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Busch EJN. Restoring the Organism as a Whole: Does NRP Resurrect the Dead? THE AMERICAN JOURNAL OF BIOETHICS : AJOB 2024; 24:27-33. [PMID: 38829586 DOI: 10.1080/15265161.2024.2337403] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/05/2024]
Abstract
The introduction of normothermic regional perfusion (NRP) in controlled donation after circulatory determination of death (cDCDD) protocols is by some regarded as controversial and ethically troublesome. One of the main concerns that opponents have about introducing NRP in cDCDD protocols is that reestablishing circulation will negate the determination of death by circulatory criteria, potentially resuscitating the donor. In this article, I argue that this is not the case. If we take a closer look at the concept of death underlying the circulatory criterion for determination of death, we find that the purpose of the criterion is to show whether the organism as a whole has died. I argue that this purpose is fulfilled by the circulatory criterion in cDCDD protocols, and that applying NRP does not negate the determination of death or resuscitate the donor.
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2
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Bernat JL, Khush KK, Shemie SD, Hartwig MG, Reese PP, Dalle Ave A, Parent B, Glazier AK, Capron AM, Craig M, Gofton T, Gordon EJ, Healey A, Homan ME, Ladin K, Messer S, Murphy N, Nakagawa TA, Parker WF, Pentz RD, Rodríguez-Arias D, Schwartz B, Sulmasy DP, Truog RD, Wall AE, Wall SP, Wolpe PR, Fenton KN. Knowledge gaps in heart and lung donation after the circulatory determination of death: Report of a workshop of the National Heart, Lung, and Blood Institute. J Heart Lung Transplant 2024; 43:1021-1029. [PMID: 38432523 PMCID: PMC11132427 DOI: 10.1016/j.healun.2024.02.1455] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/13/2024] [Revised: 02/07/2024] [Accepted: 02/16/2024] [Indexed: 03/05/2024] Open
Abstract
In a workshop sponsored by the U.S. National Heart, Lung, and Blood Institute, experts identified current knowledge gaps and research opportunities in the scientific, conceptual, and ethical understanding of organ donation after the circulatory determination of death and its technologies. To minimize organ injury from warm ischemia and produce better recipient outcomes, innovative techniques to perfuse and oxygenate organs postmortem in situ, such as thoracoabdominal normothermic regional perfusion, are being implemented in several medical centers in the US and elsewhere. These technologies have improved organ outcomes but have raised ethical and legal questions. Re-establishing donor circulation postmortem can be viewed as invalidating the condition of permanent cessation of circulation on which the earlier death determination was made and clamping arch vessels to exclude brain circulation can be viewed as inducing brain death. Alternatively, TA-NRP can be viewed as localized in-situ organ perfusion, not whole-body resuscitation, that does not invalidate death determination. Further scientific, conceptual, and ethical studies, such as those identified in this workshop, can inform and help resolve controversies raised by this practice.
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Affiliation(s)
- James L Bernat
- Department of Neurology, Dartmouth Geisel School of Medicine, Hanover, New Hampshire.
| | - Kiran K Khush
- Division of Cardiovascular Medicine, Department of Medicine, Stanford University School of Medicine, Stanford, California
| | - Sam D Shemie
- Division of Critical Care Medicine, Montreal Children's Hospital, McGill University, Montreal, PQ, Canada
| | - Matthew G Hartwig
- Division of Thoracic Surgery, Department of Surgery, Duke University Health System, Durham, North Carolina
| | - Peter P Reese
- Center for Epidemiology and Biostatistics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Anne Dalle Ave
- Kennedy Institute of Ethics, Georgetown University, Washington, District of Columbia
| | - Brendan Parent
- Division of Medical Ethics and Department of Surgery, NYU Grossman School of Medicine, New York, New York
| | - Alexandra K Glazier
- Brown University, School of Public Health, Providence, Rhode Island; New England Donor Services, Waltham, Massachusetts
| | - Alexander M Capron
- Gould School of Law and Keck School of Medicine, University of Southern California, Los Angeles, California
| | - Matt Craig
- Lung Biology and Disease Branch, National Heart, Lung and Blood Institute, Bethesda, Maryland
| | - Teneille Gofton
- Department of Clinical Neurological Sciences, Schulich School of Medicine and Dentistry, Western University, London, Ontario, Canada
| | - Elisa J Gordon
- Department of Surgery, Center for Biomedical Ethics and Society, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Andrew Healey
- Department of Medicine McMaster University and William Osler Health System, Hamilton, Ontario, Canada
| | | | - Keren Ladin
- Research on Ethics, Aging, and Community Health (REACH Lab); Departments of Occupational Therapy and Community Health, Tufts University, Medford, Massachusetts
| | - Simon Messer
