The ethics of organ donation after cardiocirculatory death: Do the guidelines of the Canadian Council for Donation and Transplantation measure up?

The practice of transplantation the world over is governed by the dead donor rule: non-paired vital organs can be retrieved only from patients who are dead. It is therefore important to have clear criteria for the determination of death. Most transplantable organs come from patients who are declared dead by neurologic criteria. These patients are called heart-beating donors; they have suffered a catastrophic brain injury, have been ventilated, and have had their vital functions maintained mechanically up to the point at which death is declared and then beyond, until their organs are retrieved. The donor pool can be expanded by permitting an alternative form of donation known as donation after cardiocirculatory death (DCD), or non-heart-beating organ transplantation. The donors in this case are patients for whom there is no hope of recovery but who are not dying because of a brain injury and hence will not suffer the neurologic death necessary for them to become heart-beating donors. DCD has been an accepted medical practice internationally for 15 years1 but came to Canada only in 2006, when the Canadian Council for Donation and Transplantation (CCDT) published its national recommendations.2 Countries that permit DCD have had variable success in increasing the supply of transplantable organs. DCD of kidneys, the organ with which the CCDT recommends that Canadian centres begin their DCD programs,2 serves as a good example. In 2003, kidneys donated after cardiocirculatory death accounted for only 4% of the total kidneys transplanted in both Spain, which has the highest per capita rate of transplantation of any organs, and the United States, which has the highest total number of transplants. By contrast, in the Netherlands, which was then the world leader in DCD, kidneys donated after cardiocirculatory death accounted for 39% of the country’s kidney transplants.3* The effect of introducing DCD into Canada is uncertain, but Doig and Rocker estimate that DCD “could contribute to an increase in the number of solid organs for transplantation including 20% or more to the supply of kidneys, and increasing the supply of other solid organs including liver, pancreas or pancreatic islet cells.”4 The CCDT recommends that, for the purposes of DCD, death be diagnosed after 5 minutes of continuously observed absence of pulse, blood pressure and respiration after life support has been discontinued.2 This recommendation of a 5-minute interval coincides with that of the Institute of Medicine5 and is commonly accepted in North America and the United Kingdom. However, it falls short of the time frame of “at least 10 minutes of proven lack of circulation to the brain” estimated for the determination of neurologic death in a report by the US President’s Commission for the Study of Ethical Problems in Medicine and Biomedical and Behavioral Research.6 It is also not a universally accepted interval for DCD, and lies between alternatives that include a 75-second interval advocated by Boucek and colleagues,7 a 2-minute interval used in Pittsburgh and at some other US and UK centres2 and a 10-minute interval used at still other US and UK centres and at St. Michael’s Hospital in Toronto.8 In its guidelines, the CCDT aimed to “promote patient-care-based principles for providing the option of donation within a sound ethical framework and provide guidance to individual programs in developing parameters for safe practice in this field.”2 We can measure the success of the CCDT in achieving this aim by considering two of the questions most often asked by families thinking about DCD: “Is my loved one really dead?” and “Will he or she feel any pain?”9 It is reasonable to suppose that any acceptable DCD program will either enable a health care professional to answer those questions with an unequivocal “Yes” in the first instance and “No” in the second or, if not, to give families the information they need to make an informed decision about donation. In this article, I will argue that a program that follows the recommendations of the CCDT will do neither of these things and hence will not satisfy ordinary consent requirements.