Decision-making in organ donation

In the second half of the 20th century, organ transplantation became a viable way to treat some medical conditions that were otherwise fatal. Further advances in medical technology lead to an increased demand for organs; in response to this demand, choice about organ donation was increasingly and prominently displayed to potential donors, and procedures surrounding organ donation were refined several times to increase viability and availability of organs. How does organ donation work in the US today?

End-of-life care

A patient who is nearing the end of their life should receive the same end-of-life care regardless of whether they are an organ donor or not.

To ensure this, the rules governing organ donation and transplantation process in the US require consent from the patient or the next-of-kin for all medical procedures, including procedures relating to organ donation. Furthermore, the rules prohibit all members of the organ procurement and transplant teams from being involved in the end-of-life care of the patient.

Withdrawal of life-sustaining measures

The timing of withdrawal life-sustaining measures is a complex consideration. The longer organs are deprived of blood, the less likely they are to be viable for transplantation. Therefore, there is an interplay between the desire to transplant organs and the desire to provide appropriate and ethical end-of-life care to the patient.

Before 1960s, organ donation took place after the patient’s heart and breathing irreversibly stopped. However, with advances in resuscitation, it was possible to keep the heart and lungs operating long after a patient’s brain had been irreparably damaged. This raised a variety of ethical and practical questions, leading the a report from the Harvard Medical School in 1968 that proposed a brain-based definition of death.

This definition was widely accepted and brain death became the new standard for organ donation. This lead to its own set of problems. In some cases, a patient’s brain could be irreparably damaged, but machines could maintain this state of not-quite-death for a long period of time, during which organs could not be transplanted. Organ recipients could die waiting for organs, while a potential organ donor was kept alive with no chance of recovery.

To address this a refined set of rules governing organ donation was put in place in 2007. Under a set of specific circumstances, it allows for withdrawal of life-sustaining measures and beginning of organ transplant procedures when a patient’s brain is irreparably damaged and they have no chance of recovery.

These rules include a number of safeguards to ensure that all patients require appropriate end-of-life care (such as the previously mentioned rule prohibiting the transplant team from being involved in end-of-life care).

Which organs might be transplanted?

Solid organs that might be transplanted include heart, lungs, kidneys, liver, pancreas, and intenstines. Procurement and transplantation of those organs is time-sensitive. After those organs are procured, additional tissues — skin, tendons, ligaments, cartilage, heart valves, blood vessels, and corneas — are procured.

Who governs organ donation and transplantation procedures?

Organ donation and transplantation procedures in the US are governed by the United Network for Organ Sharing (UNOS), under contract to the federal government. UNOS operates the Organ Procurement and Transplantation Network, which is a collaboration of transplant centers, procurement organizations, laboratories, and other institutions involved in transplant-related medical procedures.