- Department of Transplant, Golden Jubilee National Hospital, Clydebank, Scotland UK
| | - Nick Murphy
- Departments of Medicine and Philosophy, Western University, London, Ontario, Canada
| | - Thomas A Nakagawa
- University of Florida College of Medicine-Jacksonville, Department of Pediatrics, Division of Pediatric Critical Care Medicine, Jacksonville, Florida
| | - William F Parker
- Department of Medicine and Public Health Sciences, University of Chicago, Chicago, Illinois
| | - Rebecca D Pentz
- Winship Cancer Institute, Emory University, Atlanta, Georgia
| | | | - Bryanna Schwartz
- Division of Cardiovascular Sciences, National Heart, Lung and Blood Institute, Bethesda, Maryland; Department of Cardiology, Children's National Medical Center, Washington, District of Columbia
| | - Daniel P Sulmasy
- The Kennedy Institute of Ethics and the Departments of Medicine and Philosophy, Georgetown University, Washington, District of Columbia
| | - Robert D Truog
- Department of Anesthesiology, Critical Care, and Pain Medicine, Boston Children's Hospital; Center for Bioethics, Department of Global Health and Social Medicine, Harvard Medical School, Boston, Massachusetts
| | - Anji E Wall
- Department of Surgery, Baylor University Medical Center, Dallas, Texas
| | - Stephen P Wall
- Ronald O. Perelman Department of Emergency Medicine; NYU Grossman School of Medicine and Department of Population Health, NYU, New York, New York
| | - Paul R Wolpe
- Center for Ethics, Department of Medicine, Emory University, Atlanta, Georgia
| | - Kathleen N Fenton
- Advanced Technologies and Surgery Branch, Division of Cardiovascular Sciences, National Heart, Lung, and Blood Institute, and Department of Bioethics, Clinical Center, National Institutes of Health, Bethesda, Maryland
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3
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Bernat JL. The Unified Brain-Based Determination of Death Conceptually Justifies Death Determination in DCDD and NRP Protocols. THE AMERICAN JOURNAL OF BIOETHICS : AJOB 2024; 24:4-15. [PMID: 38829591 DOI: 10.1080/15265161.2024.2337392] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/05/2024]
Abstract
Organ donation after the circulatory determination of death requires the permanent cessation of circulation while organ donation after the brain determination of death requires the irreversible cessation of brain functions. The unified brain-based determination of death connects the brain and circulatory death criteria for circulatory death determination in organ donation as follows: permanent cessation of systemic circulation causes permanent cessation of brain circulation which causes permanent cessation of brain perfusion which causes permanent cessation of brain function. The relevant circulation that must cease in circulatory death determination is that to the brain. Eliminating brain circulation from the donor ECMO organ perfusion circuit in thoracoabdominal NRP protocols satisfies the unified brain-based determination of death but only if the complete cessation of brain circulation can be proved. Despite its medical and physiologic rationale, the unified brain-based determination of death remains inconsistent with the Uniform Determination of Death Act.
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4
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Ott M, Murphy N, Lingard L, Slessarev M, Blackstock L, Basmaji J, Brahmania M, Healey A, Shemie S, Skaro A, Weijer C. Sowing "seeds of trust": How trust in normothermic regional perfusion is built in a continuum of care. Am J Transplant 2024:S1600-6135(24)00345-9. [PMID: 38825154 DOI: 10.1016/j.ajt.2024.05.017] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/10/2024] [Revised: 05/23/2024] [Accepted: 05/24/2024] [Indexed: 06/04/2024]
Abstract
Normothermic regional perfusion (NRP) is a promising technology to improve organ transplantation outcomes by reversing ischemic injury caused by controlled donation after circulatory determination of death. However, it has not yet been implemented in Canada due to ethical questions. These issues must be resolved to preserve public trust in organ donation and transplantation. This qualitative, constructivist grounded theory study sought to understand how those most impacted by NRP perceived the ethical implications. We interviewed 29 participants across stakeholder groups of donor families, organ recipients, donation and transplantation system leaders, and care providers. The interview protocol included a short presentation about the purpose of NRP and procedures in abdomen versus chest and abdomen NRP, followed by questions probing potential violations of the dead donor rule and concerns regarding brain reperfusion. The results present a grounded theory placing NRP within a trust-building continuum of care for the donor, their family, and organ recipients. Stakeholders consistently described both forms of NRP as an ethical intervention, but their rationales were predicated on assumptions that neurologic criteria for death had been met following circulatory death determination. Empirical validation of these assumptions will help ground the implementation of NRP in a trust-preserving way.
