The antemortem use of heparin in non-heart-beating organ transplantation: A justification based on the paradigm of altruism

Journal of Clinical Ethics

Volumn 14, Issue 1-2, 2003, Pages 18-25

  Steinberg, David ^a,b  

^a LAHEY HOSPITAL AND MEDICAL CENTER   (United States)

^b HARVARD MEDICAL SCHOOL   (United States)

Author keywords

[No Author keywords available]

Indexed keywords

HEPARIN;

ALTRUISM; BLEEDING; BRAIN HEMORRHAGE; CEREBROVASCULAR ACCIDENT; CLINICAL PROTOCOL; DEATH; DRUG EXPOSURE; DRUG USE; FAMILY; FATALITY; HEART BEAT; HUMAN; INFORMED CONSENT; KIDNEY DONOR; KIDNEY GRAFT; LIVER GRAFT; MEDICAL DECISION MAKING; MEDICAL ETHICS; MORALITY; MORTALITY; ORGAN DONOR; ORGAN TRANSPLANTATION; REVIEW; ANALYTICAL APPROACH; ARTICLE; BIOLOGICAL PHENOMENA AND FUNCTIONS CONCERNING ORGAN SYSTEMS; BLOOD; CADAVER; DRUG EFFECT; ETHICS; HEALTH CARE AND PUBLIC HEALTH; TRANSPLANTATION; UNITED STATES;

ANALYTICAL APPROACH; HEALTH CARE AND PUBLIC HEALTH;

ALTRUISM; CADAVER; DOUBLE EFFECT; HEPARIN; HUMANS; TISSUE AND ORGAN PROCUREMENT; TISSUE SURVIVAL; UNITED STATES;

EID: 0642281767     PISSN: 10467890     EISSN: None     Source Type: Journal    
DOI: None     Document Type: Review

References (37)

