Transplant Surgery: Are We Doing Enough (Of It)?

The door was then opened a crack further by donation after cardiac death (DCD) protocols. In these scenarios, the patient is declared to have irreversible cessation of cardiac function after a sequence of tightly choreographed steps and is then permitted to have his or her organs harvested. 

Even though DCD significantly relaxes the standards required for nonliving donation, less than 10% of such gifts are provided through DCD.³ 

Curiously, DCD requires us to accept a fundamental fiction — that the donor is actually “dead.” But, in fact, DCD fails this test on its own terms. 

Not only do we have the means to keep most of these patients alive after cardiac death has been declared (if that were our intention), but the supposedly irreversibly nonfunctional heart is then routinely successfully implanted into a recipient.⁴ It’s difficult to conceive of a logically consistent definition by which the donors are actually dead. 

Yet, the idea of allowing patients or guardians to make an informed decision that would allow safe, controlled and efficient donation of organs in the absence of a declaration of brain or cardiac death remains a complete nonstarter. This is not a new suggestion. 

In a 2008 piece in The New England Journal of Medicine, Drs Robert Truong and Franklin Miller proposed that transplant surgeons be allowed to harvest from living donors (by any definition), provided informed consent has been properly obtained.

Nearly a decade later, their idea has still gained no traction, and the problems they sought to address continue to persist — our donation programs rest on shifting ethical sands, the organ recipient waitlist grows daily, and the health of transplanted organs is routinely compromised by the onerous demands of the DCD process.⁵ 

Most dispiriting, however, are cases where the patient or his/her guardians have expressed a clear preference in favor of making an organ donation, but the plan is foiled by an inability to meet the brain- or cardiac-death criteria. There’s no positive way to spin that outcome. 

The patient still has a catastrophic injury and won’t recover and all the potential recipients are still stuck on the transplant list … waiting … while the clock ticks louder and louder. This is magic undone, a potential miracle turned into a tragedy. 

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