ORGAN-DONATION AFTER VOLUNTARY DEATH


SYNOPSIS:

    When we approach the end of our lives,
we might consider donating our organs after we are finished with them.
Perhaps we registered ourselves as organ-donors years before.

    However, instead of waiting for natural death to take us,
we might coordinate the time and place of our death
with a new plan to donate our organs
immediately after death is declared.

    With careful planning (and the cooperation of transplant centers),
we should be able to choose the best time,
the best place, & the best methods of dying
so that our re-usable organs can be harvested immediately after death
and transplanted into waiting patients who will make better use of them
than if our organs were merely buried or burned.

OUTLINE:

1.  BELGIUM IS A LEADER IN ORGAN-DONATION AFTER VOLUNTARY DEATH

2.  ORGAN-DONATION AFTER VOLUNTARY DEATH IN OTHER COUNTRIES

3.  CAREFUL PROCEDURES FOR ORGAN-DONATION AFTER VOLUNTARY DEATH

    A. Has the Donor's Life Really Come to an End?

    B. Which Methods of Managing Dying Would Be Best for Organ-Donation?


    C. Might the Donor's Organs be Evaluated Before Death?

    D. Which Transplant Center in America Will be the First
            to Accept Organs Donated After Voluntary Death?

4.  ORGAN-DONATION AFTER MERCIFUL DEATH





ORGAN DONATION AFTER VOLUNTARY DEATH

by James Leonard Park


1.  BELGIUM IS A LEADER
            IN ORGAN-DONATION AFTER VOLUNTARY DEATH

    Belgium has a
presumed consent law:
This means that all organs that might be useful to others
will
automatically become available for donation
unless the patient explicitly decides NOT to donate organs after death.

    This law grew out of the wide-spread willingness to donate.
Most people philosophically favor giving their organs to others in need
—once they are dead and therefore no longer using their organs.
But, historically speaking, very few people took the actual legal steps
usually required to make their organs available after death.
So Belgian lawmakers filled this gap between
plan and action
with a law saying that all organs will be
presumed to be available.
And they wisely allowed some people to
opt-out of donation after death.
Only a few people do in fact register their preference NOT to donate.

    Also Belgium has a liberal right-to-die law,
which allows patients
to choose the best time of death for themselves.
They are not required to undergo
endless medical treatments before death.
When death seems inevitable, they can shorten the process of dying
either by taking lethal drugs to cause death
or by giving their doctors full permission
to bring their lives to a peaceful and painless end.

    And a few Belgian patients who chose their own times of death
also decided to donate their organs after their voluntary deaths.
This required some careful advance planning
to arrange their deaths to take place
within hospitals
so that their organs could be immediately harvested
to be transplanted into patients in nearby operating rooms.

    The doctors who help the patient to die
(usually by giving lethal drugs known not to damage vital organs)
must be completely separate and independent from the medical team
that will harvest the viable organs after death is declared:
One set of doctors takes care of the dying patient,
assuring him or her a completely painless and peaceful death.

   
After the patient's death has been declared,
the transplant-team takes possession of the donor's body
(while vital functions are maintained by the best medical means)
and begins the process of transferring the re-usable organs
into patients waiting in adjoining operating rooms.

    In this early practice of organ-donation after voluntary death,
the medical teams involved did not seem to be overly concerned
about the exact timing of the declaration of death.
The whole process was known to all medical persons involved:
The donor's life would come to an end,
but some of the organs would be transplanted immediately
into patients whose original organs were failing.

    The dead-donor rule says that only donors
already
officially declared to be dead would have their organs harvested.
But sometimes the time of death for the donor
was recorded as the time when the first vital organ was removed.
A philosophically more correct timing would have recorded the
time of death
for the donor as the moment when
permanent unconsciousness
was achieved by the drugs given in preparation for the operation
to remove their organs for donation.



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2. ORGAN-DONATION AFTER VOLUNTARY DEATH
            IN OTHER COUNTRIES

    The Netherlands has also had a few patients who donated their organs
after they took advantage of the Dutch right-to-die laws.
Very liberal attitudes, public policies, & laws
have allowed such donations to proceed with little controversy
either within the medical community or the larger public.

    However, there will be more initial resistance in other advanced countries.
In countries having more diverse populations
—such as the United States of America—
changing medical policies and practices will require more discussion
and perhaps even some changes in the laws governing organ-donation.

    At present, the general policy of organ-transplant centers
is to
reject organs from people who committed suicide.
Probably this is because transplant surgeons
do not want to become associated in any way with
suicide.
There might be some fear that organ-donation after suicide
would push some suicidal persons over the edge,
causing them to kill themselves irrationally,
desperately hoping that their organs would save someone else.

    But when
irrational suicide is carefully separated from voluntary death,
this sort of worry should become less relevant.
In countries that have long histories of the right-to-die,
the possible problem with irrational suicide has not arisen. 
Doctors have been deeply involved in the life-ending decisions
of patients already on the downward glide towards death.
When doctors, patients, & families know that death is inevitable,
everyone agrees to donate the patient's organs after death.

