Dr. Paul Morrissey, an associate professor of surgery at Brown University's Alpert Medical School, wrote in The American Journal of Bioethics that the protocol known as donation after cardiac death -- meaning death as a result of irreversible damage to the cardiovascular system -- has increased the number of organs available for transplant, but has a number of limitations, including the need to wait until the heart stops.
Because of the waiting time, Morrissey said that about one-third of potential donors end up not being able to donate, and many organs turn out to not be viable as a result.
Instead, he argues in favor of procuring kidneys from patients with severe irreversible brain injury whose families consent to kidney removal before their cardiac and respiratory systems stop functioning.
"These individuals, maintained on mechanical ventilation, do not meet the criteria for brain death," he wrote. In these cases, the patient would be removed from life support and kidneys would be harvested while ensuring that the patient receives anesthesia and pain relief during the operation. After that, the patients would be kept comfortable until they have not had a pulse for five minutes, a threshold at which they are declared dead.
"Under this protocol, the donor is alive at the time of kidney recovery, but a determination has been made and confirmed by medical experts that death is imminent," he wrote.
Kidney removal, he stressed, would not cause the death of the donor, which is "instead caused foremost by the original catastrophic injury and secondarily by terminating mechanical ventilation."
In addition to providing more organs usable for transplant, Morrissey said this revised protocol would allow families to grieve in peace, since surgeons wouldn't need to rush the body into the operating room to remove organs. He said they could also take comfort in the knowledge that their loved one's death saved other lives.
A number of experts responded to Morrissey's proposal in commentaries published in the same journal. Some supported his arguments, while others expressed concern that it wouldn't be in the donor's best interests and could potentially violate medical ethics and the law.
Donald Marquis, a professor at the University of Kansas, wrote that Morrissey's argument has some validity.
Removing both kidneys, he said, "will not make the donor worse off than the donor would have been in the absence of the nephrectomy."
"Though not dead yet, they are 'as good as dead' from an ethical perspective," wrote Franklin Miller, a bioethicist at the National Institutes of Health, along with Dr. Robert Truog, a professor of medical ethics, anesthesiology and pediatrics at Harvard Medical School. "No harm or wrong is committed by procuring vital organs prior to stopping life support, provided that valid consent is obtained for donation."
But removing both kidneys from a living donor would not always be in a patient's best interests.
"There is no reason to believe that registering as an organ donor involves the willingness to undergo premortem double nephrectomy," argued bioethicists Maxwell Smith of the University of Toronto, David Rodriguez-Arias of the Spanish National Research Council and Ivan Ortega of Alcala de Henares University.
And Norman Cantor, a distinguished professor of law at Rutgers School of Law, wrote that removing both kidneys before death could be legally risky.
"An organ retrieval intervention poses some hazard of accelerating death, as by hemorrhage or cardiac arrest," he said. "Any medical action potentially accelerating death, even by a few minutes and even for a gravely debilitated patient, demands a legally recognized justification."
Removing one kidney, he said, could be legally defensible, but removing both "would almost certainly be deemed unlawful under the current legal framework."