Since October 2006, the Agency of Biomedicine experiments, with discretion and in nine hospitals (in Angers, Bordeaux, Lyon, Marseille, Nancy, Strasbourg and the Saint-Louis, Pitié-Salpêtrière and Bicêtre Hospitals in Paris), the organ transplantation on cardiac arrested patient (authorised by the decree No 2005-949 of 2nd of August 2005). According to the Agency, these teams performed, in 2007, 43 kidney grafts from non-heart-beating donors, “with very encouraging results”. Up to then, organ transplantations were performed in brain dead patients.
Performed in a “total silence”, this new method of transplantation, which enables to increase noticeably the number of potential donors, raises serious ethical questions to which Jean-Michel Boles, professor of medical resuscitation, has dedicated a study1. (In June 2008, the debate about this question was already been reopened by a 45-year-old man who, after a cardiac arrest, waked up when a kidney was about to be procured.)
Protocol
According to the procedure established by the Agency of Biomedicine, the clinical observation on the inefficacy of resuscitation maneuvers after cardiac arrest requires a time limit of at least 30 minutes. Once this lapse of time is passed, the resuscitation maneuvers are then interrupted and the death is clinically confirmed after 5 minutes of observation. The body is then subject to others manipulations whereas it is shipped to the place foreseen for the organ preservation. mechanical ventilation, external cardiac massage… At this moment only the family is informed about the death of its relative and asked about a possible refusal of donation.
Real race against the clock, the total duration of this process must not exceed 300 minutes (120 minutes between the initial cardiac arrest and organ cooling; 180 minutes between the cooling and the transplantation), against one or two days after a proved brain death.
Instrumentalisation of the body
Besides the rupture of time, place and type of treatment and team in charge of the patient that such a protocol introduces, here Pr Boles indicates the “instrumentalisation” of the principle of presumed consent. “If we discover a refusal to consent to organ donation, all the maneuvers will then have been made against the consent of the patient”, he accuses.
And how not to be worried about the possible psychological impact of an “intrusive procedure” on a body, without the previous consent of the person, both on medical professionals and the family.
Resuming the resuscitation maneuvers and implementing invasive techniques in another purpose than the resuscitation of the patient generate a “deconsecration of the body which can only modify the representation of the death”.
For the author, “it is a double change we prepare in the greatest secret for the public” : “a quantitative change passing from a small number of brain deaths (3,147 in 2007) to a “tank” of potential deaths” and “a qualitative change considering that the body is a “reserve of spare parts” we can use when the person dies”.
Between a “utilitarian logic” of the human body which transforms it into a “social object instrumentalised by the community in the name of public health needs” and the fact to organise the organ donation with the absence of explicit refusal (in other words the system of presumed consent, in force in France), raises the question of the “nationalisation” of the bodies.
The “totalitarian health”?
For the author, “the intention is clearly announced to transform what was “a freely consented exceptional donation” into a right for the society to appropriate the organs of dead people without having to ask the authorisation”.
Finally, Pr Boles denounces a situation which reveals a “democratic deficit”: from one hand, because the text opening the way to non-heart-beating organ donation is of regulation order and not of legislative order, and from another hand, because the Agency of Biomedicine led this operation in a “totally occult” way.
Concluding by a warning against the risks of drifts to meet an increasing demand of grafts, he estimates first that it is essential to plot the limits and the human conditions of this new practice and asks for a society debate, in the occasion of the convention of bioethics for instance.
1- Boles J.-M., Les prélèvements d’organes à cœur arrêté, Etudes 2008/12, Tome 409, p.619-630