Alexander Morgan Capron

The circulatory-respiratory determination of death in organ donation

Objective:Death statutes permit physicians to declare death on the basis of irreversible cessation of circulatory–respiratory or brain functions. The growing practice of organ donation after circulatory determination of death now requires physicians to exercise greater specificity in circulatory–respiratory death determination. We studied circulatory–respiratory death determination to clarify its concept, practice, and application to innovative circulatory determination of death protocols. Results:It is ethically and legally appropriate to procure organs when permanent cessation (will not return) of circulation and respiration has occurred but before irreversible cessation (cannot return) has occurred because permanent cessation: 1) is an established medical practice standard for determining death; 2) is the meaning of “irreversible” in the Uniform Determination of Death Act; and 3) does not violate the “Dead Donor Rule.” Conclusions:The use of unmodified extracorporeal membrane oxygenation in the circulatory determination of death donor after death is declared should be abandoned because, by restoring brain circulation, it retroactively negates the previous death determination. Modifications of extracorporeal membrane oxygenation that avoid this problem by excluding brain circulation are contrived, invasive, and, if used, should require consent of surrogates. Heart donation in circulatory determination of death is acceptable if proper standards are followed to declare donor death after establishing the permanent cessation of circulation. Pending additional data on “auto-resuscitation,” we recommend that all circulatory determination of death programs should utilize the prevailing standard of 2 to 5 mins of demonstrated mechanical asystole before declaring death.

Brain Death — Well Settled yet Still Unresolved

If one subject in health law and bioethics can be said to be at once well settled and persistently unresolved, it is how to determine that death has occurred. Once this determination involved simpl...

International guideline development for the determination of death.

Introduction and MethodsThis report summarizes the results of the first phase in the development of international guidelines for death determination, focusing on the biology of death and the dying process, developed by an invitational forum of international content experts and representatives of a number of professional societies.Results and ConclusionsPrecise terminology was developed in order to improve clarity in death discussion and debate. Critical events in the physiological sequences leading to cessation of neurological and/or circulatory function were constructed. It was agreed that death determination is primarily clinical and recommendations for preconditions, confounding factors, minimum clinical standards and additional testing were made. A single operational definition of human death was developed: ‘the permanent loss of capacity for consciousness and all brainstem functions, as a consequence of permanent cessation of circulation or catastrophic brain injury’. In order to complete the project, in the next phase, a broader group of international stakeholders will develop clinical practice guidelines, based on comprehensive reviews and grading of the existing evidence.

Organ trafficking and transplant tourism: the role of global professional ethical standards-the 2008 Declaration of Istanbul.

By 2005, human organ trafficking, commercialization, and transplant tourism had become a prominent and pervasive influence on transplantation therapy. The most common source of organs was impoverished people in India, Pakistan, Egypt, and the Philippines, deceased organ donors in Colombia, and executed prisoners in China. In response, in May 2008, The Transplantation Society and the International Society of Nephrology developed the Declaration of Istanbul on Organ Trafficking and Transplant Tourism consisting of a preamble, a set of principles, and a series of proposals. Promulgation of the Declaration of Istanbul and the formation of the Declaration of Istanbul Custodian Group to promote and uphold its principles have demonstrated that concerted, strategic, collaborative, and persistent actions by professionals can deliver tangible changes. Over the past 5 years, the Declaration of Istanbul Custodian Group organized and encouraged cooperation among professional bodies and relevant international, regional, and national governmental organizations, which has produced significant progress in combating organ trafficking and transplant tourism around the world. At a fifth anniversary meeting in Qatar in April 2013, the DICG took note of this progress and set forth in a Communiqué a number of specific activities and resolved to further engage groups from many sectors in working toward the Declaration’s objectives.

The OHRP and SUPPORT

A group of medical ethicists and pediatricians asks for reconsideration of the recent Office for Human Research Protections decision about informed consent in SUPPORT.

Ethical Norms and the International Governance of Genetic Databases and Biobanks: Findings from an International Study

This article highlights major results of a study into the ethical norms and rules governing biobanks. After describing the methodology, the findings regarding four topics are presented: (1) the ownership of human biological samples held in biobanks; (2) the regulation of researchers’ use of samples obtained from biobanks; (3) what constitutes “collective consent” to genetic research, and when it is needed; and (4) benefit sharing and remuneration of research participants. The paper then summarizes key lessons to be drawn from the findings and concludes by reflecting on the importance of such empirical research to inform future governance norms and practices.

Living and deceased organ donation should be financially neutral acts

The supply of organs—particularly kidneys—donated by living and deceased donors falls short of the number of patients added annually to transplant waiting lists in the United States. To remedy this problem, a number of prominent physicians, ethicists, economists and others have mounted a campaign to suspend the prohibitions in the National Organ Transplant Act of 1984 (NOTA) on the buying and selling of organs. The argument that providing financial benefits would incentivize enough people to part with a kidney (or a portion of a liver) to clear the waiting lists is flawed. This commentary marshals arguments against the claim that the shortage of donor organs would best be overcome by providing financial incentives for donation. We can increase the number of organs available for transplantation by removing all financial disincentives that deter unpaid living or deceased kidney donation. These disincentives include a range of burdens, such as the costs of travel and lodging for medical evaluation and surgery, lost wages, and the expense of dependent care during the period of organ removal and recuperation. Organ donation should remain an act that is financially neutral for donors, neither imposing financial burdens nor enriching them monetarily.

