Quick Harvesting of Infant Hearts Sparks Debate over Ethics, Policy

Published November 1, 2008

When and how organ donors are declared dead is the subject of debate after the disclosure of three heart transplants from infant donors who had not been declared brain-dead before the hearts were removed.

The hearts were taken from three newborns who had suffered asphyxia—oxygen deficiency—at birth. Though left with serious brain damage and not expected to survive for long, the babies were not brain-dead according to the accepted guidelines of the American Academy of Neurology.

The transplants were performed on three infants born with defective hearts at Children’s Hospital in Denver in 2004 and 2007, according to the August 14, 2008 issue of the New England Journal of Medicine (NEJM).

The harvesting procedure could be described as “audacious” in the cases at issue, said Dr. Jane Orient, author of the medical textbook Sapira’s Art and Science of Bedside Diagnosis. Orient said the transplants at Children’s Hospital are questionable tactics employed to keep up with the demand for organs.

Victim of Success

Orient reports the transplantation of cadaver organs has become so successful that the demand for organs, especially in pediatrics, has soared and greatly exceeds supply—the success of organ transplantation is causing problems while solving others.

“There is intense pressure not to wait too long before harvesting the organs, lest they become unsalvageable,” Orient said.

In the case of Children’s Hospital, once parental consent was obtained, a “do not resuscitate” order was written and the babies were taken to the operating room. Tubes were placed in their femoral artery and vein, a blood thinner was administered, and life support was discontinued.

To ease the discomfort that may accompany removal of the breathing machine—such as intense air hunger—the babies received pain-killing and sedating drugs. Once their hearts stopped beating, the organs were harvested.

‘Artificial Shortage’

“This is a problem created by government,” said Michael Cannon, director of health policy studies at the Cato Institute. “The federal government prohibits the sale of human organs, creating an artificial shortage. As a result, people are trying anything they can think of to produce the organs that patients so desperately need, including harvesting organs before brain death.

“The difficult ethical questions surrounding that practice could be rendered moot if Congress lifted its ban on payments for organs,” Cannon concluded.

Pushing the Boundaries

The use of “cardiac-dead” donors such as those in the Children’s Hospital cases is not new.

There were 793 such donors in 2007, representing some 10 percent of all deceased infant donors. But in those cases only abdominal organs were transplanted. The hearts had been stopped for at least five minutes, to ensure the stoppage was truly irreversible. By then, the heart had probably been too damaged by lack of circulation to be useful as a transplant.

In Denver, one of the babies’ hearts had been stopped for only 75 seconds. The doctors argued “autoresuscitation” was probably impossible by this time.

Orient says that can’t be true. “Obviously the stoppage was not irreversible,” she said. “The hearts started beating promptly after being installed in the transplant recipients.”

Broadening the Definition

The definition of brain death has broadened since first introduced in the 1960s. At first, brain death meant the brain had no blood circulation and was turning into a formless liquid. Soon after, however, the criteria started becoming less strict. Now many highly regarded hospitals cut corners, according to a survey presented at the 2007 meeting of the American Academy of Neurology.

“The definition of brain death is after all not a newly discovered law of nature but an arbitrary agreement,” wrote Prof. Anna Bergmann in an article on how transplantation violates cultural taboos, in the Summer 2008 issue of the Journal of American Physicians and Surgeons.

Some doctors suggest doing away with the dead-donor rule altogether. Commentary accompanying the report of the transplants in the NEJM recommends requiring only “valid consent by the patient or surrogate” in order to “maximize the number and quality of organs available to those in need.”

That would open up a host of even thornier issues, Orient warns. “Government-mandated wealth transfer programs take on a whole new dimension—if someone else can make better use of a heart than its original owner does, why shouldn’t society transfer the wealth?” she said.

Kathryn A. Serkes ([email protected]) is coauthor of Patient Power: The Patient’s Handbook.