7/22/2024
It’s a matter of life or death; organ and tissue donations save countless lives. In 2023 alone, over 46,000 organ transplants were performed in the United States. Most organs are donated from recently deceased individuals who volunteered to donate them prior to death, or families of the deceased who donate on their behalf after passing. Patients are eligible to donate their organs once their heart stops beating or, once there is irreversible loss of brain and brainstem function.
The first organ transplant dates back to 1954, when a patient received a new kidney. Since then, the advancement of technology has allowed for more delicate organs, such as the heart, lungs, and spinal cord, to be transplanted. Two methods have been used to successfully harvest organs for transplants. The first method involves flushing the organ free of blood and packing it into an ice-cold (0-4ºC) preservation solution that contains electrolytes and nutrients called static cold storage (SCS). This method could lead to tissue damage as a result of prolonged hypothermic preservation, an inability to assess organ functionality prior to the transplant, and ischemia-reperfusion injury– tissue damage caused when blood supply is returned to tissue after a period of ischemia (lack of blood flow and oxygen).
The second, less common method is the organ care system (OCS). The OCS preserves the organ by attempting to recreate a physiological environment that resembles the inside of the human body. It maintains the organ at body temperature, pumps blood, and monitors the organ’s function in real-time. This method is less likely to be used because the OCS machine is large, difficult to transport, costly, and requires a lot of trained personnel to manage. Regardless of the method used, there is a significantly small window of time for organs to be harvested and transplanted into their recipient. The time varies depending on the type of organ, with the shortest time belonging to the lungs and heart at about 4 hours.
A new but controversial method is being considered for the future of organ transplants. This method is called normothermic regional perfusion (NRP) and is used once an organ donor has been declared dead by circulatory criteria. At this point, the heart no longer circulates blood, and respiration ceases. Then, 90 minutes are allotted to confirm that the heart does not restart and that the donor is cardiac dead. Then, blood vessels are clamped to ensure the brain does not receive any blood flow, and a machine is used to pump blood throughout the donor’s body to rejuvenate the organs. This process improves the viability of organs, extends preservation time, reduces the risks of ischemia-reperfusion injury, and increases the number of more delicate organs, such as hearts, to be considered for transplants.
Though beneficial, this method brings up serious moral scruples. That’s because once a donor is declared dead, blood flow to their brain is intentionally blocked. Only once the patient is declared brain dead will their circulation be restarted, effectively bringing them back to life. Can inducing brain death in donors who have only been declared cardiac dead, not brain dead, be justified? This question has caused a significant divide in the medical community, sparking intense ethical discussions among the medical community. Alexander Carpon, a bioethicist and lawyer at the University of Southern California, stated, “I think the procedure raises very major ethical and legal issues” and “I find it disturbing.” Meanwhile, Brendan Parent, a bioethicist at the NYU Grossman School of Medicine, supports the approach, stating, “It’s a powerful strategy for reducing the organ shortage and helping to improve outcomes.”
Recently, the NRP procedure was conducted by Dr. Marty Sellers, an organ recovery surgeon for Tennessee Donor Services. He was set to recover two kidneys and a liver from a donor, Karen “Susie” Phillips, whose family decided to withdraw her from life support. However, her vital signs remained stable past the critical 90-minute mark, making her organs nonviable for the procedure. The retrieval procedure was canceled, shattering Susie’s hopes of becoming an organ donor and causing significant emotional distress to her family. The team attempted the retrieval process again at another hospital; the donor was in her early 40s and had suffered a stroke. This time, despite facing logistical challenges, the donor stopped breathing prior to the 90-minute mark, and her kidneys were retrieved.
With 100,000 people awaiting an organ transplant and an estimated 17 dying daily, NRP is seen as a groundbreaking approach. Currently, around 50% of organ procurement organizations in the U.S. are using NRP, and more are planning to adopt the method. While NRP offers a promising way to increase the availability of quality organs while addressing the organ shortage, some experts remain concerned about its ethical implications, as it blurs the lines between life and death.