Ethics for the Pediatrician: Ethical Issues in Organ Donation

Abstract

1. Robert Macauley, MD* 1. *Medical Director of Clinical Ethics, Fletcher Allen Health Care; Associate Professor of Pediatrics, University of Vermont College of Medicine, Burlington, VT. After completing this article, readers should be able to: 1. Define the dead donor rule and identify current controversies surrounding it. 2. Describe the concept of donation after cardiac death (DCD). 3. Identify the requirements for children to serve as living hematopoietic stem cell and solid organ donors. 4. Discuss ethical issues related to organ donation that are specific to pediatrics. The primary ethical issues in organ donation involve procurement of vital organs (ie, organs necessary for life) from deceased donors, procurement of nonvital organs from living donors, and subsequent allocation of these organs. When children are involved (either as donors or recipients), each of these issues has an additional layer of complexity. The fundamental principle of vital organ donation is the “dead donor rule,” which states that donors must not be killed to obtain their organs (1) (or, alternatively, that persons must be dead before their organs are taken). (2) The matter of when a patient is considered dead, however, is rather complex. Before the advent of mechanical ventilation—when cessation of brain function would inevitably cause a patient to stop breathing—determination of death depended solely on cardiorespiratory parameters. Ventilators made it possible to sustain cardiorespiratory function even when a patient was in what was once termed “irreversible coma,” which later came to be known as “brain dead.” The Uniform Determination of Death Act (1981) established an all-encompassing definition: a patient is dead if he or she has sustained either “irreversible cessation of circulatory and respiratory functions” (cardiorespiratory criteria) or “irreversible cessation of all functions of the entire brain, including the brain stem” (neurologic criteria). The debate about brain death continues, however, with such determinations more …