    In the USA and other countries still considering right-to-die laws
the protocol for organ-donation after voluntary death
will have to be more explicitly articulated and observed. 
For example, the dead-donor rule will have to be more strictly fulfilled. 




3.  CAREFUL PROCEDURES
            FOR ORGAN-DONATION AFTER VOLUNTARY DEATH


    A. Has the Donor's Life Really Come to an End?

    Everyone involved in organ-donation after voluntary death
will have to be completely convinced
that the donor's life-ending decisions were definitely wise.

    What is causing the donor's death?
Have all reasonable attempts to delay death been exhausted?
Does the donor's terminal illness or condition
threaten the viability of some of his or her organs?
Might the donated organs transmit disease?
If some organs are not affected by the cause of death,
can these organs be transplanted into living patients?

    If ever there is any doubt about the life-ending decisions,
here are 26 possible safeguards, which might help in separating
unwise, premature decisions for death
from reasonable, well-considered end-of-life plans:

https://s3.amazonaws.com/aws-website-jamesleonardpark---freelibrary-3puxk/SG-A-Z.html.
Which of these would be most helpful in deciding
that the donor's life has come to its best stopping place
—not too soon and not too late?
Is this donor dying at the right time?




    B. Which Methods of Managing Dying
            Would Be Best for Organ-Donation?


    In states and countries that have right-to-die laws
permitting physicians to help patients to manage dying,
the doctors have a range of possible methods of achieving death.
And they will select whatever combination of life-ending measures
seems most appropriate for this donor,
depending, of course, on the medical condition of the donor.

    They might use some combination of drugs to bring death
without harming the organs intended for donation.
Where doctors are explicitly authorized to prescribe gentle poison
there will be no restrictions on the methods they use.

    For example, if they do not want to use any drugs
that might damage the organs planned for transplant,
the terminal-care doctors might decide upon some physical method
that will
cut-off the blood supply to the donor's brain
—thus causing obvious brain-death.
Blood-circulation to the rest of the donor's body
could be maintained by the well-known methods
for keeping the heart beating and the blood circulating.

    Wherever such right-to-die laws are not yet in force,
doctors know several good ways to manage dying.
Probably they will choose special combinations of anesthetic drugs.
First they will put the donor into a deep sleep
—as is needed for most surgical operations.
Then they will introduce more drugs so that
they can say with
absolute certainty that this donor's brain
will
never again have another thought or feeling.

    Then
the donor will be officially declared dead
using the criterion of permanent unconsciousness. 
This will be especially authorized by this patient beforehand.
The dying patient and/or his or her proxies
will authorize in writing their agreement to have this donor declared dead
when
permanent coma is achieved by recognized medical means.

    Only after the donor has been officially declared dead
and after that death has been duly recorded in writing
will the remains be handed over to the transplant-team.
And no doctor who was part of the terminal-care team
will be a part of the team of doctors
who will harvest and transplant the usable organs.
These two teams must be completely separate. 




    C. Might the Donor's Organs be Evaluated Before Death?

    Because this will be a death planned well in advance,
rather than a sudden accidental death
(which is the source of most donated organs),
the dying patient who wishes to donate his or her organs after death
will agree to all useful medical investigations
to determine the viability of any organs that might be donated. 

    Moreover, likely recipients of the organs can also be identified.
Good matches of blood and tissue types can be achieved
so that the donated organs will have better chances of living
than when hurried preparations are required by unexpected donor-deaths.

    All such medical preparations for donation after voluntary death
will make the whole process more real for everyone who knows about it.
The family of the donor will begin adjusting to their loss,
knowing that some organs will find new life in other persons.

    As the process continues to move ahead smoothly,
recipients can be medically prepared
to receive their new organs in nearby operating suites.




    D. Which Transplant Center in American Will be the First
            to Accept Organs Donated After Voluntary Death?


    The articles and news reports of organ-donation in Belgium
mention no problems encountered in getting cooperation from doctors.
So, perhaps it was a simple process of getting official approval
from whatever committees oversee organ-transplantation.
The obvious safeguards are mentioned:
(1) The dying patient must fulfill the safeguards for life-ending decisions.
For example, has the dying patient given full, informed consent for death?
(2) The
decision for death must be separate from the decision for donation.
These two teams of doctors must be completely separate and independent
to avoid even the
appearance of conflict of interest.
Doctors participating in the life-ending decisions of the dying patient
must not be the same doctors who are trying to save
other patients
by transplanting donated organs.

    New policies at transplant centers might first emerge as
exceptions
to previous policies and procedures.
If the transplant center has automatically rejected organs from 'suicides',
perhaps a carefully planned death in the same hospital
would never be called a 'suicide'.
This death-before-donation will be carefully planned
so that none of the worries related to people who committed suicide
would apply to this particular voluntary death.

    Transplant centers should maintain a positive public image.
They do not want
adverse publicity arising from a questionable death.
So, when considering making exceptions to the general rule
about not accepting organs from people who committed suicide,
they might accept a donation from a
former staff member,
who has now reached the end of his or her life. 

