Infant Transplant Procedure Ignites Debate
Thursday, August 14, 2008
Surgeons in Denver are publishing their first account of a procedure in which they remove the hearts of severely brain-damaged newborns less than two minutes after the babies are disconnected from life support, and their hearts stop beating, so the organs can be transplanted into infants who would otherwise die.
A detailed description of the transplants in today's issue of the New England Journal of Medicine has ignited an intense debate about whether the first-of-their-kind procedures are pushing an already controversial organ-retrieval strategy beyond acceptable legal, moral and ethical bounds.
The doctors who performed the operations as part of a federally funded research project defended the practice, and some advocates for organ donation praised the operations as offering the first clear evidence that the procedures could provide desperately needed hearts for terminally ill babies.
Critics, however, are questioning the propriety of removing hearts from patients, especially babies, who are not brain-dead and are asking whether the Denver doctors wait long enough to make sure the infants met either of the long-accepted definitions of death -- complete, irreversible cessation of brain function or of heart and lung function. Some even said the operations are tantamount to murder.
"This bold experiment is pushing the boundaries and raising many questions," said James L. Bernat, a Dartmouth medical professor who wrote one of four commentaries that the journal published with the report -- an unusual step that anticipated the firestorm of reaction the procedures would cause. The journal posted them on its Web site with a videotaped debate among three prominent bioethicists.
"This clearly shows the feasibility of doing this," Bernat said. "The question is: Should this be done?"
The operations are occurring as transplant advocates have become increasingly aggressive in trying to bridge the gap between the number of available livers, kidneys, hearts and other organs and the number of Americans on the waiting list for transplants.
Since the 1970s, most organs have been removed only after doctors declared a patient brain-dead. But in the hopes of obtaining more organs, federal health officials, transplant surgeons and organ banks have been intensely promoting "donation after cardiac death," or DCD. DCD usually involves patients who have devastating and irreversible brain damage but are not actually brain-dead. Their families consent to removing life support, and their organs are removed minutes after the patients' hearts stop beating.
While DCD has become increasingly common, it remains highly controversial. Critics say it endangers the care of dying patients -- a California surgeon is facing criminal charges that he tried to hasten the death of a potential DCD donor in 2006 -- and has raised questions about whether the donors are truly dead.
To address such concerns, hospitals follow strict guidelines, including requiring a clear division between doctors caring for the patients and those removing and transplanting the organs. Most also require surgeons to wait at least two minutes -- and usually five -- after a heart stops to make sure it does not spontaneously start beating again on its own, which has occurred in rare cases.
The Washington Post reported last year that doctors at the Denver Children's Hospital had started removing hearts from babies, sometimes waiting only 75 seconds to increase the chances that the organs would be viable. The new report marks the first time the doctors have described their efforts in a medical journal.
The report details three cases between 2004 and 2007 involving babies who experienced severe brain damage from oxygen deprivation during birth. Their parents decided to discontinue life support several days following their birth after doctors told them there was no hope. The surgeons waited three minutes before removing the first baby's heart, but just 75 seconds for the second and third after an ethics panel monitoring the research decided that would be sufficient.