An earlier version of this article misstated the affiliation of Nancy Dubler. Dubler directs the division of bioethics at the Montefiore Medical Center in New York.
N.Y. Planning Special Ambulance To Recover Organs
Saturday, May 24, 2008
In the hope of saving the lives of more people waiting for transplants, New York City is working on a plan to deploy a special ambulance to collect the bodies of people who have died suddenly from heart attacks, accidents and other emergencies and try to preserve their organs.
If the "rapid-organ-recovery ambulance" succeeds, officials would like to expand the unique pilot program citywide with a fleet of ambulances and eventually duplicate it in other cities.
"We hope this will fulfill the wishes of more potential organ donors and their families in these tragic settings, and provide more organs to save the lives of those who are now dying on the waiting list," said James Burdick of the federal Health Resources and Services Administration, which is funding the project with a $1.5 million, three-year grant.
Some doctors and ethicists, however, say the initiative raises a host of prickly issues, including whether it is ethical to perform procedures on and administer drugs to a body to preserve the organs before getting a loved one's approval, as is expected to happen often. They also worry about blurring the line between saving lives and removing organs, potentially undermining public trust in emergency medical care and the organ donor system.
"I think it's disgusting," said Michael A. Grodin, director of bioethics at Boston University. "People are going to worry when the ambulance comes out to their house whether they are there to care for them or to take their organs."
The plan comes as transplant advocates have come under criticism for increasingly aggressive efforts to boost the organ supply, including advocating the removal of organs before patients are brain-dead. "This is another example of overzealous transplant people trying to retrieve organs any way they can," Grodin said.
Proponents defend the plan, saying there would be a clear distinction between the ambulance dispatched to try to save someone and the one standing by if paramedics fail. The project will proceed only if all ethical issues have been addressed and if a series of meetings with community groups alleviates any public fears, they said.
"We have to make sure people understand our job is to save lives, and we're not going to do anything to compromise that," said Lewis R. Goldfrank, director of emergency medicine at Bellevue Hospital, who is leading the program, which he hopes to launch this year.
Currently, New York City paramedics try for about 30 minutes to revive patients whose hearts have stopped before declaring them dead, while a doctor monitors their efforts remotely. The bodies are then taken to a funeral home, morgue or medical examiner's office.
"They could have a donor card. They could have a host of wishes about donation. But they don't have that opportunity because there's no system established for that," Goldfrank said, noting that similar procedures are routine in Spain and some other European countries.
Nationwide, as many as 35,000 additional transplants could be performed each year if organs from people who die suddenly outside a hospital were usable, Burdick said.
"It's clear that lots of people are very nervous about this project," said Nancy Dubler, a Columbia University bioethicist who is helping vet the plan. "We're being very careful. You don't want to do anything that would shake the confidence of the public."
Even some organ transplant proponents expressed unease that, in a diverse city with a variety of religious and cultural values, the project could backfire when family members discover that procedures they consider objectionable were performed on loved ones' bodies.
"My main concern is really, how is this going to be perceived by the public?" said Douglas W. Hanto, chief of transplantation at Beth Israel Deaconess Medical Center in Boston. "People are very sensitive about what we do to their loved ones, even after they are dead."
Robert D. Truog, a Harvard bioethicist, voiced similar concerns.
"This is going to take a person who is either dead or near dead and do everything possible to resuscitate their organs," Truog said. "That's far from what people think is a natural death and what many people think of as a good death."
The ambulance could exacerbate the fears of disadvantaged groups that already harbor deep distrust of the medical system, some said.
"If I'm poor or a member of a minority group, I may already be very distrustful of the health-care system and think they don't try very hard to, say, save my son who was shot in the head out in the street," said Arthur Caplan, a bioethicist at the University of Pennsylvania. "Now you tell me he's in this ambulance. I'm going to think, 'What's going on here? Is he really dead? Did you really do enough to try to save him?' "
Some questioned whether paramedics could be certain that the patients were dead, noting that occasionally, people who have been pronounced dead have inexplicably revived.
"One problem is determining when the patient is 'irreversibly' dead," said Leslie M. Whetstine, a bioethicist at Walsh University in Ohio. "We're treading so finely on this line. We don't know exactly when in this process a person could be reanimated."
The push to begin the process of removing organs before a patient is brain-dead is already controversial when done in a hospital, where doctors have more time and family members can better adjust to the death of a loved one and make a decision about donation, Grodin said.
"This is taking it one step back further and blurring that distinction out in the field, where the only thing the family should care about is whether their loved one is being cared for to the maximum extent," he said.
Dubler, at Columbia, acknowledged the risks.
"Urban myths are very powerful creatures, and you don't want anything about this project to be the basis of the creation of an urban myth, such as: New York City is not doing its best to save patients because it wants more organs," she said.
Dubler and Burdick, the federal official, said the procedures to be performed in the ambulances and once the person arrives at the hospital are often done now in hospitals to preserve organs, and any ethical concerns could be addressed with strict guidelines.
"I don't think there is some new crossing of the line that makes it radically different," Burdick said.
Organ donor advocates in other cities, meanwhile, are carefully watching the New York initiative.
"All of us will be looking at the results in New York to see if it offers the opportunity for more families to donate," said Cindy Speas of the Washington Regional Transplant Community.
Washington Hospital Center launched a similar program limited to its emergency room in the late 1990s but discontinued the effort when it proved too difficult logistically. But officials said improvements in emergency medicine could make such a program more workable today.
"We believe it would be easier to handle now, and it is something we will definitely consider in the future," said Janis Orlowski, the hospital's chief medical officer.