The Transplant Paradox: Heart Donation After Cardiac Death
The use of cardiac death (as opposed to brain death) to obtain organs for transplantation has been accepted practice for more than a decade in the United States.* According to various protocols, cardiac death in the context of organ harvesting is defined as asystole for 2 or more minutes after the withdrawal of life support. The criterion is based on the fact that autoresuscitation has not been observed after 65 seconds of asystole. However, a logical problem arises when considering the transplantation of a heart after cardiac death.
As ethicist Robert Veatch writes in this week’s NEJM, it should be impossible to transplant a heart after the irreversible cessation of cardiac function. If the heart can be restarted in the graft recipient, then the donor could not have been dead in the first place on the basis of cardiac death. Moreover, the very act of removing the “restartable” heart from the donor is equivalent to killing the donor by means of organ removal. Veatch concludes that it is therefore impossible to legally harvest a heart in the setting of cardiac death and proposes 2 ways by which the paradox can be resolved.
One is to alter laws to permit heart removal from living donors. In such cases, however, strict scenarios—such as terminal illness or previous consent—would have to be explicitly defined. The other is to redefine brain death as the loss of higher cortical function (ie, consciousness), which may have popular support. Until then, Veatch argues, “[A]ny successfully transplanted heart cannot have come from a person who was declared dead on the basis of irreversible stoppage of the heart.”
Veatch’s editorial appears in the same NEJM issue in which Denver physicians report their experience with cardiac transplantation in 3 infant recipients following cardiac death in pediatric donors.
* Although the management of end-of-life care, especially if left to transplant surgeons, can go horribly wrong—for example, as in the case of Ruben Navarro.
Update: Further debate on the controversy of heart donation after cardiac death, particularly in the case of infants, was explored by The Washington Post. Veatch further defined the procedure as “homocide,” according to the paper, but a Denver cardiologist involved in the pediatric transplantations called Veatch’s assertions “fussy semantics.”