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Affiliation(s)
- Mary Ott
- Faculty of Education, York University, Toronto, Ontario, Canada; Centre for Education Research and Innovation, Schulich School of Medicine and Dentistry, Western University, London, Ontario, Canada.
| | - Nicholas Murphy
- Departments of Philsophy and Medicine, Western University, London, Ontario, Canada
| | - Lorelei Lingard
- Centre for Education Research and Innovation and Department of Medicine, Schulich School of Medicine and Dentistry, Western University, London, Ontario, Canada
| | - Marat Slessarev
- Department of Medicine, Western University Schulich School of Medicine & Dentistry, London, Ontario, Canada; Trillium Gift of Life Network, Toronto, Ontario, Canada
| | - Laurie Blackstock
- Canadian Donation and Transplantation Research Program, Edmonton, Alberta, Canada
| | - John Basmaji
- Departments of Medicine and Epidemiology & Biostatistics, Western University Schulich School of Medicine & Dentistry, London, Ontario, Canada
| | - Mayur Brahmania
- Division of Gastroenterology, Department of Medicine, Western University Schulich School of Medicine & Dentistry, London, Ontario, Canada
| | - Andrew Healey
- Trillium Gift of Life Network, Toronto, Ontario, Canada; Division of Emergency Medicine, Department of Medicine, McMaster University, Hamilton, Ontario, Canada
| | - Sam Shemie
- Division of Critical Care Medicine, Montreal Children's Hospital, McGill University Health Centre, Montreal, Quebec, Canada; Canadian Blood Services, Ottawa, Ontario, Canada
| | - Anton Skaro
- Department of Surgery, Western University Schulich School of Medicine & Dentistry, London, Ontario, Canada
| | - Charles Weijer
- Canadian Donation and Transplantation Research Program, Edmonton, Alberta, Canada; Departments of Medicine, Epidemiology & Biostatistics, and Philosophy, Western University, London, Ontario, Canada
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5
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Murphy NB, Shemie SD, Capron A, Truog RD, Nakagawa T, Healey A, Gofton T, Bernat JL, Fenton K, Khush KK, Schwartz B, Wall SP. Advancing the Scientific Basis for Determining Death in Controlled Organ Donation After Circulatory Determination of Death. Transplantation 2024:00007890-990000000-00733. [PMID: 38637919 DOI: 10.1097/tp.0000000000005002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/20/2024]
Abstract
In controlled organ donation after circulatory determination of death (cDCDD), accurate and timely death determination is critical, yet knowledge gaps persist. Further research to improve the science of defining and determining death by circulatory criteria is therefore warranted. In a workshop sponsored by the National Heart, Lung, and Blood Institute, experts identified research opportunities pertaining to scientific, conceptual, and ethical understandings of DCDD and associated technologies. This article identifies a research strategy to inform the biomedical definition of death, the criteria for its determination, and circulatory death determination in cDCDD. Highlighting knowledge gaps, we propose that further research is needed to inform the observation period following cessation of circulation in pediatric and neonatal populations, the temporal relationship between the cessation of brain and circulatory function after the withdrawal of life-sustaining measures in all patient populations, and the minimal pulse pressures that sustain brain blood flow, perfusion, activity, and function. Additionally, accurate predictive tools to estimate time to asystole following the withdrawal of treatment and alternative monitoring modalities to establish the cessation of circulatory, brainstem, and brain function are needed. The physiologic and conceptual implications of postmortem interventions that resume circulation in cDCDD donors likewise demand attention to inform organ recovery practices. Finally, because jurisdictionally variable definitions of death and the criteria for its determination may impede collaborative research efforts, further work is required to achieve consensus on the physiologic and conceptual rationale for defining and determining death after circulatory arrest.
