Contemporary transplantation initiatives: where's the harm in them?

Ethical and legal implications of elective ventilation and organ transplantation: "medicalization" of dying versus medical mission

A critical controversy surrounds the type of allowable interventions to be carried out in patients who are potential organ donors, in an attempt to improve organ perfusion and successful transplantation. The main goal is to transplant an organ in conditions as close as possible to its physiological live state. “Elective ventilation” (EV), that is, the use of ventilation for the sole purpose of retrieving the organs of patients close to death, is an option which offsets the shortage of organ donation. We have analyzed the legal context of the dying process of the organ donor and the feasibility of EV in the Italian context. There is no legal framework regulating the practice of EV, neither is any real information given to the general public. A public debate has yet to be initiated. In the Italian cultural and legislative scenario, we believe that, under some circumstances (i.e., the expressed wishes of the patient, even in the form of advance directives), the use of EV does not violate the principle of beneficence. We believe that the crux of the matter lies in the need to explore the real determination and will of the patient and his/her orientation towards the specific aim of organ donation.

Emergency medicine, organ donation and the Human Tissue Act

The Human Tissue Act 2004, which governs all activity relating to the human body, organs or tissues, is grounded in the principle of fully informed consent in line with societal expectations. The associated intention to deal with the current deficit of transplantable organs has paradoxically been translated into the legitimisation of non-consensual organ preservation manoeuvres after death. The procurement strategy targeted under this new statute is "uncontrolled" non-heart-beating donation, and the clinical arenas would be accident and emergency departments and acute medical wards. Practitioners in these fields need to have an understanding of the process and the associated ethical, logistical and legal hurdles to defensible implementation. In the light of these hurdles, there is an obvious need for more widespread professional and public consultation before adoption of this programme.

Brain death: resolving inconsistencies in the ethical declaration of death

PURPOSE

The first criteria for the determination of brain death were developed in 1968 in part to address concerns that had arisen with the retrieval of organs for transplantation. Despite over 30 years of application, some professional and public doubt persists over the validity of the theoretical construct underlying this method of determining death. Our review will address historical perspectives on the development of brain death criteria, and inconsistencies in current clinical criteria.

METHOD

Narrative review from selected MEDLINE references and other published sources.

PRINCIPLE FINDINGS

The primary construct of the determination of death is that either cardiopulmonary or neurological function irreversibly ceases. However, there is inconsistency in the neurological criteria for death between jurisdictions, between patient populations, and in the use of confirmatory tests. These inconsistencies may cause concern in the public or profession about the validity of the determination of death by neurological criteria.

CONCLUSIONS

Organ transplantation is premised on professional and public acceptance that the donor is dead. Given that the criteria for brain death or their application remain variable, we suggest that it is reasonable to consider a national consensus to address these inconsistencies. Alternatively, the standard use of confirmatory radiographic testing prior to the retrieval of organs from donors who meet clinical brain death criteria should be considered to provide conclusive evidence of permanent and irreversible loss of brain function.