Circulatory Death Determination in Uncontrolled Organ Donors: A Panel Viewpoint

One barrier for implementing programs of uncontrolled organ donation after the circulatory determination of death is the lack of consensus on the precise moment of death. Our panel was convened to study this question after we performed a similar analysis on the moment of death in controlled organ donation after the circulatory determination of death. We concluded that death could be determined by showing the permanent or irreversible cessation of circulation and respiration. Circulatory irreversibility may be presumed when optimal cardiopulmonary resuscitation efforts have failed to restore circulation and at least a 7-minute period has elapsed thereafter during which autoresuscitation to restored circulation could occur. We advise against the use of postmortem organ support technologies that reestablish circulation of warm oxygenated blood because of their risk of retroactively invalidating the required conditions on which death was declared.

Medical futility : and the evaluation of life-sustaining interventions

Preface Foreword Alexander Morgan Capron Contributors 1. Medical futility: a useful concept? Howard Brody 2. Death with dignity Patricia Brophy 3. Physicians and medical futility: experience in the critical care setting Harry S. Rafkin and Thomas Rainey 4. Physicians and medical futility: experience in the setting of general medical care Norton Spritz 5. Futility issues in pediatrics Joel E. Frader and Jon Watchko 6. Medical futility: a nusing home perspective Ellen Knapik Bartoldus 7. Alternative medicine and medical futility Joseph J. Jacobs 8. How culture and religion affect attitudes toward medical futility Mary F. Morrison and Sarah Gelbach DeMichele 9. When religious views and medical judgements conflict: civic polity and the social good John J. Paris and Mark Poorman 10. Conflict resolution: experience of consultation-liaison psychiatrists James J. Strain, Stephen L. Snyder and Martin Drooker 11. Ethics committees and end of life decision making Alice Herb and Eliot J. Lazar 12. The economics of futile interventions Donald J. Murphy 13. Medical futility: a legal perspective William Prip and Anna Moretti 14. Professional and public community projects for developing medical futility guidelines Linda Johnson and Robert Lyman Potter 15. Community futility policies: the illusion of consensus? Bethany Spielman 16. Not quite the last word: scenarios and solutions Karen Orloff Kaplan Indexes.

Open letter to Xi Jinping, president of the People's Republic of China: China's fight against corruption in organ transplantation

The international media have recently focused attention on the resolve of China’s new leadership to combat the rampant corruption within its society. The January 13, 2014, article in the China Daily, ‘‘For a clean and fair society,’’ reported your guidelines for political and legal reform. The judicial system is now charged to ‘‘carry the sword of justice and scale of equality’’ for all of China. ‘‘The Chinese dream’’ you have proposed amounts to a call for a culture of human rights linking the dignity of a great nation to the dignity of each citizen. Therefore, it is timely for the international transplant community to urge China to address the unethical practices in organ transplantation as another measure of your commitment to rid Chinese society of corruption. China is the only country in the world that still systematically takes organs from executed prisoners for the purpose of transplantation. The Transplantation Society (TTS) has expressed its strong objection to this practice through an academic embargo that prevents Chinese physicians who engage in this practice from presenting at international congresses, publishing articles in the medical literature, and achieving membership in TTS. Why is China scorned by the international community for this practice? A fundamental principle of organ donation is that potential deceased donors must have a choice whether they wish their organs to be made available for transplantation after they die. The choice to donate should not be coerced by the prospect of execution or the fear that refusal might expose members of the surviving family to retribution by the authorities. Organs and tissues should always be given freely and without coercion, a principle articulated in the Declaration of Istanbul in May 2008 and affirmed for more than 25 years by the World Health Organization, most recently at the 63rd World Health Assembly in a May 2010 resolution adopted by all member states, including China. Some Chinese officials contend that prisoners give ‘‘consent’’ before their execution. It is obvious, however, that prison inmates condemned to death are not truly free to make an autonomous and informed consent for organ donation and that no legal due process exists to assure consent. First-hand reports from our Chinese colleagues and a number of investigations suggest that the practice of obtaining organs from prisoners in China involves notorious transactions between transplant surgeons and local judicial and penal officials. Although the outcomes of this unethical practice cannot be compared with the results from other countries based on data in the peer-reviewed medical literature, the anecdotal reports of patients returning from China to their native countries with complications from clandestine organ transplantations are many. For example, a 14-year-old Saudi national who received an executed prisoner’s kidney in Tianjin returned home with the transplant never functioning, according to her physician. A biopsy of the kidney showed it to be obsolescent and scarred and thus never suitable for transplantation. This teenage patient, who contracted a viral disease that the Chinese transplantation team should have prevented or at least treated, died within weeks of the transplantation. The procedure evidently cost her mother U.S.