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Affiliation(s)
- Nicholas B Murphy
- Departments of Medicine and Philosophy, Western University, London, ON, Canada
| | - Sam D Shemie
- Division of Critical Care Medicine, Montreal Children's Hospital, McGill University, Montreal, QC, Canada
- System Development, Canadian Blood Services, Ottawa, ON, Canada
| | - Alex Capron
- Gould School of Law and Keck School of Medicine, University of Southern California, Los Angeles, CA
| | - Robert D Truog
- Department of Anesthesiology, Critical Care, and Pain Medicine, Boston Children's Hospital, Boston, MA
- Department of Global Health and Social Medicine, Harvard Medical School, Boston, MA
| | - Thomas Nakagawa
- Division of Pediatric Critical Care Medicine, Department of Pediatrics, University of Florida College of Medicine-Jacksonville, Jacksonville, FL
| | - Andrew Healey
- Ontario Health (Trillium Gift of Life Network), Toronto, ON, Canada
- Divisions of Emergency and Critical Care Medicine, Department of Medicine, McMaster University, Hamilton, ON, Canada
| | - Teneille Gofton
- Department of Clinical Neurological Sciences, Schulich School of Medicine and Dentistry, Western University, London, ON, Canada
| | - James L Bernat
- Department of Neurology, Dartmouth Geisel School of Medicine, Hanover, NH
| | - Kathleen Fenton
- Advanced Technologies and Surgery Branch, Division of Cardiovascular Sciences, National Heart, Lung, and Blood Institute, Department of Bioethics, Clinical Center, National Institutes of Health, Bethesda, MD
| | - Kiran K Khush
- Division of Cardiovascular Medicine, Department of Medicine, Stanford University School of Medicine, Stanford, CA
| | - Bryanna Schwartz
- Heart Development and Structural Diseases Branch, Division of Cardiovascular Sciences, National Heart, Lung, and Blood Institute, National Institutes of Health, Bethesda, MD
- Division of Cardiology, Children's National Hospital, Washington, DC
| | - Stephen P Wall
- Ronald O. Perelman Department of Emergency Medicine, NYU Grossman School of Medicine, New York, NY
- Department of Population Health, NYU Grossman School of Medicine, New York, NY
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6
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Dalle Ave AL, Sulmasy DP. Does Sedation Affect Patients' Spiritual Experience at the End of Life? An Intersection Between Medicine and Spirituality. J Pain Symptom Manage 2023:S0885-3924(23)00762-5. [PMID: 37871840 DOI: 10.1016/j.jpainsymman.2023.10.023] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/25/2022] [Revised: 06/03/2023] [Accepted: 10/18/2023] [Indexed: 10/25/2023]
Affiliation(s)
- Anne L Dalle Ave
- Kennedy Institute of Ethics (A.L.D.A.), Georgetown University, Washington, DC, USA.
| | - Daniel P Sulmasy
- Departments of Medicine and Philosophy and the Pellegrino Center for Clinical Bioethics (D.P.S.), Kennedy Institute of Ethics, Georgetown University, Washington, DC, USA
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7
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Kreitmair KV. On the ethical permissibility of in situ reperfusion in cardiac transplantation after the declaration of circulatory death. JOURNAL OF MEDICAL ETHICS 2023:jme-2022-108819. [PMID: 37541783 DOI: 10.1136/jme-2022-108819] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/29/2022] [Accepted: 07/15/2023] [Indexed: 08/06/2023]
Abstract
Transplant surgeons in the USA have begun performing a novel organ procurement protocol in the setting of circulatory death. Unlike traditional donation after circulatory death (DCD) protocols, in situ normothermic perfusion DCD involves reperfusing organs, including the heart, while still contained in the donor body. Some commentators, including the American College of Physicians, have claimed that in situ reperfusion after circulatory death violates the widely accepted Dead Donor Rule (DDR) and conclude that in situ reperfusion is ethically impermissible. In this paper I argue that, in terms of respecting the DDR, in situ reperfusion cardiac transplantation does not differ from traditional DCD cardiac transplantation. I do this by introducing and defending a refined conception of circulatory death, namely vegetative state function permanentism I also argue against the controversial brain occlusion feature of the in situ reperfusion DCD protocol, on the basis that it is ethically unnecessary and generates the problematic appearance of ethical dubiousness.
