7.1.4 Organ Donation
*Updated December 17, 2015, 2015 by Linda Wright, MHSc, MSW and Daniel Z Buchman, PhD
Walter Glannon, PhD
Updated by: Daniel Z Buchman, PhD, Linda Wright, MHSc, MSW
- To appreciate the ethical difference between proxy consent to withdrawal of life-support and proxy consent to organ procurement for transplantation
- To appreciate potential ethical tensions between physicians' promotion of organ donation for transplantation and their duty of care to critically ill patients
- To appreciate potential ethical tensions between a capable patient's wish to donate organs after death and family objections to organ donation.
Mr. Johnson is a 28-year-old lawyer who was previously healthy but has sustained a severe brain injury in a motor vehicle accident. Shortly after arriving comatose in emergency, he is intubated and transferred to the intensive care unit (ICU). His parents are his legal substitute decision-makers (SDMs). Given the extent of his brain injury, the intensivists treating Mr. Johnson tell his parents that his prognosis is poor. The ICU staff note the possibility that he might emerge from his coma and regain some brain function. Yet Mr. Johnson remains comatose, and his condition does not improve for seven days. At this point his parents, aware of the poor prognosis, tell the medical staff that, at an earlier time, their son told them that he wanted to donate his organs for transplantation after his death. However, the patient has not formally expressed a wish to donate organs on his driver's license or in an advance directive. The parents ask that he be extubated and that all life-support be withdrawn so that he can be declared dead and his organs donated for transplantation.
- Do Mr. Johnson's parents have the right to decide that life-support be withdrawn from their son so that his organs could be procured for transplantation?
- If the intensivists identify Mr. Johnson as a potential organ donor and approach his family for proxy consent to donation, would this create a conflict of interest for them and violate their duty of care to this critically ill patient?
- Is it possible that the ICU staff might declare death prematurely in order to procure viable organs for transplantation, even if the patient or his parents had consented to organ donation?
- If there were written documentation of Mr. Johnson's wish to donate his organs after his death, and yet his parents objected to organ donation, would they have the right to override his expressed wish?
CMA Code of Ethics
The "Responsibilities to the Patient" and the "Responsibilities to Society" sections of the "CMA Code of Ethics (updated 2004)" produced by the Canadian Medical Association are relevant to this case.1 These include benefiting and taking all reasonable steps to prevent harm to patients, as well as communicating with and obtaining consent from patients (or their surrogates) to withhold, initiate, continue or withdraw certain medical procedures. In this case, there are two distinct forms of consent at issue: proxy consent to withdraw life-sustaining treatment and proxy consent to organ donation for transplantation. The relevant responsibilities may also include promoting organ transplantation as a way of curing or controlling disease and alleviating suffering of patients with end-stage organ failure. With deceased organ donation, there is a potential ethical conflict in discharging these two professional responsibilities.
Organ donation after a death determined by neurological criteria (permanent cessation of all brain functions) and tissue donation after a death determined by circulatory criteria (DCD; permanent cessation of respiration and circulation) are legal and supported by medical practice in Canada. DCD is a relatively new practice in Canada. As of 2012, only British Columbia, Alberta, Ontario, Quebec, and Nova Scotia practice DCD2. Deceased organ donation from death determined by neurological criteria or DCD must be consistent with the Dead Donor Rule�a widely accepted ethical standard�which says that organs for transplantation may only be procured ethically after the clinically determined death of the patient.
Canada has one of the lowest organ donation rates among industrialized nations. In 2012, only 17% of eligible patients under 70 who died in a Canadian hospital became organ donors2. The number of living donors has been greater than the number of deceased donors nationally, with regional variation. The gap between the number of available organs and the number of patients on the transplant waiting list is widening. Because the need for transplantable organs far exceeds the supply, many patients in end-stage organ failure die while waiting for a transplant. Patients in end-stage renal failure may survive on dialysis, but the quality of life for patients with a kidney transplant may be better than the quality of life on dialysis. Moreover, kidney transplants are more cost-effective than dialysis over time. Deceased organ donation does not involve the same risks as living donation. Living organ donors are at some risk of complications resulting from the surgical removal of the donated organ. Also, a relatively small but significant number of living kidney donors in good health at the time of their donation have subsequently developed end-stage renal disease and have become candidates for kidney transplantation.
- Canadian Medical Association. CMA code of ethics (update 2004). Ottawa: Canadian Medical Association; 2004. Available from: http://policybase.cma.ca/PolicyPDF/PD04-06.pdf
- Canadian Institute for Health Information. Deceased organ donation potential in Canada. Ottawa, ON: CIHI; 2014.
- Goldfelt B, Caulfield T, Nelson E, Wright L, Hartell D, and the CNTRP team. Fast Policy Facts: Consent. Ottawa: Canadian National Transplant Research Program. Available at: http://media.wix.com/ugd/5a805e_abb9fbc5acb9425ba094574d4d59bdcf.pdf
- American Journal of Transplantation website: http://www.amjtransplant.com
- Canadian Council for Donation and Transplantation (CCDT) publications. Available from: http://www.ccdt.ca/english/publications
- Canadian Institute for Health Information (CIHI), http://www.cihi.ca
- Heyland DK, Dodek P, Rocker G, Groll D, Gafni A, et al. What matters most in end-of-life care: perceptions of seriously ill patients and their family members. Canadian Medical Association Journal 2006; 174: 627�33.
- Ingelfinger, J. Risks and benefits to the living donor. New England Journal of Medicine 2005; 353: 447�9.
- Shemie SD, Baker AJ, Knoll G, Wall W, Rocker G, et al. National recommendations for donation after cardiocirculatory death in Canada. Canadian Medical Association Journal 2006; 175(8 Suppl): S1�S22.
- Truog R, Robinson, W. The role of brain death and the dead donor rule in the ethics of organ transplantation. Critical Care Medicine 2003; 31: 2391�6.
- United Network for Organ Sharing (UNOS) website: http://www.unos.org
- Veatch R. Transplantation ethics. Washington, DC: Georgetown University Press, 2000.