Ethical Controversy Persists Over Organ Procurement Method
Ethical debate continues over a controversial method of procuring organs for transplantation: Normothermic regional perfusion with controlled donation after circulatory determination of death (NRP-cDCD). “A number of ACP [American College of Physicians] members brought the issue of NRP-cDCD to the attention of our Ethics, Professionalism, and Human Rights Committee with significant ethical concerns,” reports Lois Snyder Sulmasy, JD, director of the American College of Physicians Center for Ethics and Professionalism.
The committee issued a Statement of Concern recommending a pause in the practice.1 NRP-cDCD calls for using ECMO, cardio bypass, or other technologies to restore circulation to vital organs or restart the heart to improve the quality of and expand the number of organs available for transplant. According to the ACP statement, the method raises ethical concerns about obligations of respect, beneficence, and justice, as well as the ethical imperative against using one individual to serve the ends of another individual.
“After the statement came out, we also began hearing from transplant surgeons with strong concerns,” Sulmasy adds. “In the face of severe doubts about whether this is ethical and legal, institutions should be wary about allowing this procedure to be performed.”2
A member of the ACP Ethics, Professionalism, and Human Rights Committee, Joseph J. Fins, MD, MACP, FRCP, says, “as clinicians and hospitals consider the ethical propriety of NRP-cDCD, they need to be deeply concerned about transparency and informed consent.”
Do families who give consent to these donations truly understand that after a declaration of death by cardiopulmonary criteria, there is blood recirculation to the body along with ligation of the arteries to the brain so as to ensure neurological death? “This is a very complicated story that brings into question the nature and cause of death,” asserts Fins, chief of the division of medical ethics at Weill Cornell Medical College.
Fins says this is fundamentally different than traditional organ procurement, violates the dead donor rule, and could undermine public trust in medicine and about organ donation.
Some in the organ transplantation community disagree with the ACP’s statement.3 “We felt that the position was deeply flawed and needs a healthy discussion. Our paper is a point-by-point rebuttal on the areas of contusion,” says Nader Moazami, MD, chief of the Division of Heart and Lung Transplantation & Mechanical Circulatory Support at New York University Langone Health.
Moazami and colleagues argued NRP-cDCD respects the “dead donor” rule and the legal definition of death while honoring the wishes of the deceased and their family to potentially save the lives of others. They also argued the practice will result in more optimal organs becoming available for life-saving transplants. Moazami would like to see “guiding principles established for DCD heart donation to allow life-saving procedures, which are in accordance with the family’s wishes, to proceed.”
NRP-cDCD offers a way to use organs that would otherwise be discarded, and are also a way to respect a donor’s last wish, according to Ashish S. Shah, MD, FACS, chair of the department of cardiac surgery at Vanderbilt University Medical Center.4
“Transplantation has always challenged our notions of death, utility, and the greater good. Honoring the donor’s wish or their family’s wish, is a foundational element of human organ donation,” Shah says.
In Shah’s view, any ethical constructs must consider the donor’s wish but also, importantly, their decision-making surrogates’ wishes. “Similar to any end-of-life discussion, we, as a civilized society, have agreed that others can make decisions when we are incapacitated,” Shah notes.
Heart transplantation is no longer experimental; it saves lives and restores quality of life in a way that no other therapy (pharmaceutical or mechanical) can.
“Therefore, we consider it a precious resource, and it merits serious consideration when there is risk of wasting it. Unlike objects that are renewable, suitable human hearts should not be discarded, ever,” Shah says. “As such, a relevant ethical framework is necessary to guide novel and not-so-novel methods to recover human hearts.”
REFERENCES
- American College of Physicians. Ethics, determination of death, and organ transplantation in normothermic regional perfusion (NRP) with controlled donation after circulatory determination of death (cDCD): American College of Physicians Statement of Concern. April 17, 2021.
- Opole IO, Deep NN, Snyder Sulmasy L. On the ethics of NRP and the American College of Physicians NRP statement. Am J Transplant 2022; Mar 5. doi: 10.1111/ajt.17014. [Online ahead of print].
- Parent B, Caplan A, Moazami N, Montgomery RA. Response to American College of Physician’s statement on the ethics of transplant after normothermic regional perfusion. Am J Transplant 2022; Jan 24. doi: 10.1111/ajt.16947. [Online ahead of print].
- Shah AS. Normothermic regional perfusion in donor heart recovery: Establishing a new normal. J Thorac Cardiovasc Surg 2021; Dec 9:S0022-5223(21)01735-9. doi: 10.1016/j.jtcvs.2021.11.084. [Online ahead
of print].
Ethical debate continues over a controversial method of procuring organs for transplantation: Normothermic regional perfusion with controlled donation after circulatory determination of death.
Subscribe Now for Access
You have reached your article limit for the month. We hope you found our articles both enjoyable and insightful. For information on new subscriptions, product trials, alternative billing arrangements or group and site discounts please call 800-688-2421. We look forward to having you as a long-term member of the Relias Media community.