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Affiliation(s)
- Karola Veronika Kreitmair
- Medical History and Bioethics, University of Wisconsin-Madison, School of Medicine and Public Health, Madison, Wisconsin, USA
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8
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Bernat JL, Domínguez-Gil B, Glazier AK, Gardiner D, Manara AR, Shemie S, Porte RJ, Martin DE, Opdam H, McGee A, López Fraga M, Rayar M, Kerforne T, Bušić M, Romagnoli R, Zanierato M, Tullius SG, Miñambres E, Royo-Villanova M, Delmonico FL. Understanding the Brain-based Determination of Death When Organ Recovery Is Performed With DCDD In Situ Normothermic Regional Perfusion. Transplantation 2023; 107:1650-1654. [PMID: 37170405 DOI: 10.1097/tp.0000000000004642] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/13/2023]
Affiliation(s)
- James L Bernat
- Department of Neurology, Dartmouth Geisel School of Medicine, Hanover, NH
| | | | - Alexandra K Glazier
- New England Donor Services, Waltham, MA. Health Services, Policy and Practice, Brown University, Providence, RI
| | - Dale Gardiner
- Medical Directorate, Deceased Organ Donation for NHS Blood and Transplant, Nottingham, United Kingdom
| | - Alexander R Manara
- Intensive Care Medicine, The Intensive Care Unit, Southmead Hospital, North Bristol NHS Trust, Bristol, United Kingdom
| | - Sam Shemie
- Pediatric Critical Care Medicine, McGill University Health Centre, Montreal, QB, Canada
| | - Robert J Porte
- Division of HPB and Transplant Surgery, Department of Surgery, Erasmus MC Transplant Institute, Erasmus University Medical Center, Rotterdam, the Netherlands
| | - Dominique E Martin
- Health Ethics and Professionalism School of Medicine, Faculty of Health Deakin University, Geelong, VIC, Australia
| | - Helen Opdam
- Australian Organ and Tissue Authority, Austin Hospital, and Warringal Private Hospital Intensive Care Unit, Melbourne, VIC, Australia
| | - Andrew McGee
- Australian Centre for Health Law Research, Faculty of Law, Queensland University of Technology, Brisbane City, QLD, Australia
| | - Marta López Fraga
- Quality of Medicines and Healthcare, Council of Europe, European Committee on Organ Transplantation (CD-P-TO), Strasbourg, France
| | - Michel Rayar
- Service de chirurgie Hépatobiliaire et Digestif CHU Pontchaillou, Rennes, France
| | - Thomas Kerforne
- Service d'Anesthésie-Réanimation et Médecine Périopératoire-CHU de Poitiers, Poitiers, France
| | - Mirela Bušić
- SoHO Standards Department of Biological Standardisation, OMCL Network and HealthCare (DBO) EDQM, Council of Europe, Strasbourg, France
| | - Renato Romagnoli
- General Surgery 2U - Liver Transplant Center, AOU Città della Salute e della Scienza di Torino, Molinette Hospital, University of Turin, Turin, Italy
| | - Marinella Zanierato
- Department of Anesthesia and Critical Care, AOU Città della Salute e della Scienza di Torino, Molinette Hospital, Turin, Italy
| | - Stefan G Tullius
- Transplant Surgery, Harvard Medical School, Division of Transplant Surgery Brigham and Women's Hospital, Harvard Medical School, Boston, MA
| | - Eduardo Miñambres
- Donor Transplant Coordination Unit and Service of Intensive Care, Hospital Universitario Marqués de Valdecilla-IDIVAL, School of Medicine, Universidad de Cantabria, Santander, Spain
| | - Mario Royo-Villanova
- Donor Transplant Coordination Unit and Service of Intensive Care, Hospital Universitario Virgen de la Arrixaca, Murcia, Spain
| | - Francis L Delmonico
- New England Donor Services, Department of Surgery, Harvard Medical School at the Massachusetts General Hospital, Boston, MA
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9
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Dalle Ave AL. Determination of death: From irreversibility to assumability. Am J Transplant 2022; 22:1727-1728. [PMID: 35278273 DOI: 10.1111/ajt.17030] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/22/2022] [Revised: 03/08/2022] [Accepted: 03/09/2022] [Indexed: 01/25/2023]
Affiliation(s)
- Anne L Dalle Ave
- Kennedy Institute of Ethics, Georgetown University, Washington, District of Columbia, USA
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10
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Molina Pérez A. Brain death debates: from bioethics to epistemology. F1000Res 2022; 11:195. [PMID: 35844817 PMCID: PMC9253658 DOI: 10.12688/f1000research.109184.1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 02/08/2022] [Indexed: 09/05/2024] Open
Abstract
50 years after its introduction, brain death remains controversial among scholars. The debates focus on one question: is brain death a good criterion for determining death? This question has been answered from various perspectives: medical, metaphysical, ethical, and legal or political. Most authors either defend the criterion as it is, propose some minor or major revisions, or advocate abandoning it and finding better solutions to the problems that brain death was intended to solve when it was introduced. In short, debates about brain death have been characterized by partisanship, for or against. Here I plead for a non-partisan approach that has been overlooked in the literature: the epistemological or philosophy of science approach. Some scholars claim that human death is a matter of fact, a biological phenomenon whose occurrence can be determined empirically, based on science. We should take this claim seriously, whether we agree with it or not. The question is: how do we know that human death is a scientific matter of fact? Taking the epistemological approach means, among other things, examining how the determination of human death became an object of scientific inquiry, exploring the nature of the brain death criterion itself, and analysing the meaning of its core concepts such as "irreversibility" and "functions".
