Sunday, February 22, 2009

Do You Know What You're Signing Up For?

As apparently due to the ever increasing demand for organ donations and the limited supply of poor saps with brain death and viable organs, the Organ Procurement and Transplantation Network and the United Network for Organ Sharing (known as OPTN/UNOS collectively, the non-profit group which determines national policy for organ donations) has lowered the bar on death as of July 2007. No longer is brain death the only standard by which organ harvesting may begin.

According to the new rules a suitable candidate for organ donation can consist of:

"1. A patient ... who has a nonrecoverable and irreversible neurological injury resulting in ventilator dependency but not fulfilling brain death criteria may be a suitable candidate for DCD [Donation after Cardiac Death].
2. Other conditions that may lead to consideration of DCD eligibility include end stage musculoskeletal disease, pulmonary disease, and high spinal cord injury."

The idea here being that once a patient is determined to be a good organ donating candidate (i.e. ventilator dependent and without likely hope of recovery), his or her doctor can (with agreement from the next of kin) switch off the ventilator, wait five minutes or so until the heart stops beating and then declare death. After which the body is taken to the OR by the organ retrieval team. But the key thing to understand is that the patient is not yet dead when the decision for organ donation is being determined!

As Dr. Keamy notes:

"For some of the pathophysiological states enumerated, this amounts to plucking the fruit off the vine shortly before it would fall anyway. But this list also includes people with advanced ALS like Stephen Hawking, who has lived in that "donation qualifying" state for two decades or so; there is no mention of brain function whatsoever in this formulation; lack of awareness is specifically not a necessary component for inclusion."

Additionally, one must recognize that this system sets an all too likely scenario where the doctor has a conflict of interest between his patient and the organs which will go to the patients' of others. He's flipping that switch on a schedule that may have nothing at all to do with the state of his patient's health status. The drugs doctors give at the end of life can be palliative but they can also double-edgedly be used euthanizing-ly. Plus, there are drugs that can be given for the sake of organs health which do nothing for the individual's length of life. For a person to become an organ donator while still alive is extremely dangerous territory. Because while we hope each physician will keep himself minding his patient's needs and only his patient's needs, organ donation can require massive coordination and it's doubtful he'd be operating in an "ethically pure" environment. Indeed, if he starts to care about the sake of those organs (as would be difficult for him not to), might he be operating at cross-purposes?

And last but not least, the Halachic implications are obvious. The person is not brain dead and is therefore NOT DEAD when the ventilator is turned off. At least according to US law, R' Moshe Tendler and HODS, that is. This method for organ donation would therefore be totally improper by those Halachic authorities which permit donation. It would in fact be murder. Though ironically, the Israeli Chief Rabbinate Council's test of "respiratory failure coupled with profound nonresponsiveness," which rejects the need to check for brain death may fit what OPTN/UNOS has decided.

Now, practically speaking, patients are pulled off of ventilators all the time even when brain death is not determined since that may have been the expressed will of the patient or the health care proxy. The secular legal precedent is already there many times over and if that's already accepted why shouldn't they schedule an organ harvest ahead of time to act upon death? Maybe this is a good call after all that will lead to more organs being available for those who need them. Maybe. For now though, adjusting the definition of death for the sake of organ donations gives me the willies.

Sunday, February 01, 2009

Yesterday's Parsha

Exodus 13 (KJV):

6Seven days thou shalt eat unleavened bread, and in the seventh day shall be a feast to the LORD.
7Unleavened bread shall be eaten seven days; and there shall no leavened bread be seen with thee, neither shall there be leaven seen with thee in all thy quarters.
8And thou shalt shew thy son in that day, saying, This is done because of that which the LORD did unto me when I came forth out of Egypt.
9And it shall be for a sign unto thee upon thine hand, and for a memorial between thine eyes, that the LORD's law may be in thy mouth: for with a strong hand hath the LORD brought thee out of Egypt.

10Thou shalt therefore keep this ordinance in his season from year to year.

11And it shall be when the LORD shall bring thee into the land of the Canaanites, as he sware unto thee and to thy fathers, and shall give it thee,
12That thou shalt set apart unto the LORD all that openeth the matrix, and every firstling that cometh of a beast which thou hast; the males shall be the LORD's.
13And every firstling of an ass thou shalt redeem with a lamb; and if thou wilt not redeem it, then thou shalt break his neck: and all the firstborn of man among thy children shalt thou redeem.
14And it shall be when thy son asketh thee in time to come, saying, What is this? that thou shalt say unto him, By strength of hand the LORD brought us out from Egypt, from the house of bondage:
15And it came to pass, when Pharaoh would hardly let us go, that the LORD slew all the firstborn in the land of Egypt, both the firstborn of man, and the firstborn of beast: therefore I sacrifice to the LORD all that openeth the matrix, being males; but all the firstborn of my children I redeem.
16And it shall be for a token upon thine hand, and for frontlets between thine eyes: for by strength of hand the LORD brought us forth out of Egypt.

So we have eating matzah for seven days in order for it to be "a sign unto thee upon thine hand, and for a memorial between thine eyes" in order for when your son asks you what it's all about you can explain. And then we have redemption of the firstborn which is also given as "a token upon thine hand, and for frontlets between thine eyes" for the same co-generational exposure and explanation.

C'mon now, how do these verses imply leather boxes instead of simply figurative phrases describing a mnemonic device?