COMMENTARY

A New Way to Get Organs: Preserve People Who Die at Home?

Arthur L. Caplan, PhD

Disclosures

September 16, 2015

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I'm Art Caplan from the Division of Medical Ethics at the New York University (NYU) Langone Medical Center. What are we going to do about the shortage of organs and tissues available for transplant? That's a tough question because we've been facing long waiting lists and seeing many people die while on these waiting lists, because there's no organ or tissue to give them. Some people die without a heart or a liver. Others can't get a cornea so that they can see. Other people have to wait in order to get newer forms of transplant like a face or a limb. All of these things are in short supply.

We know that people say they want to be organ donors and sign a donor card. In nearly every state there's a solid majority of people who do that, but it's so difficult to actually become an organ donor because you have to be pronounced brain-dead while on life support in order to donate your organs. Even if you say you want to be a donor, the odds of your dying in a way that would allow you to do so are pretty small. This has led a lot of people to debate something that I find frustratingly useless: Maybe we should pay people to give us their organs when they die. I find that unhelpful because, first of all, it opens up a whole other can of worms about making people nervous that maybe they're worth more dead than alive, so they can't trust the doctors to treat them aggressively. More to the point, there are so few people who can actually be organ donors because of that need to be on life support and be relatively healthy, except for a severe brain injury, that haggling over markets isn't going to produce many more organ donors—a few, perhaps, if the idea worked, but not many.

I've been an advocate of moving to "default to donation," presuming that people want to be organ donors and having them opt out if they don't want to do it. In other words, you carry a card that says you don't want to be a donor instead of carrying a card, or registering with the Department of Motor Vehicles, affirming that you do want to be a donor. Again, the pool of people is so small that even if we changed our policy, I'm not sure we would get many more organs. A couple of colleagues at NYU—Stephen Wall and Carolyn Plunkett—and I have an idea. We published this viewpoint recently in the Journal of the American Medical Association.[1] What if we could expand the potential pool of people who are organ donors to people who aren't on life support, who die at home, or in other circumstances where they're not in the hospital? There is some new technology that would allow us to do this by intubating somebody and doing a few other minor procedures to preserve them to get them to the hospital so that their family could consider organ donation or you could act on the person's wish to be an organ donor if they had a donor card.

In order to do this, however, you're going to need permission to do the preservation. We think that the best way to do something about the shortage of organs and tissues is to establish a two-step process. First, somebody dies in their apartment or home, or outside of their home. You call the ambulance. They try to resuscitate. They pronounce death. Next of kin, family, or whoever is there is asked to give approval not to organ donation, but to allow preservation of the body. The body is then taken to the hospital and the responsible party can think about organ donation or discuss whether they think the person who died wanted to do this or actually had a card. A two-step process, if instituted, is tough because you're talking to people who just witnessed what is often an unexpected death and you've got to talk to them about it right in their home. However, if we could do it and do it with respect and dignity, it could make the pool of donors expand 10 or 20 times. In fact, I'll go so far as to say it's the only real solution to the problem of organ transplant shortage.

We can argue back and forth about markets or presumed consent, but going to a two-step process of permission to preserve and then permission to donate, I think, is the answer to a quandary that we've had for well over 30 years. I think it's time to take a long, hard look at this and see if the public will accept it, and then move to pilot, giving it a chance in some communities to see how it goes. I'm Art Caplan at the Division of Medical Ethics at the NYU Langone Medical Center.

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