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Affiliation(s)
- Alberto Molina Pérez
- Institute for Advanced Social Studies, Spanish National Research Council (IESA–CSIC), Cordoba, 14004, Spain
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11
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Molina Pérez A. Brain death debates: from bioethics to philosophy of science. F1000Res 2022; 11:195. [PMID: 35844817 PMCID: PMC9253658 DOI: 10.12688/f1000research.109184.2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 04/08/2022] [Indexed: 11/20/2022] Open
Abstract
50 years after its introduction, brain death remains controversial among scholars. The debates focus on one question: is brain death a good criterion for determining death? This question has been answered from various perspectives: medical, metaphysical, ethical, and legal or political. Most authors either defend the criterion as it is, propose some minor or major revisions, or advocate abandoning it and finding better solutions to the problems that brain death was intended to solve when it was introduced. Here I plead for a different approach that has been overlooked in the literature: the philosophy of science approach. Some scholars claim that human death is a matter of fact, a biological phenomenon whose occurrence can be determined empirically, based on science. We should take this claim seriously, whether we agree with it or not. The question is: how do we know that human death is a scientific matter of fact? Taking the philosophy of science approach means, among other things, examining how the determination of human death became an object of scientific inquiry, exploring the nature of the brain death criterion itself, and analysing the meaning of its core concepts such as "irreversibility" and "functions".
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Affiliation(s)
- Alberto Molina Pérez
- Institute for Advanced Social Studies, Spanish National Research Council (IESA–CSIC), Cordoba, 14004, Spain
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12
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Clamping of the Aortic Arch Vessels During Normothermic Regional Perfusion After Circulatory Death Prevents the Return of Brain Activity in a Porcine Model. Transplantation 2022; 106:1763-1769. [PMID: 35066546 DOI: 10.1097/tp.0000000000004047] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
BACKGROUND The cerebral effect of clamping following normothermic regional perfusion (NRP) in donation after circulatory death (DCD) remains unknown. We investigated the effect of cerebral reperfusion during NRP and the preventive effect of clamping on brain function in a porcine model. METHODS In 16 pigs, intracranial physiological parameters were recorded, including pressure, cerebral blood perfusion (CBF), temperature, and oxygen. Additionally, electroencephalography (EEG) and somatosensory evoked potentials (SSEPs) were used to assess brain function. The animals were cannulated for the heart-lung machine, and baseline measurements were performed before withdrawal from life support. After 8 min of mechanical asystole, the animals were randomly allocated to clamp (n = 8) or nonclamp (n = 8) of the aortic arch vessels. After 30 min of NRP, the animals were monitored for 3 h after weaning (AW). RESULTS Intracranial measurements of CBF, oxygen, and temperature indicated successful occlusion of the arch vessels following NRP and AW in the clamp group versus the nonclamp group. In the clamp group, EEG was isoelectric and SSEPs were absent AW in all pigs. In the nonclamp group, EEG activity was observed in all 8 pigs, whereas SSEPs were observed in 6 of 8 pigs. Additionally, agonal respiratory movements in the form of gasping were observed in 6 of 8 pigs in the nonclamp group. CONCLUSIONS Reperfusion of the brain during NRP led to a return of brain activity. Conversely, clamping of the arch vessels halted cerebral circulation, ensuring the permanent cessation of brain function and maintaining the determination of death in DCD.
