Organ Donation After Circulatory Death (DCD) Ethics Statement
Donation after Circulatory Death (DCD) criteria have the goal of increasing the supply of available organs for transplantation. Various DCD protocols have been implemented, for example, for potential donors with devastating brain injuries who have no reasonable prognosis for neurologic recovery yet who do not meet the conditions for determination of death by whole brain criteria. CMDA supports the ethical practice of DCD to enable the altruistic act of organ donation for transplantation for the purposes of saving and prolonging life, treating disease, and relieving pain and suffering (see CMDA statement on Organ Transplantation). However, CMDA has grave concerns about the implementation of DCD protocols in actual practice. (See Appendix)
Therefore, CMDA advises that the following strict criteria must be met for the ethical practice of DCD:
- The donor candidate must have terminal or end-stage pathology that would allow for planned withdrawal of life-sustaining medical treatment or ventilatory support, with the expectation that natural death is likely to occur soon thereafter (see CMDA statements on Euthanasia and Vegetative State).
- Patients with disabilities who are not imminently dying should not be presented with premature options for organ donation. The disabled, the frail, and the elderly should not be led to believe that they have a duty to relinquish their organs as if their lives were of inferior value (see CMDA statement on Disabled Persons).
- Psychological assessment to evaluate for possible depression and taking a spiritual history are recommended for any conscious patient who expresses a preference for withdrawal of life-sustaining treatment for donation of organs.
- The patient's care and treatment decisions at the end of life should be free from external pressure from organ solicitations. Discussions whether to remove life-sustaining medical treatment or ventilator support must occur prior to initiating organ donation requests. Such decisions must be independent of donor status and made prior to and separate from the organ procurement organization contacting the patient, the patient's surrogate or family. The patient must not be coerced into a decision to hasten death.
- Consent for donation can be withdrawn at any time prior to withdrawal of life-sustaining support. No coercion shall be used to maintain consent.
- Quality palliative care and spiritual care must be provided prior to and during the dying process. Support to the family during this process is also crucial.
- Any narcotics or sedatives administered must be justified by their being effective in the provision of the patient's comfort and not for the purposes of preserving a more usable transplant or hastening the time of death.
- Any procedures performed for the sole purpose of preserving donor organ viability that would cause the patient distress or discomfort are prohibited. These include some pharmacological agents and the placement of vascular cannulae.
- The diagnosis of death, whether by whole brain or circulatory criteria, must be based solely on the medical condition of the patient and made independently of any influence by the organ procurement organization.
- The surgical staff responsible for organ procurement shall in no way participate in the weaning process or certification of death.
- The dead donor rule must be scrupulously followed, i.e., at the time of organ retrieval the donor must meet valid criteria for death. Ethical organ retrieval occurs after the brain is dead but before transplantable organs have lost viability. It is ethically permissible to declare death either by the criterion of whole brain death or permanent cessation of circulatory function, in the latter case provided circulatory arrest has been present for a minimum of 5 minutes and the brain is not hypothermic or chemically or metabolically suppressed. Criteria for determination of death should be consistently applied and not relaxed with the intent of creating an opportunity for organ procurement.
- Interventions performed for the purpose of maintaining or improving the quality of transplantable organs must not be the proximate cause of the death of the donor. CMDA opposes the use of interventions prior to the declaration of death that would intentionally deprive circulation to the patient's heart or brain, for example, inflating an occlusive balloon in the thoracic aorta during extracorporeal membrane oxygenation procedures to prevent oxygenated blood from reaching the heart and brain, since such interventions could directly cause the patient's death.
- Physicians and other healthcare professionals who find DCD protocols to be morally objectionable or otherwise harmful to the patient must not be coerced to participate but should be allowed the freedom to recuse themselves without threat of reprisal (see CMDA statement on Healthcare Right of Conscience).
- Hospitals should be free to implement DCD protocols based on ethical criteria more stringent than those of organ procurement organizations without being penalized or disenfranchised from collaborative organ procurement and transplantation networks.
- CMDA affirms the importance of sufficient ethical safeguards in the determination of death prior to organ procurement in order to protect and respect the dignity of patients and to uphold the moral integrity of the medical profession.
- CMDA opposes abandoning the dead donor rule as a means of increasing the supply of transplantable organs. The dead donor rule is a fundamental moral principle that never should be transgressed for the sake of competing interests. Procuring life-sustaining vital organs from patients who have not yet died is incompatible with the ethical practice of medicine.
- CMDA finds proposals that would broaden DCD eligibility to include cognitively intact patients with irreversible neuromuscular paralysis who are not imminently dying yet who autonomously consent to donate their organs after electing to discontinue ventilator support to be morally problematic.
- CMDA finds the practice of DCD as an avenue to euthanasia and physician-assisted suicide to be ethically unacceptable; this may include proposals that would extend DCD eligibility to those who are not terminal but who despair of their perceived quality of life.
- CMDA is concerned that unethical DCD practices could, by association, discredit the ethical practice of organ procurement. Publicized abuses of DCD could damage the public’s trust in transplant medicine and the public's willingness to volunteer as future organ donors.
- CMDA opposes policies and procedures that shift clinical emphasis from the care of patients toward their use as a means to others’ ends. Subordinating the best interest of the patient to a purportedly higher utilitarian good is antithetical to Christian love and the ethical professional practice of medicine.
Unanimously approved by the House of Representatives
April 24, 2014
Green Lake, Wisconsin