Ethicists, Transplant Docs Mull Impact of Organ Case

A court case in which a doctor has been charged with hastening a disabled patient's death, in order to harvest his kidneys and liver, has sparked concern among ethicists and organ transplant experts alike.

According to a report in the New York Times, preliminary hearings began Wednesday for Dr. Hootan C. Roozrokh. The Times reports that the California doctor faces three felony counts, including the charge that he prescribed excessive and improper doses of drugs to 25-year-old Ruben Navarro in 2006. Navarro suffered from a rare metabolic disorder that had left him disabled and brain damaged.

Prosecutors allege that Roozrokh prescribed additional doses of sedative drugs in order to hasten Navarro's death and harvest his organs sooner, the Times reports. However, when Navarro died on Feb. 4 at Sierra Vista Regional Medical Center, about 150 miles northwest of Los Angeles, his organs had already deteriorated to the point that they could not be used.

Roozrokh has pleaded not guilty to the charges. If he is convicted on all counts, he could face up to eight years in prison.

A phone call to M.Gerald Schwartzbach, the Mill Valley, Calif., attorney representing Roozrokh, was not immediately returned.

Organ transplant and bioethics experts said the allegations, if true, point to the need for tighter controls to ensure that the interests of the potential organ donor are served first — particularly when the donor is disabled.

"As a disabled person, with a poor family who could not afford to stay near him every night, [Navarro] was a potentially very vulnerable individual who should have been protected from abuse," said Kathleen Powderly, acting director of the Division of Humanities in Medicine at SUNY Downstate Medical Center in Brooklyn, N.Y.

Of particular concern is the potential for the same doctor involved in organ transplantation to be involved with the end-of-life care of the potential donor. Most protocols for transplantation surgery maintain that end-of-life care and organ recovery be handled by two separate teams of doctors; however, as this case could reveal, these guidelines may not always be abided.

According to police reports obtained by the New York Times, one of the nurses present in the room, after Navarro's respirator was removed, said Roozrokh was also present. She also told police that he encouraged another nurse to administer additional doses of a sedative when he did not die right away.

"It is completely inappropriate for a transplant surgeon to be involved in managing the care of a dying patient," said Arthur Caplan, director of the Center for Bioethics at the University of Pennsylvania in Philadelphia. "Until the person is deemed dead, control must reside in the hands of intensive care personnel.

"The motivation to get organs must always, always be subordinate to patient wishes about dying and the provision of patient oriented palliative and comfort care."

"The most critical aspect should be the total separation of 'church and state' — in other words, no one from the organ donor or transplant community should be involved in the process leading up to the declaration of death," agreed Dr. Vivian Tellis, chief of the kidney transplant program at Montefiore Medical Center in New York.

When 'Dead' Is Not Quite

The line between whether a potential organ donor is truly alive or dead is not always as fuzzy as it may have been in Navarro's case.

One source of transplant organs are patients who are clinically determined to be brain dead. In these situations, doctors will keep the body alive — even though the brain is already dead — in order to preserve the organs long enough for them to be transplanted into someone who needs them.

The other category of potential donors — the one to which Navarro would belong — are those who are brain-damaged and near death, but who are being kept alive on a ventilator. While doctors have the option of waiting for these patients to die naturally, there is often a concern that, by the time death comes, the organs may no longer be viable for transplantation. Such was the case with Navarro.

In light of this, families may choose to allow doctors to disconnect the ventilator and wait for them to die, after which the organs are immediately removed.

This second category to which Navarro belonged is known by the term "non-heart-beating donors." And the controversy over the recovery of organs from these donors existed years before Navarro made his fateful visit to Sierra Vista.

"In 1997, the Cleveland Clinic wanted to implement a protocol for taking organs from so-called non-heart-beating donors," said Maxwell J. Mehlman, director of the Law-Medicine Center and a professor of bioethics at Case Western Reserve University in Cleveland, Ohio. "But their protocol called for waiting only a short time after turning off the ventilator before declaring the person dead, basing death rather crudely on the absence of a carotid pulse, and injecting them with heparin and a vasodilator called regitine, both of which would help preserve their organs, but which could hasten death, while they were still alive."

Mehlman said a local prosecutor learned of this practice, as did the CBS news program "60 Minutes." The Cleveland Clinic halted the implementation of the policy.

"The Institute of Medicine convened a commission to study the issue, and in 1997, they issued a report recommending that more accurate methods be used to determine death, and that the only drugs administered to the patient while alive be drugs that would provide the patient with a direct benefit," said Mehlman, who represented the woman who drew attention to the clinic's policy.

A Fear of Giving?

Organ transplant experts said that regardless of the final verdict delivered in the case, they hope the episode will not scare away potential organ donors.

"I am very concerned about the impact of this on organ donation," said Dr. Ian Holzman, vice-chair for clinical affairs at Mount Sinai Medical Center in New York.

"Most centers work very hard to prevent the ghoulish scenario of doctors removing organs from patients with the potential to recover. I had hoped Americans had gotten past that concern."

"This is the rare case that gives credence to the worst fears that sometimes influence the fears of potential donors," said Bill Allen, director of the Program in Bioethics, Law, and Medical Professionalism at the University of Florida College of Medicine. "But this is not typical or even common. Hopefully this case will reinforce the enforcement of correct procedures at all institutions and galvanize members of transplant teams to scrupulously avoid putting themselves at risk of this."