    "Retired Transplant Surgeon Donates His Own Organs"
would be a wonderful headline.
Because most of the people involved with his death
would be other doctors who knew him for years,
there would be no doubts about the wisdom
of the life-ending decisions the retired doctor is making.
Those who support the dying doctor
would be fully informed about his reasons for choosing death.
And they would agree with their dying former colleague
(given all of the medical facts and professional opinions)
that
death at this time is better than death at some later time.

    Likewise, because they know first-hand the benefits of organ-donation,
they fully approve the additional decision to donate organs
after the retired transplant surgeon has come to the end of his life. 
Are the other transplant surgeons organ donors themselves?
And this first case of organ-donation coupled with life-ending decisions
might inspire them to make similar plans for their own deaths:
They agree to forgo the last month of futile medical care
if they know that their organs will have a better chance
of coming back to life in the bodies of other patients
—giving the new owners many more years of meaningful life.

    If the surgeon's donation is the first such case in that transplant center,
the positive publicity will inspire others to become organ-donors,
even if they would not consider ending their lives in the same way.

    The example set by this very-careful first donation
could allow that transplant center to establish good policies
to allow other such donations after voluntary death.




4.  ORGAN-DONATION AFTER MERCIFUL DEATH

    Once organ-donation after voluntary death has been accepted,
then the obvious next question concerns possible donation
from patients who have already passed the point
of making their own end-of-life decisions.
The largest group of such potential 'donors' would be
patients with Alzheimer's disease or other forms of dementia
or patients with non-functioning brains.

    If the patient can no longer cooperate with any plans for death,
then it could not be called a "voluntary death".
The decision-making authority has passed to the
proxies,
who were probably carefully chosen by the patient
before the patient's mental capacities disappeared.

    And when proxies must make all remaining end-of-life decisions,
and if they conclude that a
chosen death now
is better than a
random death later,
their life-ending decisions might be called choosing a "merciful death". 

    Patients who come to the end of their lives because of mental decline
or because of any neurological or brain-disease
would make ideal candidates for organ-donation.
Even tho their meaningful lives are over
because of whatever has happened to their minds or brains,
the best of their other organs might be still working well.

    If and when this happens at the end of
my life,
I want my proxies to choose a merciful death for me
and then to donate my usable organs so that others might live.
Others can make similar plans for their organs:
Once meaningful life has become impossible,
let my proxies choose a merciful death for me
—followed by the donation of whatever organs
might have continued life in the bodies of other persons.
My plan is more explicitly stated here:
If I Get Alzheimer's, Donate My Organs.

    Of course, even more elaborate safeguards must be applied
when the patient can no longer make such life-ending decisions
—or plans for recycling organs after death.
Here is a detailed account of how several possible safeguards
might be applied to life-ending decisions
for patients beyond deciding for themselves:
Life-Ending Decisions for Alzheimer's Patients.

    The other questions concerning organ-donation after
voluntary death
also apply to situations where
proxies make the life-ending decisions:
B.  the best methods of bringing this life to an end;
C.  evaluating the best organs beforehand for transplant;
D.  finding a transplant center open to donation after merciful death.

    As medical science makes transplantation more workable
and as ethics accept organs donated following freely-chosen deaths,
more patients in need of new organs will have their lives extended.




AUTHOR:

    James Leonard Park is an independent philosopher
with deep interest in many end-of-life issues.
He does intend to donate his own body to medical science
—including possibly organ-donation—
when meaningful life is no longer possible for him.
If he is still able to decide, he will choose voluntary death for himself.
If his capacities to make such decisions disappear,
his proxies are authorized to donate his organs
after his merciful death has been achieved. 

    Much more will be discovered about James Park
on his personal website
—the last link below.



Created December 3-4, 2014; Revised 12-17-2014; 12-21-2014;
1-20-2015; 3-7-2015; 3-14-2015; 10-16-2015;
1-19-2016; 3-15-2016; 8-9-2017; 10-16-2018; 



As noted in the last section of this essay,
organ-donation should be available for patients
who have already lost their capacity to make end-of-life decisions:
If I Get Alzheimer's, Donate My Organs



These two on-line essays about organ donation
have been gathered with several others to create
Medical Ethics at the End of Life



background articles:

"Should We Allow Organ Donation Euthanasia?
Alternatives for Maximizing the Number and Quality
of Organs for Transplant"

Bioethics Vol. 26, Issue 1, pages 32-48, January 2012.

http://www.onlinelibrary.wiley.com/doi/10.1111/j.1467-8519.2010.01811.x/full


"Organ Procurement After Euthanasia: Belgian Experience"

www.coma.ulg.ac.be/papers/death/organ_euthanasia09.pdf


"Safeguards for Life-Ending Decisions Used in Belgium"

https://s3.amazonaws.com/aws-website-jamesleonardpark---freelibrary-3puxk/SG-BELG.html




If we worry that someone might be put to death
for the purpose of harvesting his or her organs,
here is a chapter listing 22 safeguards to prevent such abuses:

"Protecting Patients from Being Put to Death without Authorization"



Go to the beginning of this website
James Leonard Park—Free Library