Defining the vital condition for organ donation

Brain-dead patients are not cadavers: the need to revise the definition of death in Muslim communities

The utilitarian construct of two alternative criteria of human death increases the supply of transplantable organs at the end of life. Neither the neurological criterion (heart-beating donation) nor the circulatory criterion (non-heart-beating donation) is grounded in scientific evidence but based on philosophical reasoning. A utilitarian death definition can have unintended consequences for dying Muslim patients: (1) the expedited process of determining death for retrieval of transplantable organs can lead to diagnostic errors, (2) the equivalence of brain death with human death may be incorrect, and (3) end-of-life religious values and traditional rituals may be sacrificed. Therefore, it is imperative to reevaluate the two different types and criteria of death introduced by the Resolution (Fatwa) of the Council of Islamic Jurisprudence on Resuscitation Apparatus in 1986. Although we recognize that this Fatwa was based on best scientific evidence available at that time, more recent evidence shows that it rests on outdated knowledge and understanding of the phenomenon of human death. We recommend redefining death in Islam to reaffirm the singularity of this biological phenomenon as revealed in the Quran 14 centuries ago.

The case for kidney donation before end-of-life care

Donation after cardiac death (DCD) is associated with many problems, including ischemic injury, high rates of delayed allograft function, and frequent organ discard. Furthermore, many potential DCD donors fail to progress to asystole in a manner that would enable safe organ transplantation and no organs are recovered. DCD protocols are based upon the principle that the donor must be declared dead prior to organ recovery. A new protocol is proposed whereby after a donor family agrees to withdrawal of life-sustaining treatments, premortem nephrectomy is performed in advance of end-of-life management. Since nephrectomy should not cause the donor's death, this approach satisfies the dead donor rule. The donor family's wishes are best met by organ donation, successful outcomes for the recipients, and a dignified death for the deceased. This proposal improves the likelihood of achieving these objectives.

Enforcement of presumed-consent policy and willingness to donate organs as identified in the European Union Survey: the role of legislation in reinforcing ideology in pluralistic societies

To increase the supply of transplantable organs, some European Union (EU) countries have begun implementing and enforcing presumed consent policies for organ donation. Mossialos and colleagues performed an analysis of samples of citizens in 15 EU countries and found that legislation, enforcement, and awareness of presumed consent policies for organ donation increase people's willingness to donate their own organs and those of a deceased relative. The authors concluded that, in countries with enforced presumed consent, citizens are willing to donate because they accept organ donation as an ideology. This ideology originates in the thinking that organ donation is an implicit communal contract i.e., a mechanism by which individuals pay back society for the inclusion and social support that they have already experienced and hope to experience in the future. Acceptance of this ideology enhances people's willingness to donate organs and the efficiency in pursuing this collective action, thus, paving the way toward increased paternalism in society. We highlight some potential biases that may have been incorporated in the survey design and in Mossialos et al.'s conclusions, including (1) how the survey questions were constructed, (2) whether sufficient information was communicated about organ procurement practices in heart-beating and non-heart-beating donation before participants responded to the survey, and (3) whether respondents' knowledge about donation legislation can be equated with understanding of processes involved in organ donation. We address the consequences of using legislative authority to enforce the ideology of organ donation, thereby superseding the varying moral values, beliefs, and attitudes about human life and culture that are inherent in multicultural societies.

Death, organ transplantation and medical practice

A series of papers in Philosophy, Ethics and Humanities in Medicine (PEHM) have recently disputed whether non-heart beating organ donors are alive and whether non-heart beating organ donation (NHBD) contravenes the dead donor rule. Several authors who argue that NHBD involves harvesting organs from live patients appeal to "strong irreversibility" (death beyond the reach of resuscitative efforts to restore life) as a necessary criterion that patients must meet before physicians can declare them to be dead. Sam Shemie, who defends our current practice of NHBD, holds that in fact physicians consider patients to be dead or not according to physician intention to resuscitate or not. We suggest that criteria for a concept are not necessarily truth conditions for assertions involving the concept. Hence, non-heart beating donors may be declared dead without meeting the criterion of strong irreversibility even though strong irreversibility is implied by the concept of death. Our perception that a concept applies in a given case is determined not by the concept itself but by our necessary skill and judgment when using it. In the case of deciding that a patient is dead, such judgment is learned by physicians as they learn the practice of medicine and may vary according to circumstances. Current practice of NHBD can therefore be defended without abandoning death as an empirical concept, as Shemie appears to do. We conclude that the dead donor rule continues to be viable and ought to be retained so as to guarantee what the public most cares about as regards organ donation: that physicians can be trusted to make determinations of eligibility for organ donation in the interests of patients and not for other purposes such as increasing the availability of organs.