Ethicists wary of organ harvest after euthanasia

Could play role in patient’s decision to end life

Doctors have already harvested organs from dozens of Canadians who underwent medically assisted death, a practice supporters say expands the pool of desperately needed organs, but ethicists worry could make it harder for euthanasia patients to voice a last-minute change of heart.

In Ontario, 26 people who died by lethal injection have donated tissue or organs since the federal law decriminalizing medical assistance in dying, or MAID, came into effect last June, according to information obtained by the Post. A total of 338 have died by medical assistance in the province.

Most of the 26 were tissue donors, which usually involves eyes, skin, heart valves, bones and tendons.

Bioethicists and transplant experts say people who qualify for assisted dying deserve to be offered the chance to donate their organs. The gesture could bring a profound sense of psychological comfort, they say, provided the request for assisted death and the decision to donate are kept entirely separate.

“If we accept people can make decisions to end life, and we accept the idea of cardiac death being sufficient for organ donation, this should be acceptable,” said Dr. James Downar, a Toronto critical care doctor and co- chair of a Canadian Blood Services committee developing organ donation guidelines for what is being called the “conscious competent patient.”

“The concern that comes up is, could the decision for one drive the decision for the other?”

Ethicists say organ donation could put pressure on those who qualify for assisted suicide to choose death, that the terminally ill “may feel they would better serve society by dying and saving other people’s lives,” Dr. Marie- Chantal Fortin, a transplant nephrologist at the Centre hospitalier de l’Université de Montréal, and ethicist Julie Allard write in the journal Clinical Ethics.

Others are asking what if people agree to donate, but then change their mind about hastening death? Would they feel compelled to follow through with the act, knowing recipients are waiting for their organs?

“This is a theoretical possibility,” says Jennifer Chandler, a professor in the centre for health law, policy and ethics at the University of Ottawa. “Imagine a situation where the workup is done — people have gone out and done the medical tests and found the recipients and set everything up. And then you change your mind.

“One wonders if perhaps that might create pressure to continue with the MAID,” Chandler said. “It would be very important in these scenarios to make it very clear to people that they can change their mind at any time — that someone shouldn’t stick with MAID just because they feel an obligation, having set the process in motion.”

The issue is so volatile, Fortin said that after she and her co- author concluded organ donation after assisted dying would be ethically acceptable if the person is competent and under no pressure to choose either, “it was like we were vultures” to those opposed to euthanasia.

“I think it’s really important we keep the public’s trust, in all of this,” Fortin said. “We have to be transparent. And it has to be clear that the two must be kept separate, that there is no pressure to go for MAID to procure organs.”

Organ harvesting after euthanasia is a reality in Belgium and the Netherlands.

Historically, the major source of organs for transplant has been people declared “brain dead,” often following a severe head injury. In those cases, patients are removed from ventilators and other life support that keep hearts and lungs functioning.

More recently, Canadian experts have adopted the practice of donation after cardiac death. Life support is withdrawn, and, once the heart stops beating — and after a five- to 10- minute “notouch” period — organ procurement can begin.

However, death can take up to two to three hours, during which time vital organs like the heart and lungs are deteriorating from lack of blood flow and oxygen.

With assisted dying, organs can be retrieved much sooner, because the heart stops within two to three minutes of the lethal injection.

“There’s a lot riding on this,” Downar said. “If somebody has organs that would be appropriate to donate, you’ll never get better organs than you would by this process.”

However, the intersection of assisted death and organ donation raises other ethical questions, said Chandler the law professor, including whether organ recipients who have moral or religious objections to euthanasia have a right to know that the organ being offered is coming from someone who chose an assisted death.

“I’m torn between a sense of, is it any harm to let people know (the donor died by assisted death)? After all, if it really bothers them, there will be someone else who will benefit greatly from this donation,” Chandler said. “They will just bypass the person who objects, and go to the next.”

Still, the pool of organs would likely be relatively small. Most patients who request assisted dying have advanced cancer, which typically makes their organs unsuitable for transplant. However, organs can be retrieved from those suffering from such neurological disorders as multiple sclerosis.

In Canada in 2014, more than 4,500 people were waiting for an organ, and 278 died waiting.