Time, resourcing, and ethics: how the routinisation of organ donation after circulatory death in the NHS has created new ethical issues

Abstract

ABSTRACT Controlled Organ Donation after Circulatory Death (DCD) was re-introduced in the UK in 2008, in efforts to increase rates of organs for transplant. Following reintroduction there were debates about the ethics of DCD, leading to production of legal and ethical guidelines. Today, DCD makes up 40% of deceased organ donors, leading to claims that the UK has ‘overcome’ its ethical challenges. However, there is little understanding of how DCD works in practice and the ethical implications of making DCD routine in the context of the NHS. This paper draws on data from an ethnographic study examining the practices of DCD in two acute NHS Trusts in England. Interviews with Intensive Care staff and Specialist Nurses in organ donation, observations of organ donation committee meetings and analysis of Trust documents were conducted. Findings reveal that the routinisation of DCD has created new ethical issues relating to interactions between organisational timeframes for DCD and (under)resourcing for, and de-prioritisation of, donation within an NHS subject to austerity. They include: the perceived burden on families and implications for consent when there are delays in the donation process, due to theatre space and retrieval team shortages; family and staff distress when death does not happen ‘on time’; and the problem of where to take patients who do not die in time to donate. I argue these temporal-ethical issues are likely to become heightened as potential donor rates increase with the new opt-out legislation, unless the resourcing required to deal with these problems are also addressed.