Ethicists Propose Solution for U.S. Organ Shortage Crisis in JAMA

‘Respectful Approach’ Balances Vulnerabilities of Families with Need for More Organ Donors

The United States has a serious shortage of organs for transplants, resulting in unnecessary deaths every day. However, a fairly simple and ethical change in policy would greatly expand the nation’s organ pool while respecting autonomy, choice, and vulnerability of a deceased person’s family or authorized caregiver, according to medical ethicists and an emergency physician at NYU Langone Medical Center.

The authors share their views in a new article in the May 11 online edition of The Journal of the American Medical Association’s “Viewpoint” section.

“The U.S. organ donation system is neglecting the much larger pool of potential donors who could provide organs following unexpected death outside an intensive care unit,” writes NYU Langone’s Stephen P. Wall, MD, associate professor in the Ronald O. Perelman Department of Emergency Medicine; Arthur Caplan, PhD, professor in the Division of Medical Ethics in the Department of Population Health; and Carolyn Plunkett, MA, a PhD candidate at City University of New York and a researcher in the Medical Ethics Division.

The authors opine that the current approach in the U.S. cannot meet increasing demand for transplants. They specifically point out that currently more than 124,000 patients are wait-listed for organs, a number that increases annually despite attrition from 10,500 who die or become too sick for transplantations.

Current U.S. policy promotes organ recovery from three sources: neurologic deaths, controlled circulatory deaths, and live donors for kidneys and partial liver transplantation. “The dying or their families have to express a willingness to donate,” Dr. Wall says. “It is unlikely that this kind of altruistic donation alone will ever meet demand. Nor will calls for creating markets in body parts.”

The solution the authors propose is similar to a policy in Europe, where unexpected deaths provide substantial numbers of transplantable organs. The “uncontrolled donation after circulatory determination of death,” or UDCDD, approach considers the deceased candidates for donation even when death is unexpected and occurs outside a hospital, as long as preservation of organs begins after all life-sustaining efforts have been exhausted.

“To encourage donation through UDCDD, we propose an approach that would consider the decision-making capacity of grieving family members,” Dr. Caplan says. “Rather than requesting full authorization for donation of an organ immediately after the death of a loved one outside a hospital setting, a family would be asked only if they would like to preserve the deceased’s organs so that they might consider donation later.”

The authors conclude that this type of approach supports the aim of being sensitive to the specific needs of family members at a time of immense grief and overwhelming stress. “A decision to preserve organs is less complex and consequential than the decision to donate,” Dr. Caplan adds.

At a later stage, the family would be asked to consider donation.

The importance of “decoupling” pronouncement of death and requests for organ donation is well established, the authors write. They also suggest language be changed from “uncontrolled donation” to “permission to preserve” after an “unexpected” death.

“With an appropriate ethical framework to obtain permission for preservation immediately following unexpected circulatory determination of death, and with the actual decision to authorize donation made hours thereafter,” Ms. Plunkett says, “the pool of potential donors could be greatly expanded while respecting autonomy, choice, and vulnerability.”

Work for the article was supported by grant R38OTO8761 from the Health Resources and Services Administration’s Division of Transplantation (HRSA/DoT), U.S. Department of Health and Human Services. The sponsor had no role in the preparation, review, or approval of the manuscript or the decision to submit the manuscript for publication.

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