Ask the Ethicist: Declaring death
prematurely? Responding to concerns
about organ donation
In December, 2005, the Canadian Council for Donation and Transplantation (CCDT) published a report entitled, “Public Awareness and Attitudes on Organ and Tissue Donation and Transplantation Including Donation After Cardiac Death.” The report included the results of a survey of more than 1500 Canadians about their views on organ donation. Although 96 per cent of Canadians surveyed approve of organ donation, only 55 per cent reported having made a decision to be a donor.
This is not surprising – increasing organ donation rates continues to be one of the most significant challenges in healthcare. The most recent data from the Canadian Institute for Health Information indicates that, as of June 30, 2011, there were a total of 1065 organs transplanted across Canada, while there were more than 4500 still waiting for transplants. The waiting list numbers don’t include the 123 patients who died while waiting.
There are several factors that contribute to the continued under supply of transplantable organs but I’m going to focus my first column on one in particular. If you dig into the CCDT report you’ll find an interesting statistic: in response to the statement, ‘Doctors may declare death prematurely in order to get donations,’ a full 20 per cent of respondents said this statement is either probably or definitely true. This is especially relevant to those of you who work in areas in which organs or tissues may be retrieved. It means that one out of every five people you encounter is worried that you or the physicians on your team may prematurely declare them or their loved ones dead in order to obtain their organs. Now let’s talk about what you can do to help address this concern.
First, since this is an ethics column, I want to say a few words about the ethical issue underlying the concern. The ethical issue is a prime example of what we like to call a conflict of interest. A conflict of interest arises when there is potential for a secondary interest to interfere with the pursuit of your primary interest (or responsibility or obligation).
As a health care provider your primary interest (obligation) is to promote the best interests of your patient. It doesn’t matter what kind of professional you are, every professional code of ethics shares this primary interest in common. Of course you also have secondary interests – some of them may be “selfish” interests, such as prestige, reputation, or money, while others may have a basis in your codes of ethics or practice guidelines, such as an interest in promoting organ donation.
So when someone expresses the concern that doctors may declare death prematurely to obtain organs, they are expressing a concern about the doctor being in a conflict of interest – in particular that his or her (secondary) interest in obtaining transplantable organs may interfere with his or her (primary) interest in doing what is best for the patient. Why is this a problem? Because conflicts of interest, even if they are just perceived conflicts, erode the trust that patients and their family members have in health care professionals. It is also worth noting that this is not just a concern on the part of patients or families but also of health care providers. I have heard physicians and nurses express discomfort about broaching the subject of organ and tissue donation with family members of a patient in part because they worry that doing so will create the perception of a conflict of interest.
The way to address a potential conflict of interest such as this is to implement safeguards to prevent health care providers from finding themselves in the potential conflict. There are two main safeguards that exist in Ontario to address this issue. One is that the role of the team that retrieves and/or transplants the organs and tissues is separated from the role of the team that is caring for the patient.
This separation enables the team caring for the patient to remain focused on the patient’s interests until death occurs, at which point a different team takes over to retrieve and transplant the organs (assuming consent has been obtained). Separating the roles in this manner helps reduce the likelihood that individual health care providers will find themselves playing conflicting roles.
The second safeguard that exists, which directly addresses the concern regarding declaration of death, is that the option to donate is raised and discussed with the patient’s next of kin by an external professional, a coordinator from the Trillium Gift of Life Network (TGLN). Health care providers in Ontario are instructed to call TGLN when a patient has died or meets certain indicators for high risk of imminent death, at which point the TGLN coordinator takes over. Health care providers who have a close relationship with the patient’s family may choose to remain involved to provide emotional support, but they are not required to do so. Having the independent TGLN coordinator raise the topic of donation with the next of kin helps separate the conflicting interests even further.
Armed with this knowledge the best thing you can do as a health care provider to help close the gap between the supply and demand for transplantable organs is to help spread the truth about organ donation: that we are in great need of organ donors, that physicians are dedicated professionals who would not prematurely declare death to obtain organs, and that our system is designed to meet the highest ethical standards.