Pro-life concerns with organ donation

A briefing paper prepared by the Society for the Protection of Unborn Children (SPUC)

On 20 May 2020 there was an important change to organ donation in England. Instead of opting in to becoming an organ donor you will have to opt out if you do not want your organs to be taken for transplant purposes. A system of “presumed consent” came into force. This means that unless you specifically register with the NHS that you do not want your organs to be used for transplantation after you have been declared legally dead, the state will have the power to take your organs.

This article will help you understand the facts about organ donation and will help you to decide whether you want to donate your organs.

Are organ donation and transplantation issues of pro-life concern? Yes. Organ donation raises fundamental issues concerning:

1. Determination of death. 2. Respect for the human person and their remains when truly dead. 3. The meaning of gift giving. 1. Determination of death Tests for the determination of death vary from country to country and even within a single country. Traditional criteria for determining death changed after the first successful human heart transplant in 1967 with the introduction in 1968 of the concept of “brain death”.

A person may legally be declared dead by reference to irreversible cessation of heartbeat, circulation and respiration (cardiopulmonary or circulatory death) or irreversible cessation of brain functions (neurological determination of death or “brain death”).

Organs for transplantation must be taken while there is circulation of the blood or within minutes after circulation has ceased. The majority of organs are extracted from donors who have been declared “brain dead”. These donors, although not able to take a breath on their own, have a beating heart, circulation, and respiration (exchange of oxygen and carbon dioxide in the tissues) and are known as

“The majority of organs are extracted from donors who have been declared ‘brain dead’. These donors, although not able to take a breath on their own, have a beating heart, circulation, and respiration and are known as ‘heart beating donors’ .”

“heart beating donors”. In England, heart beating donors are legally declared to be dead by “brain death” criteria.

Some donor candidates have a functioning brain and are on a life-supporting ventilator. To take organs from these patients, a decision is made not to resuscitate the patient. The patient either remains in the ICU, or is moved to an operating room where they may have intra-vascular catheters placed and receive blood thinners in anticipation of the operation to take their organs. Without ventilator support, heart function may decrease until the patient is without a pulse or heartbeat, and then a waiting period of time ensues from the time of either absence of electrical heart activity or absence of pulsation, which may vary, usually 2 to 5 minutes but in some places as short at 75 seconds to as long as 20 minutes. Then the patient is pronounced legally dead and organ procurement continues. These patients are known as “non-heart beating donors” (donation after “circulatory” death, formerly “cardiac” death). It should be noted that the patient may be declared dead and considered a non-heart beating donor, even though their heart may not have stopped beating, but was not strong enough to produce a pulse. Sometimes the patient continues to have a pulse and/or does not stop all breathing efforts and so cannot be considered dead. These patients are neither resuscitated nor put back on the ventilator but are taken back to a non-ICU room to die.

Dead donor rule and “brain death” In 1999, thirty-one years after the JAMA 1968 Harvard Committee article invented the concept of “brain death”, bioethicist John Robertson, writing in The Hastings Centre Report, used the term “the dead donor rule”.1 This term expresses the view that the taking of organs must not cause the death of the person and that vital unpaired organs should not be taken until after death. This begs the question of what true death is and how it is determined. “Brain death” is the fiction that its supporters claim fulfils the dead donor rule.

What are the problems with “brain death”? The first problem is that “brain death” is not true death. So, when the procedures are initiated to take the organs, the patient is alive, but once the organs are excised, the patient is truly dead. A “brain death” declaration enables doctors to remove vital organs from a patient who has a beating heart, circulation and respiration, which are signs of life, although the patient may not be able to demonstrate consciousness, or able to take a breath on their own, and may even be close to death.

A donor heart, for example, is harvested after a declaration of “brain death” in a living person with a beating heart and circulation, who instead of being considered a living person, albeit with an injured brain, is considered a “heart beating cadaver”. Publicity to encourage people to donate their organs does not reveal that heart beating donors may move when the organs are taken unless given drugs to prevent movement. Transplant surgeons know this, and they also know that the person’s blood pressure goes up when an incision is made. Some anaesthetists recommend that the supposed “cadaver” should be anaesthetised when his/her organs are removed.

2. Respect for the human person and their remains when truly dead It matters to people what happens to their bodies after death. Many people have specific instructions about their funeral arrangements. Families may dedicate a lot of time to organising the funeral of a loved one.

There should be full disclosure of what is involved in organ donation for both donor and recipient. Are organ donors fully aware of what will happen to their bodies? Probably not. Most organ donors are not given full and complete information and therefore cannot give truly informed consent. Most organ donors, including those who give explicit consent in accord with whatever information was provided before they die, are unaware that their heart may be beating when their organs are taken, and that they may be pink, warm, able to heal wounds, fight infections, respond to stimuli, etc. It is also the case that “brain dead” people (such as pregnant women who are given ventilation, nutrition and hydration and perhaps other medical support) can survive for months while demonstrating integrated bodily activity of a kind that arguably indicates that life still remains.

