Ethical analysis of organ recovery denials by medical examiners, coroners, and justices of the peace

For Victims of Fatal Child Abuse, Who Has the Right to Consent to Organ Donation?

In rare circumstances, children who have suffered traumatic brain injury from child abuse are declared dead by neurologic criteria and are eligible to donate organs. When the parents are the suspected abusers, there can be confusion about who has the legal right to authorize organ donation. Furthermore, organ donation may interfere with the collection of forensic evidence that is necessary to evaluate the abuse. Under those circumstances, particularly in the context of a child homicide investigation, the goals of organ donation and collection and preservation of critical forensic evidence may seem mutually exclusive. In this Ethics Rounds, we discuss such a case and suggest ways to resolve the apparent conflicts between the desire to procure organs for donation and the need to thoroughly evaluate the evidence of abuse.

The impact of organ donation on coronial processes and forensic investigation: A literature review

There are competing requirements between organ donation for transplantation and coronial/forensic investigation. Both require access to the body of the deceased. Optimally preserving physical evidence may reduce availability of organs for life saving transplants. Performing organ retrieval could impact on death determination and at worst could potentially interfere with criminal trial outcomes.

OBJECTIVE

To summarise published literature regarding the interaction between organ donation and coronial/forensic processes.

METHODS

A standard search strategy using the terms organ donation and coroner or medical examiner.

RESULTS

There is a paucity of published literature. The incidence of coronial restriction of donation varies between jurisdictions and between individual practitioners. A significant number of organs are lost to transplantation through coronial restrictions. A number of strategies have been proposed to reduce the rate of coronial restrictions but implementation is inconsistent despite support from forensic professional bodies. There was no published report of a significant impact on death determination or trial outcome caused by organ retrieval.

CONCLUSIONS

Increased consistency in coronial/forensic decision making and implementation of recognised strategies would increase the availability of organs for transplantation.

Management of the Potential Organ Donor in the ICU: Society of Critical Care Medicine/American College of Chest Physicians/Association of Organ Procurement Organizations Consensus Statement

This document was developed through the collaborative efforts of the Society of Critical Care Medicine, the American College of Chest Physicians, and the Association of Organ Procurement Organizations. Under the auspices of these societies, a multidisciplinary, multi-institutional task force was convened, incorporating expertise in critical care medicine, organ donor management, and transplantation. Members of the task force were divided into 13 subcommittees, each focused on one of the following general or organ-specific areas: death determination using neurologic criteria, donation after circulatory death determination, authorization process, general contraindications to donation, hemodynamic management, endocrine dysfunction and hormone replacement therapy, pediatric donor management, cardiac donation, lung donation, liver donation, kidney donation, small bowel donation, and pancreas donation. Subcommittees were charged with generating a series of management-related questions related to their topic. For each question, subcommittees provided a summary of relevant literature and specific recommendations. The specific recommendations were approved by all members of the task force and then assembled into a complete document. Because the available literature was overwhelmingly comprised of observational studies and case series, representing low-quality evidence, a decision was made that the document would assume the form of a consensus statement rather than a formally graded guideline. The goal of this document is to provide critical care practitioners with essential information and practical recommendations related to management of the potential organ donor, based on the available literature and expert consensus.

Limitations of cadaveric organ donation on judicial cases and problems confronted in autopsy: Istanbul data in comparative perspective

Organ transplantation is one of the most important services of modern medicine to the humanity. In judicial death cases the interaction between judicial needs and transplantation needs is inevitable and both should be provided in a short time before the decomposition of the body. Thus, the description of this interaction and the algorithm which should be carried out to manage these cases are important. Aim of this study is to determine the problems confronted in forensic autopsies and to determine what to do for both judicial processes' and cadaveric organ donations' not becoming limited due to each other. With these aims, autopsy case archive of the Council of Forensic Medicine Istanbul Morgue Department was reviewed, between the years 2009 and 2011, to reveal the number of organ donors among autopsy cases and also to find out the judicial problems confronted during autopsies. Among 12,016 judicial death cases referred to Istanbul Morgue Department in 3 years, 35 cases were found to have undergone cadaveric solid organ harvesting procedure and 307 cases cornea-only harvesting procedure. Manner of deaths for organ donor cases were blunt trauma due to traffic accident in 20 cases, firearm injury in 3 cases, stabbing in 2 cases, suspicious criminal battery in 4 cases and fatal falls in 5 cases. Only 1 case was suspected to have died due to high dose insulin administration. Through the whole data presented in this study, it can be concluded that consulting with the Forensic Medicine Expert not only for the autopsies but also during the clinical process of a judicial case, who is a candidate to be an organ donor, is absolutely important. The early contribution of the Forensic Medicine Expert would provide help to plan both the judicial process and the transplantation process which needs urgent decisions. A Forensic Medicine Expert may be an organ harvest team member performing initial investigations on the cause of death and collecting some of the toxicological screening samples when needed.

