National Post (National Edition)
TAKING ORGANS FROM THE LIVING?
Doctors debate ‘euthanasia by organ donation’
Three years after assisted death became legal in Canada, the medical community is debating a provocative question: should organs be removed from consenting euthanasia patients while they’re still alive?
Some say changing the rules would allow people choosing an assisted death to donate as many organs as possible — in the most optimal condition possible — because blood and oxygen would continue to flow through vital organs until the moment of retrieval.
Under this scenario, people granted an assisted death would, with their full knowledge and consent, be transported to an operating room, put to sleep under general anaesthesia and their organs removed, including the heart and lungs. Death would follow removal of the beating heart. Under so-called “euthanasia by organ donation,” the act of organ donation itself — not a lethal injection or a doctor-prescribed, life-ending dose of drugs — would be the mode of death.
Organ donation after euthanasia is already occurring, legally, in Canada. About 30 people who have died by “medical assistance in dying,” or MAID, since the law decriminalizing the act was passed in 2016 have consented to donate kidneys or other organs. In Ontario, 168 more have donated tissues such as corneas, skin, veins, tendons and ligaments — tissues that don’t require the same conditions as organs to survive and can be taken up to 24 hours after death.
However, under the long-standing “dead donor rule,” organs can’t be procured until donors are declared dead — typically, five minutes after the heart has stopped beating — and the organ retrieval itself can’t lead to the death of the donor.
The rule is intended to maintain a “firewall” between the team removing a person from life support — and determining death — and the transplant surgeons waiting to retrieve precious, desperately needed organs.
However, Western University’s Dr. Ian Ball and a Harvard Medical School bioethicist and pediatrician argue that firewall may be less important when it comes to people choosing to die by euthanasia.
“Although some patients may want to be sure that organ procurement won’t begin before they are declared dead, others may want not only a rapid, peaceful and painless death, but also the option of donating as many organs as possible and in the best condition possible,” they wrote in the New England Journal of Medicine. “Following the dead donor rule could interfere with the ability of these patients to achieve their goals.
“In such cases it may be ethically preferable to procure the patient’s organs in the same way that organs are procured from brain-dead patients (with the use of general anesthesia to ensure the patient’s comfort.)”
Doing so would require an amendment to the Criminal Code of Canada, the authors note, which states that medical assistance in dying must involve the administration of medications or a “substance” — not organ extraction.
“Because voluntary euthanasia creates organ-donation opportunities that differ from existing pathways,” they wrote, “it may be necessary to develop new protocols specific to these patients.”
The idea provokes a visceral kind of horror for some. “Death by donation would, at present, be considered homicide to end a life by taking organs,” Dr. E. Wesley Ely, a professor of medicine at Vanderbilt University School of Medicine wrote in USA Today.
But others see logic in the suggestion, especially as the very definition of “death” is being challenged. Some argue organs are already being recovered from people who have been defined as irreversibly dead, only because we have chosen not to resuscitate them.
Historically, most transplant organs were taken from people declared brain dead. More recently, Canada and other countries have embraced “donation after circulatory death,” or DCD. These cases usually involve people on life support with such a bleak prognosis their family decides they would rather be dead. Life support is withdrawn and, once the heart stops beating — and after a five-minute “hands off ” period, long enough to be satisfied the heart won’t spontaneously restart on its own — organ procurement can begin.
However, death can take up to two to three hours. Organs like the heart and lungs rapidly deteriorate from lack of blood flow and oxygen.
Euthanasia by organ donation would shorten the ischemic time — the elapsed time without blood flow to the organs — to essentially zero, said Dr. Michael Shapiro, professor of general surgery at New Jersey Medical School/ Rutgers.
Doctors should fulfil a patient’s wishes to the extent they can, said Shapiro, author of a paper on euthanasia by organ donation published in the Dalhousie Law Journal. “And so, if the patient says, ‘I want two things: I want to have a good death, I want to die peacefully, I don’t want to suffer,’ we can do that.
“And then if the patient also says, ‘I’d also like to be an organ donor.’ Well, if you said to me, what is the optimal way to accomplish both of those things? It’s to put the patient to sleep so they won’t have any discomfort, and there won’t be air hunger, there won’t be any anxiety or fear, and then take their organs out.
Still, the idea of euthanasia via organ donation would be profoundly unsettling to many, said bioethicist Jennifer Chandler, who holds the Bertram Loeb Chair in Organ and Tissue Donation at the University of Ottawa.
“It is a legitimate question in a society that has said it’s OK to bring about death — euthanasia. Why does it matter to bring it about one way versus the other?”