Reply from authors: Tying off brain vessels: Can that be ok?

Abstract

The authors reported no conflicts of interest.The Journal policy requires editors and reviewers to disclose conflicts of interest and to decline handling or reviewing manuscripts for which they may have a conflict of interest. The editors and reviewers of this article have no conflicts of interest. The authors reported no conflicts of interest. The Journal policy requires editors and reviewers to disclose conflicts of interest and to decline handling or reviewing manuscripts for which they may have a conflict of interest. The editors and reviewers of this article have no conflicts of interest. We appreciate the comments and analysis of Peled and Bernat,1Peled H. Bernat J. Why arch vessel ligation is unethical for normothermic regional perfusion.J Thorac Cardiovasc Surg. 2022; 164: e93Abstract Full Text Full Text PDF Google Scholar whose contributions to the ethics of organ donation we recognize and value. Our paper was a consensus document from the Cardiothoracic Ethics Forum and represents the majority view of the Forum participants.2Entwistle J.W. Drake D.H. Fenton K.N. Smith M.A. Sade R.M. Cardiothoracic Ethics Forum. Normothermic regional perfusion: ethical issues in thoracic organ donation.J Thorac Cardiovasc Surg. March 24, 2022; ([Epub ahead of print])Abstract Full Text Full Text PDF PubMed Google Scholar Some participants agreed with Peled and Bernat's position, so we raised and discussed similar concerns in our paper, including the view that additional study is needed for deeper scientific understanding of brain function in thoracoabdominal normothermic regional perfusion (TA-NRP). As a group, however, we disagree with the assertion that TA-NRP is definitively unethical. The permissibility of organ donation after circulatory-determined death is based on permanent cessation of circulation to the brain, which inevitably will be totally destroyed. In donation after circulatory-determined death, circulatory cessation is permanent rather than strictly irreversible because the physicians have no intention of restarting circulation; intentional ligation of the arch vessels (ILAV) respects and implements the intention not to reperfuse the brain. ILAV also allows the transplant team to respect the donor's autonomous wishes (often through a surrogate decision maker's decisions) to donate the thoracic organs for transplantation, which is less likely to occur without this intervention. Peled and Bernat state, “ILAV can be plausibly viewed as causing death by preventing brain blood flow during resuscitation.” While this might be true, death can also be plausibly viewed as caused by the patient's unrecoverable devastating brain injury. When a physician performs the positive act of removing life support from an imminently dying patient, this act is the proximate cause of death, but ethics and law view death as ultimately caused by the underlying disease. Similarly, when a physician performs the positive act of ligating arch vessels to prevent brain reperfusion in a patient already determined to be dead, ethics and law can view death as caused by the preexisting lethal brain injury. An emotional feeling that ligating arch vessels is different and somehow less acceptable than removing life support does not change the fact that both acts are the proximate cause of death. In both cases, the ultimate cause of death is the patient's underlying illness. The authors further write, “This biological fact is not mitigated by donor desires or utilitarian benefits,” but they offer no justification for that unqualified assertion. When two opposing views are equally plausible, the patient's autonomous wish to donate organs and the life-saving benefits to others play an important role in determining the ethics of TA-NRP. We also wonder, when the authors state, “ILAV can be plausibly viewed as causing death by preventing brain blood flow during resuscitation,” how an act can cause death in a patient already determined to be dead. This seems to be logically inconsistent. While our group has some sympathy with the views of Peled and Bernat, overall we conclude, as we did in our paper, that TA-NRP should initially be carried out under research protocols to demonstrate absence of spinal collateral blood flow to the brainstem. If this proves to be the case, TA-NRP will have been shown to be consistent with ethical and legal standards and can be used clinically, thereby honoring the donor's wishes and increasing the availability of life-saving hearts for transplantation. Why arch vessel ligation is unethical for thoracoabdominal normothermic regional perfusionThe Journal of Thoracic and Cardiovascular SurgeryVol. 164Issue 2PreviewWe thank Entwistle and colleagues for a balanced and thoughtful review of the ethics of normothermic regional perfusion (NRP).1 As an author of the cited section on the unifying concept of death,2 we here state our position that thoracoabdominal (TA) NRP is unethical. The unifying concept of death of the donation after circulatory determination of death (DCD) donor requires the permanent cessation of brain circulation and function. In the absence of collateral blood flow to the brainstem, TA-NRP would be consistent with our unifying concept of death. Full-Text PDF