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13
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Restoring Activity of Pig Brain Cells After Death Does not Invalidate the Determination of Death by Neurologic Criteria or Undermine the Propriety of Organ Donation After Death. Transplantation 2020; 103:1295-1297. [PMID: 31107825 DOI: 10.1097/tp.0000000000002782] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
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14
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White FJ. Controversy in the Determination of Death: The Definition and Moment of Death. LINACRE QUARTERLY 2019; 86:366-380. [PMID: 32431429 PMCID: PMC6880073 DOI: 10.1177/0024363919876393] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
This essay reviews recent controversy in the determination of death, with particular attention to the definition and moment of death. Definitions of death have evolved from the intuitive to the pathophysiologic and the medicolegal. Many United States jurisdictions have codified the definition of death relying on guidance from the Uniform Determination of Death Act (UDDA). Flaws in the structure of the UDDA have led to misunderstanding of the physiologic nature of death and methods for the determination of death, resulting in a bifurcated concept of death as either circulatory/respiratory or neurologic. The practice of organ donation after circulatory determination of death (DCDD) raises a number of ethical questions, most prominently revolving around the moment of death and manifested as an expedited time to determination of death, a departure from the unitary concept of death, a violation of the dead donor rule, and a challenge to the standard of irreversibility. Attempts to redefine the determination of death from an irreversibility standard to a permanence standard have significant impact on the social contract upon which deceased donor organ transplantation rests, and must entail broad societal examination. The determination of death is best reached by a clear, strict, and uniform irreversibility standard. In deceased donor organ transplantation, the interests of the donor as a person are paramount, and no interest of organ recipients or of the greater society can justify negation of the rights and bodily integrity of the person who is a donor, nor conversion of the altruism of giving into the calculus of taking.
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15
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Ethische Relevanz und faktische Mängel in der Kommunikation von Spezifika der Organspende nach Kreislaufstillstand. Ethik Med 2018. [DOI: 10.1007/s00481-018-0501-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/28/2022]
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Dalle Ave AL, Shaw DM, Elger B. Practical Considerations in Donation After Circulatory Determination of Death in Switzerland. Prog Transplant 2017; 27:291-294. [PMID: 29187117 DOI: 10.1177/1526924817715458] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Faced with similar issues of organ scarcity to its neighbors, Switzerland has developed donation after circulatory determination of death (DCDD) as a way to expand the organ pool since 1985. Here, we analyze the history, practical considerations, and ethical issues relating to the Swiss donation after circulatory death programs. In Switzerland, determination of death for DCDD requires a stand-off period of 10 minutes. This time between cardiac arrest and the declaration of death is mandated in the guidelines of the Swiss Academy of Medical Sciences. As in other DCDD programs, safeguards are put to avoid physicians denying lifesaving treatment to savable patients because of being influenced by receivers' interest. An additional recommendation could be made: Recipients should be transparently informed of the worse graft outcomes with DCDD programs and given the possibility to refuse such organs.
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Affiliation(s)
- Anne L Dalle Ave
- 1 Institute for Biomedical Ethics, University of Basel, Basel, Switzerland.,2 Ethics Unit, University Hospital of Lausanne, Lausanne, Switzerland.,3 Institute for Biomedical Ethics, University Medical Center, Geneva, Switzerland
| | - David M Shaw
- 1 Institute for Biomedical Ethics, University of Basel, Basel, Switzerland
| | - Bernice Elger
- 1 Institute for Biomedical Ethics, University of Basel, Basel, Switzerland.,4 Centre for Legal Medicine, University of Geneva, Geneva, Switzerland
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Dalle Ave AL, Bernat JL. Donation after brain circulation determination of death. BMC Med Ethics 2017; 18:15. [PMID: 28228145 PMCID: PMC5322624 DOI: 10.1186/s12910-017-0173-1] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/25/2016] [Accepted: 02/03/2017] [Indexed: 11/29/2022] Open
Abstract
Background The fundamental determinant of death in donation after circulatory determination of death is the cessation of brain circulation and function. We therefore propose the term donation after brain circulation determination of death [DBCDD]. Results In DBCDD, death is determined when the cessation of circulatory function is permanent but before it is irreversible, consistent with medical standards of death determination outside the context of organ donation. Safeguards to prevent error include that: 1] the possibility of auto-resuscitation has elapsed; 2] no brain circulation may resume after the determination of death; 3] complete circulatory cessation is verified; and 4] the cessation of brain function is permanent and complete. Death should be determined by the confirmation of the cessation of systemic circulation; the use of brain death tests is invalid and unnecessary. Because this concept differs from current standards, consensus should be sought among stakeholders. The patient or surrogate should provide informed consent for organ donation by understanding the basis of the declaration of death. Conclusion In cases of circulatory cessation, such as occurs in DBCDD, death can be defined as the permanent cessation of brain functions, determined by the permanent cessation of brain circulation.
