The question of organ removal on controlled cardiac death donors

While At the occasion of the 41st International Congress of the Society of French Language Resuscitation, the Parliamentary Office for Scientific and Technological Assessment (OPECST) under the impulsion of the Agency of Biomedicine (ABM) organized on 7th February 2013 a hearing on the removal of organs on controlled cardiac death donors. France already allows the removal of organs on uncontrolled cardiac death donors, the removal of organs controlled cardiac death donors arises a real ethical question.


Transplantations in France


“The first cause of death in France related to a transplantation is not a medical complication nor a rejection but the absence of transplants” (Jean-Louis Touraine vice-chairman of the OPECST). France lacks of organ donors and the number of patients registered in the waiting list is still increasing. In 2011 12,329 patients were waiting for kidney transplantation (30% more in five years) and 2,976 kidney transplantations have been performed. An idea proposed to allow more transplantations is the removal of organs on controlled cardiac death donors.


Maastricht protocol


The Maastricht protocol, established in 1995, during an international conference of consensus, regulates four categories of cardiac dead donors. France adopted them all, except the category III which gives rise to many ethical ambiguities. The first category concerns the persons dead even before arriving to the hospital and who did benefit from resuscitation. The second concerns the person dead from cardiac arrest in the hospital, and whose resuscitation failed. The category IV concerns the persons dead from encephalic death and whose removal of organs can then be planed. Finally the category III or M3 called “waiting for a cardiac arrest” is a subject of debate. This category concerns living persons who present a “major neurological problem” and whose vital prognostic is so bad that we decide to stop any treatment. The cardiac arrest is then controlled, and the removal of organs planed.


A risk of “altruist” euthanasia.


In this last case, while the person is alive, she/he is already perceived as a “potential donor”. In this case the treatments are voluntarily stopped knowing that this will generate a cardiac arrest. The ethical question which arises could fall under euthanasia. Would regulating such a category of so called "controlled” cardiac death donators while they are still alive when the medical decision is made, be a kind of “altruist euthanasia”?   


Of course, the current regulation reassures some people. Emmanuelle Prada Bordenave, director of the ABM considers that the fact resuscitators and transplant physicians are not part of the same team guarantees a clear distinction between the end of life and the donation of organs. Or even because the Léonetti law must be respected, and with it the end of life. And then the consent of relatives would oblige to think about the elements one after the other. 


Nevertheless, does such category of donors, even if it attempts to respect a real distinction between the end of life and the donation of organ, not make enter a criterion of judgment on the state of the person? Indeed, the cardiac arrest is performed when the “prognostic is so bad”. The assessment of the quality of life of the other would not come into play and the subjectivism with it?

Moreover, Dr. Louis Puybasset, anesthetist-resuscitator, Head of the surgical neuro-resuscitation department at the Pitié-Salpêtrière hospital, present at this hearing, draws attention to the problem of the temporality in which the medical teams will be. Indeed, “if care is stopped too early for this category of persons, the organs will be in very good condition, but the neurologic prognostic will be uncertain.  On the contrary if we make a decision at a later time, the prognostic will be better, but the graft may not be good.” This way, even distinguished, the decisions to stop treatment and to donate organs are deeply related, from there the danger to hasten death in view of a removal of organ the best it could be.  The representative of the Society of French Language Resuscitation confirms that this category 3 is a “slippery slope” and that we need to be particularly vigilant not to use the dying patient as a donator, which can only be done with the respect to the letter of the Léonetti law.  

The question may arise on a more acute way if the Léonetti law becomes obsolete, and if euthanasia is legalized, as the government wants it. The automaticity of the end of life will be more significant, and the programming of the donation of organs on controlled cardiac death donators even more debatable. The integration of this category of donators in the practice could be made by simple regulatory way. Some MPs, like Jean-Sébastien Vialatte, are in favor. Yet such a question would need an institutional public debate.