Undetermined cause and manner of death after organ/tissue donation

The Harris County Medical Examiner's Office (HCME) is proactive and supportive with regard to organ and tissue donation. Steps taken to facilitate donation include development of standardized multiagency protocols for organ/tissue requests and transfer of decedents out of the facility for tissue recovery prior to autopsy. The organ/tissue agencies have 24-hour access to a liaison staff member. No blanket denials are issued for any case type; instead each case is evaluated for feasibility of donation. In rare instances donation of one or more organs is considered detrimental to the mission of determining cause and manner of death. In these cases, the HCME requests that specific organ(s) not be recovered. In this jurisdiction, the organ procurement organization often proceeds with organ recovery despite medical examiner objection. In such cases, the autopsy examination is incomplete and the cause of death cannot be determined. A series of 5 organ donation cases are presented for illustration. Four of these cases are infant deaths in which the HCME requested specific organs not be donated. In the fifth case no denial was issued, but release was granted on incomplete or erroneous information. The cause and manner of death in each case remains undetermined.

National Association of Medical Examiners position paper on the medical examiner release of organs and tissues for transplantation

The medical examiner community plays a key role in the organ and tissue procurement process for transplantation. Since many, if not most, potential organ or tissue donors fall under medicolegal jurisdiction, the medical examiner bears responsibility to authorize or deny the procurement of organs or tissues on a case-by-case basis. This responsibility engenders a basic dichotomy for the medical examiner's decision-making process. In cases falling under his/her jurisdiction, the medical examiner must balance the medicolegal responsibility centered on the decedent with the societal responsibility to respect the wishes of the decedent and/or next of kin to help living patients. Much has been written on this complex issue in both the forensic pathology and the transplantation literature. Several studies and surveys of medical examiner practices, as well as suggested protocols for handling certain types of cases, are available for reference when concerns arise that procurement may potentially hinder medicolegal death investigation. It is the position of the National Association of Medical Examiners (NAME) that the procurement of organs and/or tissues for transplantation can be accomplished in virtually all cases, without detriment to evidence collection, postmortem examination, determination of cause and manner of death, or the conducting of criminal or civil legal proceedings. The purpose of this position paper is to review the available data, the arguments for and against medical examiner release, and to encourage the release of organs and tissues in all but the rarest of circumstances.

Review of Pathologic Findings in Remnant Hearts Following Valve Donation

The failure of medical examiners/coroners (ME/C) to allow heart valve donation is a major problem encountered by tissue agencies. Even though many ME/C favor tissue donation they remain responsible for determination of cause and manner of death. In 2001, the Jesse E. Edwards Registry of Cardiovascular Disease was approached by one of the nation's largest tissue procurement agencies (The American Red Cross--ARC) for the purpose of performing cardiovascular pathologic examinations following valve donation. The affiliation existed from October 2001 to January 2005. This study was undertaken to review all 593 postvalve recovery heart remnants received during that time period to tabulate the abnormalities identified and to determine whether donation interfered with the determination of cause of death. For each case, a preliminary cause of death was provided by the ARC. The decedent's body height and weight were also provided. Using the preliminary cause of death, the 593 cases were divided into natural and nonnatural manner of death groups. This division of the cases resulted in 106 cases placed in the natural manner of death group and 487 cases in the nonnatural manner of death group. For each case, all cardiac findings including significant conditions, additional findings, incidental findings, and congenital abnormalities were tabulated. Within the natural manner of death group, 15 cases had a noncardiac cause of death and 91 cases had a cause of death suspected to be cardiac related. In the 91 cases, a total of 132 significant cardiac findings were identified and there were six structurally normal hearts including two infants. In the nonnatural manner of death group, 214 significant cardiac findings were identified and 222 cases had a structurally normal heart. In both natural and nonnatural groups, the most common cardiac abnormality was atherosclerotic coronary artery disease. Other frequently encountered conditions were also identified including 11 cases with acute angle of origin of a coronary artery (five cases natural group; six cases nonnatural group). An important feature of this review was the recognition of potentially inheritable conditions that were diagnosed in both natural and nonnatural manner of death groups. There were three cases of hypertrophic cardiomyopathy (one natural; two nonnatural), three cases of arrhythmogenic right ventricular cardiomyopathy (one natural; two nonnatural), and one case of mitral valve prolapse (natural). In reviewing these cases, we did not feel that valve donation severely impaired cardiac pathologic examination. The benefits of cardiovascular pathologic examination by a cardiac pathologist include the identification of significant and incidental findings and recognition of potentially inheritable conditions.

