Non-heartbeating [organ] donors.

Canada is now engaged in a very healthy debate over whether to initiate protocols to harvest organs from non-heartbeating donors (NHBD), according to a story in Thursday's Ottawa Citizen. The concept involves a return to the days before "brain death" criteria had been developed, at least in those cases in which waiting for brain death may result in the degradation of the viability of the transplantable organs. The protocol, some version of which is in place in many transplant centers around the U.S., involves disconnecting a patient from life support, waiting for a nominal period of pulseness and apnea, declaring death according to traditional cardiopulmonary criteria, and then harvesting the organs. The ethical questions have to do with two features of the protocol: (1) A drug (phentolamine, e.g.) is administered to dilate blood vessels and maximize blood flow and oxygenation, but dilation may lower blood pressure, perhaps catastrophically, raising the question whether death is being induced by the regitine. If the regitine is causing death, is the procedure homicide? (2) How long should surgeons wait after the termination of life support before declaring (to borrow a widely adopted state-law standard for declaring death) that circulatory and pulmonary functions have irreversibly stopped? The longer the surgeons wait, the more damage is done to the organs. An article in the current issue of the Canadian Medical Association Journal argues that the protocol could increase the supply of transplantable organs dramatically. But, as the redoubtable Margaret Sommerville stated in the news article, "I know the pressure to get organs for donation. . . . But we must be very careful that we're not fudging the criteria of death for the purposes of organ transplantation. . . . If they're suggesting nearly dead is as good as dead then there's a big problem in it. . . . The Criminal Code says any shortening of life, no matter how small, is murder." In this day and age of passive euthanasia, terminal sedation, and physician-assisted suicide, the lines are getting blurrier all the time. This is one opportunity for some needed clarity.