While the practice of organ donation after cardiac death has long been trending upwards in acceptance and use, it is still a highly controversial and practically inefficient method of organ procurement. One policy that has recently been proposed to try and alleviate some of the ethical and practical concerns with organ donation after cardiac death is the practice of imminent death organ donation. This type of live organ donation comes in patients at the end of their life who have decided to withdraw life-sustaining treatment, but still want to ensure that their organs are donated and not wasted, which isn't always the case with organ donation after cardiac death. This paper then gives some ethical and practical reflections and recommendations regarding the potential implementation of this controversial practice into regular transplant practice and policy.
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This scenario is similar to the case mentioned briefly earlier from the UCLA Medical Center Ethics Committee. In this case, the ethics committee allowed surrogate consent for IDD based upon both (a) a close relative (first cousin) needing a kidney who was a match with the patient, and (b) the patient’s previous character and values, which were thoroughly demonstrated by the family to be significantly altruistic (e.g. the patient was a firefighter). This is despite the fact that neither the family nor friends had knowledge of the patient’s preferences and values regarding organ donation. More difficult scenarios would be whether to allow surrogate consent for IDD in this case if (a) the potential recipient was a stranger rather than a relative, or (b) the potential recipient was a relative, but there was no substantial evidence of the patient’s prior altruistic character, which treads into a moral gray zone. For more detail on this case, see: K.Brown-Saltzman, A.Diamant, I. C.Fineberg, H. A.Gritsch, M.Keane, S.Korenman, M.Lewiset al., “Surrogate Consent for Living Related Organ Donation,”JAMA291, no. 6 (2004): 728-731.
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In cases where an incapacitated patient is a registered organ donor, it is ethically appropriate and justifiable for the transplant team to approach the patient’s surrogate decision-makers regarding the possibility of IDD. Given the patient’s past preferences for organ donation, this justifies the transplant team inquiring about the possibility of IDD in order to best respect the patient’s preferences and values. Of course, as already detailed above, a positive organ donor status does not necessarily justify pursuing IDD on its own, and more positive evidence is required to justifiably pursue IDD from an ethical perspective; however, a positive organ donor status does at least justify an inquiry regarding IDD to the surrogate decision-makers.
