Intended for healthcare professionals

Rapid response to:

Editorials

Kidneys for transplant

BMJ 2006; 332 doi: https://doi.org/10.1136/bmj.38833.785984.47 (Published 11 May 2006) Cite this as: BMJ 2006;332:1105

Rapid Response:

Kidney Donation and Harm to the Donor

No one can deny the tragedy of those who die prematurely from kidney
failure or live debilitated lives due to complications from dialysis.
Although kidney transplantation offers a more effective form of treatment
than dialysis, medical personnel must take care not to harm the donor. A
recent BMJ editorial (1) calls for more transplant organs (to be better
allocated) from two sources: the "brain dead" and "non-heart beating
donors."

Removal of organs for transplant from the "brain dead" is morally
problematic, for it is not at all clear that individuals diagnosed as
"brain dead," especially under the UK "brainstem death" criterion, are
really dead. These individuals still function as organic wholes at the
physiological level, retaining circulatory and respiratory functions (the
ventilatory function is taken over by a machine but oxygen and carbon
dioxide exchange continue at the cellular and tissue level in just the
same way as before) (2). In addition, as Evans (3) and Hill (4) have both
noted, it is not clear that the brainstem, much less the rest of the
brain, is dead. If such donors are not dead, removing vital organs harms
them, violating nonmaleficence.

Removal of organs from "non-heart beating" donors is morally
problematic for other reasons, as Renée Fox (5) notes. "Treatment" is not
oriented toward the patient but toward the goal of preserving organs.
Proper comfort care for the dying patient may be omitted because the donor
is considered as a repository for organs rather than as a person. The
patient may be pronounced "dead" prematurely after circulatory cessation
and the place and timing of its certification may be orchestrated in the
interests of the organs to be removed. This is a form of technological
death befitting "things" and not "persons" in which dying individuals are
"treated" solely on the basis of their utility for others.

Non-heart beating donation may be morally acceptable if the patient
receives standard care (as for any other patient dying of the same
condition) beforehand, there being no non-therapeutic interventions for
the sole purpose of protecting the wanted organs, and if the patient is
pronounced dead according to the same circulatory-respiratory criteria
applied to other patients in similar situations (and in general use).
Then, if warm ischemic time has not been too long for the kidneys to be of
use, they may be removed without harming the patient—even then, care must
be taken to avoid even a remote potential for the patient to experience
distress. Only when no harm is done can the removal of organs from donors
be considered morally justifiable.

(1) Geddes CC and Roger RSC. Kidneys for transplant: more of them,
better allocated (editorial). BMJ, doi:10.1136/bmj.38833.785984.47
(published 27 April 2006; accessed 11 May 2006).

(2) Potts M. A requiem for whole brain death: a response to D. Alan
Shewmon’s ‘The brain and somatic integration.’ J. Med. Phil. 2001;26:479-
91.

(3) Evans DW. The demise of ‘brain death’ in Britain" In Beyond Brain
Death: The Case Against Brain Based Criteria for Human Death, ed. M Potts,
PA Byrne, and RG Nilges, pp. 139-58. Dordrecht, The Netherlands: Kluwer
Academic Publishers, 2000.

(4) Hill DJ. Brain stem death: a United Kingdom anaesthetist’s view.
In Beyond Brain Death: The Case Against Brain Based Criteria for Human
Death, ed. M Potts, PA Byrne, and RG Nilges, pp. 159-69. Dordrecht, The
Netherlands: Kluwer Academic Publishers, 2000.

(5) Fox RC. An ignoble form of cannibalism’: Reflections on the
Pittsburgh Protocol for procuring organs from non-heart-beating cadavers,"
Kennedy Inst of Ethics J 1993;3: 231-39.

Competing interests:
None declared

Competing interests: No competing interests

13 May 2006
Michael Potts
Associate Professor of Philosophy
Methodist College, Fayetteville, NC USA 28311