Role of brain death and the dead-donor rule in the ethics of organ transplantation

[Guest guest]

Critical Care Medicine 2003; 31(9):2391-2396

Role of brain death and the dead-donor rule in the ethics of organ

transplantation

D. Truog, MD, FCCM; Walter M. , MD, MPH

The " dead-donor rule " requires patients to be declared dead before the

removal of life-sustaining organs for transplantation. The concept of brain

death was developed, in part, to allow patients with devastating neurologic

injury to be declared dead before the occurrence of cardiopulmonary arrest.

Brain death is essential to current practices of organ retrieval because it

legitimates organ removal from bodies that continue to have circulation and

respiration, thereby avoiding ischemic injury to the organs. The concept of

brain death has long been recognized, however, to be plagued with serious

inconsistencies and contradictions. Indeed, the concept fails to correspond

to any coherent biological or philosophical understanding of death. We

review the evidence and arguments that expose these problems and present an

alternative ethical framework to guide the procurement of transplantable

organs. This alternative is based not on brain death and the dead-donor

rule, but on the ethical principles of nonmaleficence (the duty not to harm,

or primum non nocere) and respect for persons. We propose that individuals

who desire to donate their organs and who are either neurologically

devastated or imminently dying should be allowed to donate their organs,

without first being declared dead. Advantages of this approach are that

(unlike the dead-donor rule) it focuses on the most salient ethical issues

at stake, and (unlike the concept of brain death) it avoids conceptual

confusion and inconsistencies. Finally, we point out parallel developments,

both domestically and abroad, that reflect both implicit and explicit

support for our proposal.

Key Words: brain death; transplantation; organ procurement; medical ethics;

persistent vegetative state; anencephaly

From the Departments of Anaesthesiology and Medical Ethics, Harvard Medical

School, Cambridge, MA (RDT, WMR); and the Medical Intensive Care Unit,

Children's Hospital, Boston, MA (RDT).

[Guest guest]

Critical Care Medicine 2003; 31(9):2391-2396

Role of brain death and the dead-donor rule in the ethics of organ

transplantation

D. Truog, MD, FCCM; Walter M. , MD, MPH

The " dead-donor rule " requires patients to be declared dead before the

removal of life-sustaining organs for transplantation. The concept of brain

death was developed, in part, to allow patients with devastating neurologic

injury to be declared dead before the occurrence of cardiopulmonary arrest.

Brain death is essential to current practices of organ retrieval because it

legitimates organ removal from bodies that continue to have circulation and

respiration, thereby avoiding ischemic injury to the organs. The concept of

brain death has long been recognized, however, to be plagued with serious

inconsistencies and contradictions. Indeed, the concept fails to correspond

to any coherent biological or philosophical understanding of death. We

review the evidence and arguments that expose these problems and present an

alternative ethical framework to guide the procurement of transplantable

organs. This alternative is based not on brain death and the dead-donor

rule, but on the ethical principles of nonmaleficence (the duty not to harm,

or primum non nocere) and respect for persons. We propose that individuals

who desire to donate their organs and who are either neurologically

devastated or imminently dying should be allowed to donate their organs,

without first being declared dead. Advantages of this approach are that

(unlike the dead-donor rule) it focuses on the most salient ethical issues

at stake, and (unlike the concept of brain death) it avoids conceptual

confusion and inconsistencies. Finally, we point out parallel developments,

both domestically and abroad, that reflect both implicit and explicit

support for our proposal.

Key Words: brain death; transplantation; organ procurement; medical ethics;

persistent vegetative state; anencephaly

From the Departments of Anaesthesiology and Medical Ethics, Harvard Medical

School, Cambridge, MA (RDT, WMR); and the Medical Intensive Care Unit,

Children's Hospital, Boston, MA (RDT).