There is also reason for concern over how quickly a medical team might “move in” following cessation of cardiac functioning (known as “donation after circulatory death” or DCD; previously known as “donation after cardiac death”). Fears that death is declared too quickly, to obtain usable organs, have been expressed and discussed by well-informed commentators.2

One worrying development noted in Australia has been the move from declaring that organ removal must be attempted only after “irreversible” loss of cardiac function to saying that it must only be attempted after “permanent” loss of cardiac function, where the latter can include scenarios where a decision has already been made that resuscitation not be attempted. As one report puts it,

“One cannot rightly claim that death has occurred if cardiac function could be restored, even if a decision has been made not to do so.”3

Should relatives have a say before an organ is taken from a loved one? Yes. Even if an adult donor has given “informed consent” to organ donation after death is declared, objections to donation raised by close relatives should be seriously considered given that a life and death decision is involved. The relatives may have more explicit information about the current

medical condition of the prospective donor and know that the patient himself/herself would have wanted an advocate for preserving and protecting their life in what are now known, not hypothetical circumstances.

This is particularly the case with retrieval of organs from heart beating donors, which can be most distressing for relatives who believe – not without evidence – that their loved one may still be alive.

However, there are also more general concerns about respect for the feelings of relatives, including in situations where no information exists on the potential donor’s wishes, but relatives are reluctant for organ harvesting to go ahead. Relatives should not be asked merely for information on the wishes of the potential donor, about which nothing may be known. Organ harvesting should not take place against relatives’ objections, as a matter of humanity.

3. The meaning of gift giving A major objection to the change in organ donation in England to presumed consent is that the State is seen as effectively owning the bodies of its citizens.

The role of the State is to protect and respect the person during life and their remains after death. Presumed consent to organ donation means that the State owns your body after a declaration of “brain death” or “heart death” and any opposition of your relatives may be (though it need not be) disregarded.

A gift is something freely given. You cannot donate your organs, i.e. give them as a gift, if the State has already usurped ownership on the part of your body and you have not even considered the matter.

Under the new system of presumed consent, you can opt out of “donating” your organs. But if you do not opt out, your organs may be harvested and your relatives may be powerless to stop this.

What about vulnerable adults and children? Clearly adults with learning or mental disabilities will likely be unable to understand what is involved in organ donation. They may not have the capacity to opt out of organ donation. Their caregivers should serve the best interests of those they look after and be ready to speak out should the question of organ donation arise.

Parents should take the time now to think carefully about whether they would want to give consent to donate their child’s organs. Not spending time now to gather information needed for clear thinking about this means that if a tragic accident should take place involving a child or teenager, distraught and grief-stricken parents may make a decision to donate their child’s organs without full knowledge of what is involved.

Pressure may be placed on parents as there is a shortage of children’s organs. This has been attributed to the reluctance of parents to donate their child’s organs.4

Is there an ethical approach to organ transplantation? The issues discussed above must be faced by anyone wishing to promote ethical forms of organ donation to protect donors. These issues should also be considered by those for whom an organ transplant has been suggested. Those who have been told they could receive a transplant are entitled to full information about what is involved for the donor.

In seeking to benefit a patient whose need for organs may be urgent and compelling, the rights of the potential donor and their family must always be respected.

Developing an ethical approach to organ donation:

• Not all organs need to be taken from “brain dead” heart beating donors or after tests for

“brain death”. A person in need of a donated organ should obtain in advance full and complete information about how the organ will be retrieved. • There should be increased opportunity for relatives to object to organ donation. • Taking organs should not occur without full and complete information provided to both the donor and recipient. • Alternatives to organ transplantation should be developed. There have been reports that heart transplants could be obsolete within 10 years because they help so few people. Heart pumps and stem cells, it has been said, have the potential to help many more people.5

“If you are an adult living in England, and you do not opt out of organ donation, you will be considered to have agreed to be an organ donor when you are declared ‘dead’.”

The law has changed on organ donation, but you still have a choice about whether to donate your organs or not.

If you are an adult living in England, and you do not opt out of organ donation, you will be considered to have agreed to be an organ donor when you are declared “dead”.

The only circumstance in which the State will not presume you have consented to donate your organs is if you are in an excluded category: Those excluded will be people under 18, people who have lived in England for less than 12 months or who are not living here voluntarily, and people who lack the capacity to understand the change.

A person cannot become an organ donor if they have or are suspected of having:

• Creutzfeldt-Jakob Disease (CJD) • Ebola virus disease • Active cancer • HIV To opt out of organ donation you should go online to NHS Blood and Transplant to the page “Register your decision”. On this page you can “Register” or “Opt out”. Alternatively, you may wish to communicate your decision by phoning: 0300 123 2323.

Once you have made your choice you will be advised by the NHS to inform one or more relatives or friends of your decision. It is important that others know your position. You will also receive a letter in the post confirming your decision, which you should keep in a safe place. Your family and friends should know where this letter is kept in case of an emergency.

Endnotes:

1. Robertson, J.A., The Dead Donor Rule, in The Hastings Center Report 1999, The Hastings Center: Garrison, NY. p. 6-14. 2. See the discussions of DCD, and also of brain death, in Jason T. Eberl (ed) Contemporary Controversies in Catholic Bioethics Gewerbeststrasse: Springer International Publishing (2017). 3. http://bioethics.org.uk/Ontheethicsoforgantransplantationfinal.pdf 4. https://www.organdonation.nhs.uk/get-involved/news/parents-less-likely-todonate-child-s-organs/ 5. https://www.telegraph.co.uk/science/2017/12/03/heart-transplants-likely-obsolete-within-10-years-says-heart/