Logo used to promote organ donation
Officials running a federal program that is considering redefining death are going to be seeking further public comment after members of the Christian Medical Association raised alarms about several problems, including what they believe would be an open door to pressure families to donate organs before their loved one has died.
The proposal could move the federal government closer into alignment with what has been proposed by longtime Barack Obama adviser Cass Sunstein.
Obama's "regulatory czar" was revealed in 2009 to have pushed strongly for the removal of organs from those who did not give their consent to becoming an organ donor.
In his book, "Nudge: Improving Decisions about Health, Wealth and Happiness," Sunstein and co-author Richard Thaler presented the possibility of the "routine removal" of organs because "the state owns the rights to body parts of people who are dead or in certain hopeless conditions, and it can remove their organs without asking anyone's permission."
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"Though it may sound grotesque, routine removal is not impossible to defend," he wrote. "In theory, it would save lives, and it would do so without intruding on anyone who has any prospect for life."
He also has argued for presumed consent, the idea that anyone who has not left specific orders against organ donation is a voluntary contributor to the program, a plan that has been proposed in some state legislatures as recently as the last few years.
A spokeswoman for the the operators of the Organ Procurement and Transplantation Network told WND that a new round of public comments will be heard regarding the issue that the CMA said would allow those caring for critically ill patients to start considering them for their potential to donate organs while they remain alive.
"Gone [would be] the crucial wall separating patient care from donation solicitations," said a letter this week from the chief of the CMA. "Such undue influence on difficult decisions at a heart-wrenching time is ethically unacceptable."
The letter was from Dr. David Stevens, the CEO of the Christian Medical Association, to John Lake, the president of the OPTN, which is run under contract by a company called UNOS, the United Network for Organ Sharing.
At issue are proposed changes to various definitions and standards that the nationwide organ-donation coordination program uses.
The CMA said the first was the removal of an important stipulation "separating patient care from donation solicitations."
"Previously the hospital's primary healthcare team and the legal next of kin must have decided to withdraw ventilated support or other life-sustaining treatment before the patient may be evaluated as a DCD [donation after cardiac death] candidate," the letter warned.
"Under the proposed policy a patient may be evaluated as a DCD candidate prior to a decision by family members and caregivers, which ought to be free from external pressure."
The proposed language change specifically would instruct, "A potential DCD donor should be evaluated by the primary healthcare team and the local OPPO to determine if the candidate meets the following criteria:"
Those included irreversible disease or "end-stage musculoskeletal disease."
The changes also call for a plan for patient care "in the event that death does not occur within the established time period after the withdrawal of life-sustaining medical treatment or ventilated support."
And the proposed changes involve the deletion of a long section of guidelines on defining "irreversibility."
Those said that irreversibility is a "persistent cessation of function during an appropriate period of observation." It also says "donor death occurs when respiration and circulation have ceased and cardiopulmonary function will not resume spontaneously."
"The removal of the requirement of 'irreversibility' of cardiopulmonary cessation exposes patients to potential exploitation," the CMA letter said. "CMA is concerned that relaxing the definition of death would considerably increase the risk that procedures to remove vital organs would be performed on some patients lacking unambiguous signs that death has occurred. CMA is also concerned about the impact that publicized abuses of the new policy could have on the public's trust in transplant medicine and their willingness to volunteer as future organ donors," the CMA letter said.
A spokeswoman for the OPTN program said the organization would be distributing requests for comment and accepting those statements in preparation for consideration of the changes sometime during 2012.
Steven's letter also expressed that the "model elements" that previously had been recommended were to be made "mandatory," and further, "The proposed requirements broaden donor criteria to include patients without cognitive neurological injury. As physicians, we are greatly concerned that patients with chronic illnesses such as spinal cord injury or amyotrophic lateral sclerosis (ALS) would be vulnerable to real or perceived pressure to decline further treatment in order to donate their organs…" he continued.
"The unintended consequences of the proposed requirements would be antithetical to the ethical practice of medicine. By loosening previous stricter guidelines, by eliminating vital safeguards and by failing to clarify key criteria, the proposed requirements signal that hospitals and healthcare professionals can now relax ethical concerns and safeguards in favor of pursuing a utilitarian 'higher good' of obtaining a greater number of organs for transplant," the CMA letter said.
"We believe that such a change in emphasis, however subtle, would erode the ethical practice of medicine by promoting a culture of utilitarianism or casualness regarding life and death decisions," the statement said.
"If physicians conscientiously opposed to such policies were forced to retire from the practice of critical care medicine rather than participate in them, society would lose many dedicated, skilled and compassionate caregivers."
The government proposal makes clear its intentions: "The proposed changes will help to maximize the number of donors and transplants by identifying the currently unrealized donor potential."
The doctors' concern, however, was found a few pages later: "A controlled Donation after Circulatory Death donor is a donor whose life support will be withdrawn and whose family has given written consent for organ donation in the controlled environment of the operation room."