Jane

Tharaphi

Kendra

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Christy

Chris

Perfect Drugs: Media Critiques

Transplant Tradeoffs and the Use of Regitine

As of February 2000 there were in the United States 67,340 people waiting for organ transplants.8 In 1998, 4,855 Americans on that list died waiting.8 Against this backdrop of critical need, physicians in Wisconsin are using a controversial drug, Regitine, to preserve organs from patients on life support who still have brain activity, but who are not expected to survive their injury or illness.4 These donors, who typically die of cardiac arrest following the removal of life-sustaining technologies, are called non-heart-beating donors (NHBDs) and differ from traditional "brain-dead" donors in that the cessation of heart beat is sufficient to declare death and begin organ removal.3

According to the non-heart-beating donor (NHBD) protocol, transplant surgeons turn off a patient's respirator in an operating room. The patient is then injected with Regitine, which does not benefit him, but helps preserve his organs by increasing oxygen flow to them. This increased flow to the major organs results in a large general drop in blood pressure. Two minutes after the patient's heart ceases to beat, he is declared dead and organ removal begins.9 Critics, including Wisconsin prosecutor Carmen Marino, contend that the temporary loss in blood pressure caused by Regitine hastens death and that therefore transplant surgeons are killing patients to get their organs.4

While I agree that upholding strict transplant ethics is important, I here argue that the fully informed use of Regitine is acceptable, even if Regitine hastens death several minutes. If a patient (or immediate family members) has consented to organ donation, understands the effects of Regitine, and gives consent for its use after life-sustaining technologies have been removed, Regitine should be administered. Preserving sought-after organs ensures maximum benefit will result from the sacrifice of the individual patient. Additionally, although Regitine's use clearly increases the viability of organs, the resulting blood pressure drop has not been directly linked to hastened patient death. Antony D'Alesandro, chief of transplantation at Wisconsin notes, "[Regitine] clearly does not benefit the donor, but our belief is that it doesn't harm the donor either, and it improves the ability to transplant organs, which is what [the donor] wanted."9 He added that the hospital's use of NHBD has boosted the number of organ donations by almost ten percent. Here I provide an overview of attempts to increase organ donation, explore both sides of the Regitine debate, and explain why I think that fully informed use of Regitine is justifiable.

The Uniform Anatomical Gift Act (UAGA), passed in 1967, allows individuals to determine the use of their organs through voluntary donation.7 All 50 states have programs in which individuals can indicate their willingness to donate their organs on their driver's license. Unfortunately, although a majority of Americans support the idea of organ transplant, only about half of this majority actually do donate.7 Because of this relatively low rate of donation, the UAGA system of "encouraged donation" is generally viewed as inadequate to meet the growing need for organs.

In the early 1990s, "required request" laws were enacted to increase the supply of organs by tying hospital eligibility for Medicare reimbursement to the existence of protocols for informing families of organ donation options and approaching families with requests for donation.7, 6, 8 This initiative only marginally increased donation rates and a critical deficit in the number of available organs remains.2,11,3 There are critics who object to all forms of organ procurement, but the real issue here is whether, among those who accept the legitimacy of obtaining organs from planned demises that include the withdrawing of life support, administering a drug that might hasten death is also acceptable.

To begin to address this question, we need a concrete definition of the biological moment of death-an event laden with social meaning. Whereas we once could pronounce death based on the rapid succession of an inevitably linked series of bodily events--heart stoppage, cessation of respiration and brain death--technology has made possible the separation of these "death events". Our capacity to prolong the dying process and separate death events has been matched by an increasing usefulness of human organs for transplantation, making the definition of death critical for donors and recipients.

Medically, Wisconsin's protocols are hard to dispute. Anything that puts donor organs in better shape for transplantation makes sense to the transplanters and to the recipients. Regitine widens blood vessels, improving oxygenation and slowing organ degeneration. Speed and precise timing are important to the success of transplant surgery, and, because Regitine adds hours to an organ's "shelf-life," it saves lives.

Regitine also makes NHBD donation possible, increasing the supply of organs available for transplant. Although the number of people who die in the US under circumstances that leave their organs viable for transplant is debatable, it has been estimated that widespread inclusion of NHBD donors could increase organ supply 20-50%.9 Presumably, the thousands of individuals on transplant waiting lists would endorse Regitine use.

