The retrieval of organs after cardiac arrest: an ethical issue

Publié le : 28 February 2013

 During its international congress held in Paris in early February, the Biomedicine Agency, in partnership with the Parliamentary Office for Evaluating Scientific and Technological Choices (OPECST) "organised a public hearing on the retrieval of organs from donors who died from cardiac arrest."  (The weekly bioethic newsletter from 11th to 15th of February 2013)   Currently, the number of "donors who die from brain failure is constantly declining and the increase in living donors (7.6% for kidneys) is not enough." The journalist explains that "the alternative gradually becoming dominant is the retrieval of organs from deceased donors after cardiac arrest” (donation after cardiac death, DCD). The classification of the 1995 Maastricht protocol distinguishes 4 categories of donation after cardiac death: the first category concerns the uncontrolled DCD "without treatment," the second concerns the uncontrolled DCD "in the presence of treatment," the third, called "Maastricht 3" or (M3), concerns the controlled DCD, i.e. "the cardiac arrests provoked by a decision to stop the treatments because of the prognosis," and the fourth "supposes an unexpected and irreversible cardiac arrest occurring during the reanimation treatment."

Describing Maastricht 3 as "very ambiguous in ethical terms," the journalist explains that in this category of donor, "the doctors decide to end the treatments" by "applying the provisions of the law of 2005 on the end of life, called the Leonetti law." However, "the opening of organ retrieval to DCD introduces the possibility of utilitarian euthanasia, the objectification of the dead." On this practice, a doctor expresses his concern: "There is a temporal paradox. If we stop the treatments at an early stage, the organ will be in very good condition, but there will be uncertainty about the neurological prognosis. If we wait, the uncertainty is removed but there is a risk that the implant will no longer be good." On this point, Prod. Laurent Beylon, chairman of the ethics committee of the French Anaesthesia and Reanimation Society (SFAR), adds: "when we retrieve organs from a brain-dead person, there is no doubt. With M3, the situation changes. It is a clinical supposition, which introduces a decision based on probability." The SFAR chairman refers to a legal vacuum: "as reanimation providers, we feel our fragility. About 45% of patients die within 60 minutes after a cardiac arrest, but 1.2% survive. The legislation must be changed to help us handle this disputed point.
Elsewhere, organs have been retrieved from category 3 donors in Spain since 2009. Dr Rafael Matesanz, director of the Organización Nacional de Transplantes points out: "there were no heated discussions in society, no difficulties with M3. Perhaps because we have a positive view of therapeutic limitation.". In Great Britain, Prof. Rutger Ploeg explains that "the decision on the end of life has nothing to do with organ donation." He adds: "we talk a lot more about the end of life in England than in France. It is necessary because the family must first accept the ending of the treatment. The question of a donation arises only afterwards – unless the family raises it spontaneously.

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