“Ethically Sourced?” Is it important in organ transplantation?

“Ethically sourced” is a common phrase in international trade these days, referring to the way a business's products and services are obtained. The phrase considers environmental sustainability, responsible harvesting and production, even factoring in whether the business respects the rights of its workers.

The standard has become much more than a catchphrase but has failed to gain traction in an arena where it is perhaps most sorely needed.

The industry of organ transplantation fails to meet any element of the ethically sourced standard, and the weak and faltering rules already in place are now suffering an all-out assault they cannot hope to withstand.

Organ transplantation is incredibly profitable. Few, if any, other medical disciplines offer such a steady stream of income to both surgeons and the hospitals that host them. However, transplantation requires viable donor organs which are never in plentiful supply.

Many organs, like hearts and lungs, must be taken immediately following circulatory death before they degrade to the point of disutility.

As medical technology surges past the ability of medical ethics to keep pace, securing avenues for procuring a reliable supply of transplantable organs and tissues has become job one.

In the middle of the last century, medical science developed techniques to replace or augment more and more failing organs, creating a need for a comprehensive, repeatable strategy for procuring those organs. This circumstance led to one of the earliest, and most successful, public information campaigns in America.

As the United States became a highly mobile, automobile dependent society, the number of deaths in vehicle accidents increased dramatically.

This presented an opportunity to greatly increase the donor pool, if a means of reaching large numbers of people before an accident could be found. Pre-consent to organ donation was soon coupled to applications for driver’s licenses in many states, with frequent advertisements raising awareness of the need. The campaign prompted a huge increase in willing donors.

But again, technology outpaced supply. Even with the advent of Organ Procurement Organizations (OPO), which standardized reporting and sourcing methods, the unpredictability of death meant a majority of cadavers still went unharvested, even when the deceased had already given consent to donation.

Most organ donations are wholly time sensitive, making it functionally impossible to deploy transplant teams in the short interim between death and the degradation of organs. A new, more predictable source of organs had to be identified, a source that could be made available with greater predictability, even with scheduled predictability.

Once again, the victims of tragic accidents would be called on to fuel this exploding industry.

In the late ‘60’s, an ad hoc committee at Harvard launched an effort to redefine the clinical meaning of “death.” Internal notes within the committee later revealed this was knowingly done to increase the supply of viable donor organs from a new category; those declared to be “brain dead.”

Like nearly every major shift in medical policy, the subject of what constitutes brain death wasn’t hashed out in a series of scientific study-based debates, or developed from hard clinical data proving the thesis, but instead grew from an assertion made in a medical journal, bandied about in competing articles for a period of time, then simply adopted as the new “rule” as opinion coalesced around a consensus.

Of course, achieving a consensus is irrelevant to accuracy – many people can be just as wrong as a few people. However, this is the methodology the medical industry follows, largely due to a lack of consensus on a better way.

While this aggregation of opinion may serve well for determining the best method to treat a hangnail, it fails miserably when applied to far more complex and irreducible problems, like deciding when someone is dead enough to start harvesting bits and pieces of them.

Groups dedicated to promoting organ donation often compound the problem by declaring donation to be an unqualified social good, a blanket assertion which serves to obscure the question of ethics in procuring those donations. A question might be asked, is informed consent present when the donor and/or their loved ones aren’t fully informed?

Ask any number of people who have checked the organ donation box on their driver’s license how they feel about making that final, life-giving gift, and nearly all will respond with some form of “I don’t need them anymore, let someone else have them.”

Ask those same people if they would want such donations to occur while there’s still some question about whether the donor is still alive, and the horror in their faces is evident.

Who among us would permit our loved one – wife, husband, child – to be trolleyed beyond those Operating Room doors for organ harvest if they knew their family member was not only still alive, but very possibly aware of what was happening to them.

Organ harvesters don’t waste anesthesia on donor bodies. Yet, if that donor is aware, even dimly, of their surroundings and the pain their bodies are sensing, wouldn’t that procedure qualify as the furthest thing from a “social good?”

As medical science has pushed the boundaries of the possible, we frequently encounter instances where we push beyond a moral line. Even when pursuing a praiseworthy goal, the journey can be wholly reprehensible. In mid-20th century Germany, great strides in understanding human physiology, function and disorder were made, but at the cost of humanity itself.

Human experimentation without restriction resulted in medical insights, which under different circumstances would be laudable advancements in medicine, but in reality, were so repugnantly obtained they were rendered less than worthless, they were anathema to medicine itself.

As technology is increasingly brought to bear on the various maladies and complaints of mankind, the temptation to step beyond the line of propriety is ever-present, and too often indulged.

The Uniform Determination of Death Act – which is no act in the legislative sense, but rather a protocol adopted largely by consensus – originally laid out some fairly stark lines, but as the “possible” in medicine became the “profitable,” these lines have been smudged into near invisibility.

The “Dead Donor Rule,” which in essence states that organ harvesting cannot be done until the donor is indeed dead, nor can the act of harvesting bring about the death of the donor, while not a legal proscription, has always been the governing principle under which organ transplantation takes place in the United States.

Once groused about under the breath of those medicos who saw it as an obstacle to be overcome, the rule is now all but dead as physicians’ groups and organ donation organizations have declared it outdated and inappropriate for the modern complexities of transplantation.

The meaning of words like “permanent,” and “irreversible” are being challenged by transplantation advocates who are increasingly discovering advances in medical tech don’t merely benefit their particular bailiwick, but also offer greater insight into the meaning of brain death, and circulatory death.

Death was once defined as blue, lifeless and cold, but now comes in many shades and temperatures, depending on the definition. A person today can be pink, warm, and functioning, and still be considered dead for the purposes of organ harvesting.

The silver platter boon to transplantation we call “brain death,” is meant to describe someone whose brain functions have irreversibly ceased, leaving only a body operating minimally, with artificial, mechanical support. However new diagnostic tools have revealed this to be an unjustified assumption in far more cases than previously thought.

With mechanical ventilation, “brain dead” individuals still maintain a wide array of biological functions, including circulation, respiration, wound healing, infection fighting, temperature regulation, and secretion of neurohormones. Some have even gestated a fetus. They are not dead according to the established biological conception of death.

Moreover, many of these functions are entirely directed by the brain, putting the lie to the idea that brain functions have “irreversibly ceased.”

Some counter this argument by pointing to the necessity of mechanical ventilation, suggesting the ventilator is acting as a “life substitute.” This point falls apart when one considers that a ventilator only pushes air in and out of a patient. The patient’s body has to negotiate the oxygen transfer, the myriad processes of blood oxygenation, and removal of waste products at the cellular level, etc.

Clearly there’s a lot more going on than a simple air handling, HVAC operation.

The current rush to redefine the Uniform Determination of Death Act is both unseemly and starkly mercenary. Same goes for advocating the abandonment of the “Dead Donor Rule.”

If any changes need to be made at this juncture, it would be to strengthen both guiding principles by adopting them as law. Until we have a much deeper understanding of brain function, anything less restrictive is brutally inhumane.