However, critics are quick to point out that the voluntary donation model used in the United States rests first and foremost on trust.9 They argue that drugs like Regitine undermine this trust. As Dr. Arthur Caplan, the director of the Center for Bioethics at the University of Pennsylvania puts it, "there's a real danger here. If you scare people about fuzzing the line between life and death, if you frighten people into thinking that doctors kill patients to obtain organs, you devastate the system. The whole system depends on altruism and altruism depends on clear standards that everyone agrees to."9 That Regitine allows medical professionals to push this envelope has caused some physicians and public policy leaders to oppose its use.5

These critics also point out that physicians and hospitals have a vested interest in attempting to increase the number of transplants done, calling the motives behind Regitine use further into question. In one study, the total charges accumulated from date of transplant through the first year for a liver transplant were $302,900; for a heart-lung transplant, $246,000; and for a kidney transplant, $87,700.7 The money-making potential of the "transplant business" has led to an explosive increase in the number of hospitals performing transplants. Between 1980 and 1996, the number of transplant centers in the US increased from 170 to 281.8 The financial payoffs of transplant surgery make drugs like Regitine the subject of more intense scrutiny, as proponents and critics alike struggle to separate the ethics from the economics of transplantation.

The economic component of organ donation further raises issues of the protection of socially and economically disadvantaged groups. Concerns about the acceptability of the use of executed prisoner's organs, the danger of explicit organ sale, and the possibility of 'organ theft' have led some to warn that it is better to be overly cautious than risk appearing to condone these practices.6,11

In a perfect world in which there is an organ for every person in need, the use of Regitine would be a moot point, as brain-dead organ donors (the group that traditionally accounts for most organ donation) would be able to service the current demand. However, in the world in which we do live, thousands of people die each year waiting for an organ transplant. The supremely moral high road requires that full death, including heart cessation, respiratory failure and stoppage of brain activity all occur "naturally" before recovering organ. The desperate nature of the organ shortage makes that high road inadequate, unrealistic, and fundamentally illogical. Such an approach would stop donations from brain-dead-donors (the group that traditionally accounts for most organ donations) and demands a natural death for individuals in an unnatural state of life. The complicated nature of this dilemma was encapsulated by Roger Evans, head of the section of health services evaluation at the Mayo Clinic in Rochester, Minnesota, who quipped, "when people refuse to donate, depriving individuals of organs that could save their life, maybe we should consider that a homicidal act."

Clearly, Evans's view is extreme, but it does reflect the life-or-death nature of the organ shortage. In light of all the information discussed above, I support the informed use of Regitine. In choosing between the life of someone who can be saved, and the use of a drug that may or may not shorten the life of a terminally ill patient by minutes, I choose life.

Bibliography
1. Cooper, D., Lanza, R. 2000. XENO: The Promise of Transplanting Animal Organs into H Humans. Oxford: Oxford University Press.
2. Council on Ethical and Judicial Affairs, American Medical Association. "The use of anancephalic neonates as organ donors." JAMA, 1995; 273(20): 1614-18.
3. Kolata, G. Controversy Erupts Over Organ Removals. New York Times, April, 13, 1997.
4. Online Forum. The Waiting Game: Organ Transplant Controversy, January 2, 1998. http://www.pbs.org/newshour/forum/january98/organ_1-2.html.
5. Prottas, J. "The Politics of Transplantation" 1996. In Organ and Tissue Donation; Ethical, legal, and policy issues. Speilman, B. (ed.). Carbondale: Southern Illinois University Press.
6. Rothman, D. 1996. "Bodily Integrity and the Socially Disadvantaged: The traffic in Organs for Transplantation." In Organ and Tissue Donation; Ethical, legal, and policy issues. Speilman, B. (ed.).
7. Spielman, B. (ed.) 1996. Organ and Tissue Donation; Ethical, legal, and policy issues. Carbondale: Southern Illinois University Press.
8. Veatch, R. 2000. Transplantation Ethics. Washington, D.C.: Georgetown University Press
9. Weiss, R. "Demand for Organs Fosters Aggressive Collection Methods." The Washington Post, November 24, 1997.
10. Youngner, S., and Fox, R. 1996. Organ Transplantation Meanings and Realities. Madison: The University of Wisconsin Press.
11. Youngner, S. and Arnold, R. "Ethical, psychosocial, and public policy implications of procuring organs from non-heart-beating donors. JAMA, 1993; 269(21): 2769-2774.