Clinical review: moral assumptions and the process of organ donation in the intensive care unit

The objective of the present article is to review moral assumptions underlying organ donation in the intensive care unit. Data sources used include personal experience, and a Medline search and a non-Medline search of relevant English-language literature. The study selection included articles concerning organ donation. All data were extracted and analysed by the author. In terms of data synthesis, a rational, utilitarian moral perspective dominates, and has captured and circumscribed, the language and discourse of organ donation. Examples include "the problem is organ shortage", "moral or social duty or responsibility to donate", "moral responsibility to advocate for donation", "requesting organs" or "asking for organs", "trained requesters", "pro-donation support persons", "persuasion" and defining "maximising donor numbers" as the objective while impugning the moral validity of nonrational family objections to organ donation. Organ donation has recently been described by intensivists in a morally neutral way as an "option" that they should "offer", as "part of good end-of-life care", to families of appropriate patients. In conclusion, the review shows that a rational utilitarian framework does not adequately encompass interpersonal interactions during organ donation. A morally neutral position frees intensivists to ensure that clinical and interpersonal processes in organ donation are performed to exemplary standards, and should more robustly reflect societal acceptability of organ donation (although it may or may not "produce more donors").

Vital role of medical examiners and coroners in organ transplantation

Many people die owing to the shortage of donor organs. Medical examiners and coroners (MEs/Cs) play a vital role in making organs available for potential recipients. Medical examiners'/coroners' case data were collected using a structured confirmatory-recorded methodology for calendar years 2000-01 and were linked and analyzed with donor and transplant data from the United Network for Organ Sharing, predicting the nature and extent of the loss of donor organs. Nearly seven percent of ME/C cases were denied recovery during 2000-01. Because 353 and likely, 411 potential organ donors (PODs) were denied, as many as 1400 persons on transplant waiting lists did not receive organs because of ME/C denials. Problematically for pediatric patients awaiting transplantation, nearly half of all ME/C denials occurred in pediatric patients. Eighteen percent of PODs aged five or less and 44.2% of child abuse PODs were denied recovery by the ME/C. There were no (zero) denials in three of the five largest U.S. cities and in four states. Since 1994, two states have enacted legislation restricting the circumstances of ME/C denials, resulting in an 83% decrease in ME/C denials. Release of all organs from ME/C cases is needed urgently to protect the lives of those persons awaiting transplantation. Medical examiners and coroners deserve recognition for their efforts in advocating methods and/or regulation/legislation designed to achieve 100% release of life-saving organs for transplantation.

Heart valve tissue donation does not preclude the diagnosis of clinically significant pediatric cardiac abnormalities

Medical examiners/coroners often have the responsibility of deciding whether to allow organ and tissue donation to proceed in cases under their jurisdiction. A 10-year retrospective study was conducted of autopsy cases in children younger than 6 years to determine whether the donation of cardiac valve tissue would preclude the diagnosis of clinically significant pediatric cardiac abnormalities. Only 1 case (0.1%) was found in the entire 10-year period in which valve tissue donation might have prevented the correct diagnosis. According to the results of the study, (1) most cardiac findings in forensic pediatric autopsies are not clinically significant; (2) clinically significant findings will be diagnosed in properly examined hearts, even those processed for valve tissue donation, and special studies will remain possible in nearly all hearts except those with suspicion of conduction defects; and (3) as long as there is good communication between forensic pathologists and organ and tissue procurement organizations, the concern of failing to diagnose significant cardiac findings should not inhibit medical examiners/coroners from allowing the donation of pediatric cardiac valve tissue.

Modified cardiectomy: documenting sudden cardiac death in hearts selected for valve allograft procurement

Medical examiners frequently deny requests by tissue procurement organizations for heart valves intended for allograft transplantation. Most of these denials are in cases of sudden apparent natural death, often where a cardiac cause is suspected. The basis of denial in these cases is that the heart must be removed and the valves procured off site under sterile conditions. This prevents the medical examiner from determining and documenting the cause of death. A dissection technique was therefore devised to increase the number of heart valves available for allograft transplantation and to simultaneously allow the pathologist to document a cardiac cause of sudden death. Interagency procedures, the dissection technique, and case summaries are provided.