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Affiliation(s)
- Anne L Dalle Ave
- Ethics Unit, University hospital of Lausanne, Rue du Bugnon 21, 1011, Lausanne, Switzerland.
| | - James L Bernat
- Neurology Department, Dartmouth-Hitchcock Medical Center, Lebanon, NH, 03756, USA
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Dalle Ave AL, Bernat JL. Uncontrolled Donation After Circulatory Determination of Death: A Systematic Ethical Analysis. J Intensive Care Med 2016; 33:624-634. [PMID: 28296536 DOI: 10.1177/0885066616682200] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/05/2023]
Abstract
Uncontrolled donation after circulatory determination of death (uDCDD) refers to organ donation after a refractory cardiac arrest. We analyzed ethical issues raised by the uDCDD protocols of France, Madrid, and New York City. We recommend: (1) Termination of resuscitation (TOR) guidelines need refinement, particularly the minimal duration of resuscitation efforts before considering TOR; (2) Before enrolling in an uDCDD protocol, physicians must ascertain that additional resuscitation efforts would be ineffective; (3) Inclusion in an uDCDD protocol should not be made in the outpatient setting to avoid error and conflicts of interest; (4) The patient's condition should be reassessed at the hospital and reversible causes treated; (5) A no-touch period of at least 10 minutes should be respected to avoid the risk of autoresuscitation; (6) Once death has been determined, no procedure that may resume brain circulation should be used, including cardiopulmonary resuscitation, artificial ventilation, and extracorporeal membrane oxygenation; (7) Specific consent is required prior to entry into an uDCDD protocol; (8) Family members should be informed about the goals, risks, and benefits of planned uDCDD procedures; and (9) Public information on uDCDD is desirable because it promotes public trust and confidence in the organ donation system.
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Affiliation(s)
- Anne L Dalle Ave
- 1 Ethics Unit, University Hospital of Lausanne, Lausanne, Switzerland.,2 Institute for Biomedical Ethics, University Medical Center, Geneva, Switzerland
| | - James L Bernat
- 3 Neurology Department, Dartmouth-Hitchcock Medical Center, Lebanon, New Hampshire, USA
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Dalle Ave AL, Shaw DM, Bernat JL. Ethical Issues in the Use of Extracorporeal Membrane Oxygenation in Controlled Donation After Circulatory Determination of Death. Am J Transplant 2016; 16:2293-9. [PMID: 26999771 DOI: 10.1111/ajt.13792] [Citation(s) in RCA: 60] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/17/2015] [Revised: 02/25/2016] [Accepted: 03/03/2016] [Indexed: 01/25/2023]
Abstract
The use of donor extracorporeal membrane oxygenation (ECMO) to improve graft outcomes by some controlled donation after circulatory determination of death (cDCDD) programs raises ethical issues. We reviewed cDCDD protocols using ECMO and the relevant ethics literature to analyze these issues. It is not obvious that ECMO in cDCDD improves graft outcomes. In our opinion, ECMO implemented before death can interfere with end-of-life care and damage bodily integrity. By restoring systemic circulation, ECMO risks invalidating the preceding declaration of death if brain and cardiac perfusion is not adequately excluded because of malfunction or misplacement of the supradiaphragmatic aortic occlusion balloon. The use of ECMO is not compatible with the acronym DCDD because circulation is restored after the determination of death. Because of these deficiencies, we concluded that other techniques are preferable, such as rapid recovery or in situ cold infusion. If ECMO is performed, it requires a specific informed consent and transparency.
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Affiliation(s)
- A L Dalle Ave
- Ethics Unit, University hospital of Lausanne, Lausanne, Switzerland.,Institute for Biomedical Ethics, University Medical Center, Geneva, Switzerland
| | - D M Shaw
- Institute for Biomedical Ethics, University of Basel, Basel, Switzerland
| | - J L Bernat
- Neurology Department, Dartmouth-Hitchcock Medical Center, Lebanon, NH
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