A federally funded research project has described how surgeons were able to snatch the hearts from severely brain-damaged newborns only seconds after they were disconnected from life-support units and transplant the organs into other diseased infants, but the work is raising alarms from those who say the donors weren't dead yet.
The work was documented in a report in the New England Journal of Medicine today, which in an unusual move also published a series of commentaries about the study that offered harsh criticism.
"It is impossible to transplant a heart successfully after irreversible stoppage: if a heart is restarted, the person from whom it was taken cannot have been dead according to cardiac criteria. Removing organs from a patient whose heart not only can be restarted, but also has been or will be restarted in another body, is ending a life by organ removal," wrote Dr. Robert Veatch, professor of medical ethics at the Kennedy Institute of Ethics at Georgetown University.
According to the published study, surgeons at Children's Hospital in Aurora, Colo., took the hearts of severely brain-damaged newborns seconds after they were disconnected from life support and their hearts stopped.
According to the report from a team led by Dr. Mark M. Boucek, at a typical children's hospital, "on any given day, between 2.2 and 10.6 children will die, with about half on life support systems.
"A child's death can be anticipated and considered within a family-centered end-of-life care plan, which can include the possibility of donation after withdrawal of life support and subsequent circulatory or cardiac death," the report said.
"The appropriate period of observation after the cessation of cardiocirculatory function and before the declaration of death has not been established. We initially used a 3-minute period after loss of cardiac function. This time was based on a recommendation of 2 minutes in the critical care literature. After the first donation, the ethics committee recommended a period of observation of 1.25 minutes to reduce the risk of injury from warm ischemia," the report said.
However, critics warned of the dangers of taking organs from donors before the traditional complete cessation of heart and brain functions that typically defines death,
"This bold experiment is pushing the boundaries and raising many questions," James Bernat, a Dartmouth medical professor, told the Washington Post. He wrote one of four commentaries that the journal published with the report.
"This clearly shows the feasibility of doing this," Bernat said. "The question is: Should this be done?"
The report noted that the changeover from waiting until brain death is confirmed to a "donation after cardiac death" procedure has potential pitfalls: one California surgeon is accused criminally of hurrying a potential organ donor's death in 2006.
The report documented the transplantation of hearts from the three infants into three other babies, ages 1 month to 4 months, who were dying of their own heart conditions. All three subsequently lived past the six-month age.
"We're very pleased with the lives we saved," Boucek said. "We're trying to deal with a very difficult situation where children die waiting for transplant and parents of other children want to donate."
But others, including George Annas of Boston University, condemned the work.
"This practice cannot be ethically justified," he told the Post. "The donors are not dead."
"The whole issue is whether the infants from whom the hearts were taken were dead. It seems very clear to me that they were not," Veatch said. "I think it's illegal, and if it's illegal, what we're talking about is the physicians causing the death of the three patients, and that would be homicide. It's immoral. I think it should be stopped."
Dr. Robert Truog, of Harvard Medical School, said it appears the door to questioning when a person is dead is wide open.
"The definition of brain death requires the complete absence of all functions of the entire brain, yet many of these patients retain essential neurologic function, such as the regulated secretion of hypothalamic hormones. Some have argued that these patients are dead because they are permanently unconscious (which is true), but if this is the justification, then patients in a permanent vegetative state, who breathe spontaneously, should also be diagnosed as dead, a characterization that most regard as implausible," he wrote.
"Others have claimed that 'brain-dead' patients are dead because their brain damage has led to the 'permanent cessation of functioning of the organism as a whole.' Yet evidence shows that if these patients are supported beyond the acute phase of their illness (which is rarely done), they can survive for many years. The uncomfortable conclusion to be drawn from this literature is that although it may be perfectly ethical to remove vital organs for transplantation from patients who satisfy the diagnostic criteria of brain death, the reason it is ethical cannot be that we are convinced they are really dead," he wrote.
He said the concept of cardiac death also has its hurdles.
"This … creates the paradox that the hearts of patients who have been declared dead on the basis of the irreversible loss of cardiac function have in fact been transplanted and have successfully functioned in the chest of another. Again, although it may be ethical to remove vital organs from these patients, we believe that the reason it is ethical cannot convincingly be that the donors are dead," he said.
He argued in the end, "proper safeguards" should allow physicians to retrieve "vital organs before death."
No patient, he said, "will die from vital organ donation who would not otherwise die as a result of the withdrawal of life support."
But Veatch warned against tampering with the standards for declaring death.
"Surely, definitions should not be changed simply to make hearts available," he said. However, "A good case can be made for letting those whose values support such a definition choose to have it applied to them."
WND has reported previously on the life-and-death issues involved in cases such as the severely disabled Terri Schiavo, who died after judges told doctors to follow her husband's orders and stop giving her food and water.