Rethinking the Ethics of Vital Organ Donations: Accepted Medical Practice Already Violates the Dead Donor Rule. Explicitly Jettisoning the Rule-Allowing Vital Organs to Be Extracted, under Certain Conditions, from Living Patients-Is a Radical Change Only at the Conceptual Level. but It Would Expand the Pools of Eligible Organ Donors

By Millerand, Franklin G.; Truog, Robert D. | The Hastings Center Report, November-December 2008 | Go to article overview

Rethinking the Ethics of Vital Organ Donations: Accepted Medical Practice Already Violates the Dead Donor Rule. Explicitly Jettisoning the Rule-Allowing Vital Organs to Be Extracted, under Certain Conditions, from Living Patients-Is a Radical Change Only at the Conceptual Level. but It Would Expand the Pools of Eligible Organ Donors


Millerand, Franklin G., Truog, Robert D., The Hastings Center Report


Mr. Jones, aged thirty, is lying in a bed in an intensive care unit, breathing with the help of a respirator. His face looks ruddy, and he is warm to the touch. Indeed, he looks healthier than other patients in the unit. He has also just been diagnosed as "brain dead."

Two ethically important questions arise with respect to Mr. Jones: (1) Is he really dead, or is he a living patient with traumatic brain injury? (2) Is it acceptable to retrieve his organs--including vital organs such as the heart, lungs, liver, and both kidneys--for donation to patients in need of transplantation? According to the moral status quo, the answers to these two questions are linked. It is thought permissible to retrieve vital organs only from dead patients--the "dead donor rule." What makes it permissible to retrieve organs from Mr. Jones (with his prior consent or the consent of his family) is that Mr. Jones is dead, despite appearances to the contrary. The constellation of neurological findings that since 1968 has been called "brain death" is death, pure and simple.

The same two questions are pertinent to patients who have experienced traumatic brain injury but do not meet the criteria for brain death. With increasing frequency, vital organs are extracted from such patients following a decision to withdraw life-sustaining treatment and only a few minutes after their hearts have stopped beating. Are such patients really dead, or are they imminently dying? Is it ethical to retrieve vital organs when it is not certain that the donors are already dead--that the cessation of heart and lung function is irreversible?

Although firmly entrenched, the moral status quo of vital organ donation poses a dilemma. On the one hand, the dead donor rule appears ethically necessary. It is based on the seemingly unassailable principle that it is wrong to kill (or cause the death) of an innocent person to save the life of another. Accordingly, it is ethical to retrieve vital organs only from dead people. On the other hand, scientific and ethical commentators have raised serious doubts about whether donors of vital organs are genuinely dead at the time that vital organs are extracted for transplantation.

In this article, we argue that it is time both to face honestly the fact that our current practices of vital organ donation violate the dead donor rule, and to provide a coherent alternative ethical account of these practices that does not depend on this norm. Others have contemplated or advocated repeal of the rule, but a systematic justification, including consideration of pertinent objections, has been lacking. (1)

Current Practices

Currently, vital organs are retrieved for transplantation from brain dead patients whose hearts continue to beat owing to mechanical ventilation, and from patients declared dead by traditional cardiopulmonary criteria immediately after life support is withdrawn. Are these donors really dead?

In a New Yorker article provocatively titled "As Good as Dead," Gary Greenberg noted that "By the nineteen-sixties, as doctors began to perfect techniques for transplanting livers and hearts, the medical establishment faced a paradox: the need for both a living body and a dead donor." (2) To overcome this paradox, clinicians and ethicists have endorsed the idea that patients diagnosed as brain dead are really dead--despite not appearing dead--thus facilitating retrieval of vital organs consistent with the dead donor rule. According to this idea, living but catastrophically brain-injured patients are not being killed to retrieve their organs; rather, these patients, being brain dead, are actually corpses breathing mechanically. By telling themselves, patients, and patients' families that brain death is a form of death, clinicians and ethicists have become comfortable with "cadaveric" organ donation.

We contend that the proposition that brain death constitutes death of the human being is incoherent and, therefore, not credible. …

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Rethinking the Ethics of Vital Organ Donations: Accepted Medical Practice Already Violates the Dead Donor Rule. Explicitly Jettisoning the Rule-Allowing Vital Organs to Be Extracted, under Certain Conditions, from Living Patients-Is a Radical Change Only at the Conceptual Level. but It Would Expand the Pools of Eligible Organ Donors
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