1. Less commonly, patients with cardiopulmonary arrest who were not previously on life supports are used as non-heart-beating organ donors. This is referred to as an "uncontrolled situation," in contrast to the controlled circumstances that exist when life supports are electively removed.
2. Institute of Medicine Non-Heart-Beating Organ Transplantation Medical and Ethical Issues in Procurement (Washington, B.C.: National Academy Press, 1997); Institute of Medicine, Non-Heart-Beating Organ Transplantation Practice and Protocols (Washington, D.C.; National Academy Press, 1999) the full text is available at 〈www.nap.edu/readingroom.com〉.
3. Institute of Medicine Non-Heart-Beating Organ Transplantation Medical and Ethical Issues in Procurement (Washington, B.C.: National Academy Press, 1997); Institute of Medicine, Non-Heart-Beating Organ Transplantation Practice and Protocols (Washington, D.C.; National Academy Press, 1999) the full text is available at 〈www.nap.edu/readingroom.com〉.
4. University of Pittsburgh Medical Center-Presbyterian, Policy and Procedures Manual: Non-Heartbeating Organ Donation (Pittsburgh, Pa.: University of Pittsburgh Medical Center-Presbyterian, 3 February, 1999).
5. See note 2 above.
6. "Not Quite Dead," 60 Minutes, CBS News, 13 April 1997; G. Agich, "From Pittsburgh to Cleveland: NHBD Controversies and Bioethics," Cambridge Quarterly of Healthcare Ethics 8 (1999): 269-74; G. Agich, "From Pittsburgh to Cleveland: NHBD Controversies and Bioethics: Say It Ain't So, 60 Minutes on NHBD," Cambridge Quarterly of Healthcare Ethics 8 (1999): 517-22.
7. "Not Quite Dead," 60 Minutes, CBS News, 13 April 1997; G. Agich, "From Pittsburgh to Cleveland: NHBD Controversies and Bioethics," Cambridge Quarterly of Healthcare Ethics 8 (1999): 269-74; G. Agich, "From Pittsburgh to Cleveland: NHBD Controversies and Bioethics: Say It Ain't So, 60 Minutes on NHBD," Cambridge Quarterly of Healthcare Ethics 8 (1999): 517-22.
8. "Not Quite Dead," 60 Minutes, CBS News, 13 April 1997; G. Agich, "From Pittsburgh to Cleveland: NHBD Controversies and Bioethics," Cambridge Quarterly of Healthcare Ethics 8 (1999): 269-74; G. Agich, "From Pittsburgh to Cleveland: NHBD Controversies and Bioethics: Say It Ain't So, 60 Minutes on NHBD," Cambridge Quarterly of Healthcare Ethics 8 (1999): 517-22.
9. The declaration of death in non-heart-beating organ transplantation has been the subject of extensive discussion. See S.J. Youngner, R.M. Arnold and R. Schapiro, ed., The Definition of Death (Baltimore, Md.: Johns Hopkins University Press, 1999).
10. Another drug used in organ retrieval, phentolamine, which has the trade name Regitine, was also mentioned in the 60 Minutes program. The administration of drugs is facilitated by the antemortem placement of cannulas into blood vessels. Although I do not mention these cannulas, justification for their use under an altruistic paradigm is similar to that for antemortem heparin.
11. Many non-heart-beating organ donors can be anticipated to have head injuries
12. F. Koughan and W. Bogdanich, Response to "From Pittsburgh to Cleveland: NHBD Controversies and Bioethics," Cambridge Quarterly of Healthcare Ethics 8(1999)514-23.
13. T.L. Beauchamp and J.F. Childress, Principles of Biomedical Ethics, 3rd ed. (Oxford, England: Oxford University Press, 1989), 127-34.
14. J.M. Dubois, "Non-Heart-Beating Organ Donation," Health Progress 82 (January-February 2001); 18-21; R.M. Veatch, Transplantation Ethics (Washington D.C.: Georgetown University Press: 2000), 217-20.
15. J.M. Dubois, "Non-Heart-Beating Organ Donation," Health Progress 82 (January-February 2001); 18-21; R.M. Veatch, Transplantation Ethics (Washington D.C.: Georgetown University Press: 2000), 217-20.
16. J.F. Childress, "Non-Heart-Beating Donors of Organs: Are the Distinctions Between Direct and Indirect Effects and Between Killing and Letting Die Relevant and Helpful?" Kennedy Institute of Ethics Journal 3, no. 2 (1993): 203-16.
17. T.L. Beauchamp and J.F. Childress Principles of Biomedical Ethics, see note 10 above, pp. 130-4.
18. A.J, Weisbard "A Polemic on Principles:, Reflections on the Pittsburgh Protocol," Kennedy Institute of Ethics Journal 3, no. 2 (1993): 217-30.
19. R.M. Veatch, "Consent For Perfusion and Other Dilemmas with Organ Procurement from Non-Heart-Beating Cadavers in Procuring Organs For Transplant" in The Debate Over Non-Heart-Beating Cadaver Protocols (Baltimore, Md: Johns Hopkins University Press, 1995), 195-206.
20. John Rawls, A Theory of Justice (Cambridge Mass.: Harvard University Press), 1971.
21. Webster's New Universal Unabridged Dictionary (New York: Simon and Schuster, 1983).
22. R.J. Moore, "Promoting Blood Donation: A Study of the Social Profile, Attitudes, Motivation and Experience of Donors," Transfusion Medicine 1 (1991): 201-7.
23. J.F. Childress, "Non-Heart-Beating Donors of Organs: Are the Distinctions between Direct and Indirect Effects and between Killing and Letting Die Relevant and Helpful?" Kennedy Institute of Ethics Journal 3, no. 2 (1993): 210.
24. A.L. Spital, "Unrelated Living Donors: Should They Be Used?" Transplantation Proceedings 24, no. 5 (1992): 2215-7.
25. "New Yorker Dies After Surgery to Give Liver Part to Brother," New York Times, 25 January 2002, p. 17.
26. "Assistant U.S. Surgeon General Honors Living Organ Donors at Hopkins at August 31 Ceremony," press release from Johns Hopkins Medical Institutions Office of Communications and Public Affairs 31 August 1998; "Lahey Clinic to Honor Living Organ Donors," press release from Lahey News Media Center, 5 June 2001.
27. "Lynch Awake, Alert After Transplant Surgery With In-Law, " Boston Globe 23 March 2001.
28. It is important to be sensitive to the possibility that bleeding related to heparin could be psychologically traumatic for the surrogate who approved its use.
29. Data as of April 2002 reported to the Organ Procurement and Transplantation Network, provided to the author by the United Network for Organ Sharing 〈www.unos.org〉.
30. G. Gridelli and R. Remuzzi, "Strategies for Making More Organs Available for Transplantation," New England Journal of Medicine 343: (2000) 404-10; R.S. Brown, "A Survey of Liver Transplantation from Living Adult Donors in the United States," New England Journal of Medicine 348 (2003): 818-25.
31. G. Gridelli and R. Remuzzi, "Strategies for Making More Organs Available for Transplantation," New England Journal of Medicine 343: (2000) 404-10; R.S. Brown, "A Survey of Liver Transplantation from Living Adult Donors in the United States," New England Journal of Medicine 348 (2003): 818-25.
32. "International Stroke Trial (IST): A Randomized Trial of Aspirin, Subcutaneous Heparin, Both, or Neither among 19435 Patients with Acute Ischemic Stroke," Lancet 349 (1997): 1569-81.
33. M.S. Pessin et al., "Safety of Anticoagulation after Hemorrhagic Infarction," Neurology 43 (1993) 1298-303.
34. I use the word "virtually" because absolute certainty is elusive in clinical medicine. The requirement of absolute inevitability for decision making in clinical medicine is unrealistic; however, I mean the difference between "absolute" and "virtual" inevitability to be minuscule.
35. Those who believe that even a brief period of poor-quality living should not be placed at risk should consider that failure to use antemortem heparin may place another life, of potentially longer duration, at risk.
36. An example is a mentally intact quadriplegic who requests extubation when a possibility exists that he might breathe on his own after extubation and then reverse his decision regarding comfort measures only. Since a fatal bleed due to heparm might deprive this patient of years of acceptable living, the comprehensive risk of heparin would not be minimal.
37. This view is understandable, because, theoretically, an intruder who fatally shoots a convicted murderer as he is seated in the electric chair, seconds away from electrocution, would be charged with murder, even though the victim would have died anyway in a short period of time. The murder of a terminal cancer patient with hours to live would, nonetheless, be considered murder. However, these examples differ from the antemortem use heparin because the non-heart-beating organ donor has voluntarily accepted the risk of bleeding as part of an altruistic act.