We read Graham Campbell and Francis Sutherland's paper on non-heart-beating organ donation1 with interest. Several aspects of their proposal concerned us.
We feel it is inappropriate for a physician to approach a live patient's substitute decision-maker regarding consent for organ donation. This approach would undermine confidence in the physician's (and institution's) primary commitment to optimizing the interests of the patient.
However, it is not simply the appearance of primary commitment to the patient that is important. Although clinicians caring for brain-injured patients may consider the potential for organ donation before declaration, criteria for brain death are firm. It is therefore straightforward at present for a physician to mentally separate the time for management in accordance with primary concern for the patient from that for potential organ donation. Under the authors' proposal, the assessment of severity of brain damage could be influenced by the prospect of organ donation. The authors retrospectively propose criteria for donation. When defining candidacy in practice, the potential for bias in recommending withdrawal of life support on the basis of irremedial damage would be far greater.
This type of bias might also affect dosage or timing of palliative medication. Under the authors' proposal, transplant physicians would have an interest in rapid deterioration of organ donors, thereby avoiding protracted hypotension and optimizing organ integrity. Over time, this interest might influence others' management of palliation following withdrawal of life support.
Another difficulty would arise in the operating room: Who would pronounce the patient dead? A physician would need to be immediately available to minimize delay in harvesting. However, there would be no reason for an anesthetist or intensivist to be involved at this stage and the harvesting team would have a conflict of interest regarding timing of the pronouncement.
Reference
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