Organ Prolongation in Anencephalic Infants: Ethical & Medical Issues

Abstract

Organ Prolongation in Anencephalic Infants: Ethical & Medical Issues Transplantation of neonatal solid organs is now capable of saving scores of fatally ill newborns, and the possibility for saving more is on the horizon as techniques and medications are perfected. An unfortunate paradox exists, however: as neonatal transplant science advances, the already acute shortage of small organs will likely grow worse unless new sources of organs are identified. Today the most promising major pool for neonatal organs is anencephalic newborns. Our intent here is to assess the current controversy over using anencephalic infants as organ sources, and to present a rationale for limited respirator use while death of the anencephalic newborn is being determined for possible utilization of these neonates as organ sources. Anencephalic Infants and Transplantation Anencephalic infants are severely impaired. Both cerebral hemispheres are missing, and there is little if any brain function above the brainstem. Although most anencephalic infants are stillborn, between 25 and 45 percent are live births. Their brainstems do allow for some typical newborn activity. Most important, circulatory and respiratory functions are performed naturally. Such infants are not dead, then, according to currently accepted standards--common law using cardiopulmonary criteria or the newly enacted state laws reflecting the Uniform Determination of Death Act and including whole brain death. Approximately 40 percent of these infants who are born alive survive at least twenty-four hours. Of these survivors, one of three will be living at the end of the third day and one of twenty will live to at least seven days. [1] Rarely have anencephalic infants lived to several months. Possibly these infants could live longer but aggressive treatment is routinely withheld. Standard treatment is "comfort care" because the condition is incompatible with a life of any self-awareness and an early death is inevitable. Some two thousand anencephalic infants are born in this country annually, although most are stillborn. If a significant percentage of these infants born alive could be utilized as organ sources, a major supply of neonatal organs would become available. Theoretically, a single anencephalic infant with healthy thoracic and abdominal organs could supply vital organs to save the lives of two other infants (one needing a heart and another a liver) and enhance the lives of several others (who need kidneys, corneas, and various transplantable tissues.) Use of these infants as organ sources following death determined by cardiovascular criteria is not new. This practice dates back to the early 1960s, and medical literature reports at least twenty-three renal transplants from anencephalic infants, with a success rate varying according to clinician and age of recipient. [2] Reliable clinical data on the quality of organs and tissues from anencephalic infants is not yet available, but early indications suggest optimism. Surgeons from the Children's Hospital in Cincinnati who have had the greatest success with such kidney transplantation, have found that the kidneys are only three quarters the size of normal kidneys but assume normal weight rapidly after transplantation. Further, these surgeons report a 50 percent success rate in their kidney transplants, with one patient functioning well nine and a half years after transplantation. [3] Widespread public interest in organ procurement from anencephalic infants is a recent phenomenon, however. It was prompted by the first successful heart transplant from an anencephalic newborn, Canadian baby Gabrielle, to Paul Holc, a newborn afflicted with hypoplastic left-heart syndrome. Why the sudden public interest? First, the successful transplant of a heart to baby Paul illustrated the possibility of routine donation of various organs, including vital organs, from dead anencephalic infants. …