponsive because of the influence of drugs (illegal or legal), or because they are truly brain dead.

He also said the U.S. still has the best organ donation system in the world and has been a leader particularly when it comes to kidney transplants.

There is a lot of nuance to this subject, as it can be hard to determine when exactly someone is deceased. While technology is wonderful and has allowed us some incredible medical breakthroughs, it has also ushered in a host of ethical questions that we didn’t have to answer earlier in human history. Even 100 years ago, we did not have all the modern methods of life support we have today.

Part of the increase in transplants is due to the rise of donation after circulatory death (DCD), also known as non-heart-beating donation, which refers to the recovery of organs from a deceased individual after their heart has stopped beating and cannot be restarted, but before brain death is declared. This is opposed to donation after brain death (DBD), which involves donation after a patient has been declared brain dead, meaning there are no signs of neurological activity. In these cases, patients are kept on a ventilator until their organs are retrieved.

DCD initially was limited to a small number of facilities, primarily in Europe, in the early 2000s. Since then, it has become more widespread to where it accounted for a third of all donations last year, about 20,000 organs. That is triple the number from five years ago.

There has also been a greater incentive to pursue DCD.

“H.H.S. said in 2020 that it would begin grading procurement organizations on how many transplants they arranged. The department has threatened to end its contracts with groups performing below average, starting next year. Many have raised their numbers by pursuing morecirculatorydeathdonors,”Rosenthal wrote.

There is additional pressure because of the short time frame to transplant organs. For example, a donor heart must be transplanted within four to six hours of removal from the donor. For lungs, that timeframe is four to eight hours. A liver must be transplanted within eight to 12 hours.

The need is also great. More than 100,000 are on the organ transplant waiting list, and 12 to 13 people die every day while waiting for an organ.

Of course, outside pressures never justify killing someone just so their organs can be given to someone else. Every life has dignity, and the potential saving of someone’s life through organ donation does not justify prematurely taking someone else’s life.

To be clear, I am not against organ donation. When done ethically, it can be a wonderful, redemptive thing. I have written about the merits of organ donation before in this space. But, I can understand people’s hesitancies given the new information that has come out.

In the end, organ donation is a very personal decision and one that should be discussed with one’s family, along with other end-of-life topics, including matters such as do-not-resuscitate (DNR) orders, will and estate planning, or funeral and burial wishes. If someone has a terminal condition, it’s important to talk about whether they wish to continue treatment — such as chemotherapy for cancer — or would prefer to let the disease run its course for however long they have.

Although these can be taboo topics, it’s better to have these conversations now and make your wishes fully known rather than leave family members guessing at what you would have wanted. It also alleviates a measure of stress for them, knowing there is a plan laid out.

Food for thought. Have a good week!