Infant heart transplants stir debate

A quarter of infants who need new heart transplants die before organs can be found for them, 10 times the rate for adults.

Many other children die in hospitals when life support is withdrawn, after their parents and doctors agree that continuing care would be futile. But they are not considered potential organ donors because most of them don't fit the definition of brain death used since the 1960s; their brains still show some activity before they stop breathing and their hearts stop beating.

Now doctors at Denver Children's Hospital have transplanted hearts from three such "cardiac death" donors, prompting a debate about the ethics of the procedure that receives a full airing in this week's New England Journal of Medicine.

The Denver team reports in the journal that it tested the feasibility of using hearts recovered from three babies with severe neurological injuries who died after life support was withdrawn and their hearts stopped beating. They believe their trial is the first to examine heart transplants for children from donors after cardiac death. Such transplants have been done in adults for more than a decade.

The transplant team also shortened the time between when death was declared -- which ranged from 11.5 to 27.5 minutes after life support was stopped -- and the interval after which the hearts were removed. That fell from five minutes to 75 seconds in an effort to protect the fragile organs they were transplanting.

The three children, who got their new hearts between 2004 and 2007, are doing as well as 17 children in the study's control group who received organs from donors after brain death, the team reported.

The topic is the focus of four editorials and a videotaped roundtable discussion on the ethics involved in organ donation after cardiac death, a discussion welcomed by cardiologist Dr. Mark M. Boucek, a former member of the Denver team who is now director of cardiovascular services at Joe DiMaggio Children's Hospital in Hollywood, Fla.

"It's important for the field of transplantation -- and important for the public to understand and to think about -- to make sure all this is transparent and out in the open," he said in an interview. "I hope it leads to many more opportunities to save lives."

A cardinal rule of transplantation is the "dead donor rule," which says that organs can come only from donors who have been unequivocally declared dead. A key question the ethicists debated is how to determine whether a "cardiac death" donor is irreversibly dead -- an unsettled question in children.

The Denver doctors waited 3 minutes after their first donor's heart stopped to declare death, and 75 seconds for the next two, saying they were trying to prevent deterioration of the heart by transplanting it as soon as possible. They said they arrived at 75 seconds based on the longest reported time before a stopped heart had started again -- 1 minute -- and increased that by a quarter.

The "dead donor rule" serves to protect people from being rushed into donation, along with measures that make sure the people seeking donation and the people performing transplants are never the same, a separation of roles emphasized by Dr. James L. Bernat in his perspective.

"The tendency in these policy fights is to give more priority to the interests of people who might be saved," ethicist Arthur Caplan of the University of Pennsylvania. said in an interview. "In some senses that's morally appropriate, but there are other interests involved beyond just the donor, [including] the donor families and how they feel about how things are handled and the public's confidence in what's going on."

Ethicist George Annas of Boston University, who joined Caplan in the roundtable discussion moderated by Dr. Atul Gawande of Harvard Medical School, said the dead donor rule is also the law, pointing out that dying people have rights, even though they might die soon.

"Doctors have an obligation to take good care of them, right? So they don't suffer at least? And not to kill them," Annas said during the discussion.

Asking questions about how soon to declare death isn't helpful, according to Dr. Robert Truog, a professor of ethics, anesthesia, and pediatrics at Harvard, who also took part in the roundtable and also wrote a perspective piece in the journal. He is a critical care physician at Children's Hospital Boston.

"The debate about 75 seconds is totally beside the point," he said in an interview. "If we look at kids in the Denver case series, they all had devastating neurological injury and the decision was made to withdraw life support to allow them to die. They were certain to die when life support was withdrawn -- they were going to die no matter what. The parents were highly motivated to offer organs for transplant and there were recipients who could only survive if these organs were given. All of those taken together make a very compelling case for why this kind of transplant should occur."

Medical ethicist Robert M. Veatch of Georgetown University said in the journal cardiac death can't be used for heart transplants because logically, a heart that can be started in another body can't be viewed as the cause of irreversible death. Boucek of Denver responded that the parents' decisions to withdraw life support is what's irreversible, trumping the status of the heart.

Caplan thinks the Denver team started a discussion that should continue with input from disciplines other than transplant medicine and from other parts of the country until a national consensus is achieved. It's a bitter irony, he said, that the brain-death gold standard forged so long ago and after considerable controversy may now give way. But the dead donor rule is still key, he said.

"I think you can't bend it, change it, or alter it because it assures the public that no one is being hastened in their death and no shortcuts are being taken, that when vital organs are donated from the dead, we take advantage of the tragedy that occurred, not a tragedy we create," he said.

What do you think? Should organs be transplanted from donors after cardiac death?