Increasing the supply of organs available for transplant serves the interests of patients and the public and is in keeping with physicians’ ethical obligation to contribute to the health of the public and to support access to medical care. Physicians should support innovative approaches to increasing the supply of organs for transplantation, but must balance this obligation with their duty to protect the interests of their individual patients.
Organ donation after cardiac death is one approach being undertaken to make greater numbers of transplantable organs available. In what is known as “controlled” donation after cardiac death, a patient who has decided to forgo life-sustaining treatment (or the patient’s authorized surrogate when the patient lacks decision-making capacity) may be offered the opportunity to discontinue life support under conditions that would permit the patient to become an organ donor by allowing organs to be removed promptly after death is pronounced. Organ retrieval under this protocol thus differs from usual procedures for cadaveric donation when the patient has died as a result of catastrophic illness or injury.
Donation after cardiac death raises a number of special ethical concerns, including how and when death is declared, potential conflicts of interest for physicians in managing the withdrawal of life support for a patient whose organs are to be retrieved for transplantation, and the use of a surrogate decision maker.
In light of these concerns, physicians who participate in retrieving organs under a protocol of donation after cardiac death should observe the following safeguards:
- Promote the development of and adhere to clinical criteria for identifying prospective donors whose organs are reasonably likely to be suitable for transplantation.
- Promote the development of and adhere to clear and specific institutional policies governing donation after cardiac death.
- Avoid actual or perceived conflicts of interest by: ensuring that the health care professionals who provide care at the end of life are distinct from those who will participate in retrieving organs for transplant; ensuring that no member of the transplant team has any role in the decision to withdraw treatment or the pronouncement of death.
- Ensure that the decision to withdraw life-sustaining treatment is made prior to and independent of any offer of opportunity to donate organs (unless organ donation is spontaneously broached by the patient or surrogate).
- Obtain informed consent for organ donation from the patient (or surrogate), including consent specifically to the use of interventions intended not to benefit the patient but to preserve organs in order to improve the opportunity for successful transplantation.
- Ensure that relevant standards for good clinical practice and palliative care are followed when implementing the decision to withdraw a life-sustaining intervention.
AMA Principles of Medical Ethics: I, III, V
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