Ethicists Debate Ambulance for Organs

May 9, 2008 — -- Ethicists and emergency medicine experts are raising concerns over New York City's plan to dispatch the first ambulance service in the country equipped to preserve the organs of the newly deceased.

They question whether the organ-preserving ambulances will create tension among EMTs who may be charged both to save lives and to preserve organs for reuse.

The aim of the Rapid Organ Recovery Ambulance service, city officials say, is to buy precious time for families to decide whether they want their loved ones' organs to be donated to needy patients.

New York City plans to start the service rolling within a month. And the plan, which has already received federal funding, is being eyed as a possibility by other emergency medical departments.

The services provided by such ambulances -- namely, efforts to save the organs of the newly dead without direct consent -- have some concerns among some experts.

"Will raising organ donation follow pronouncement of death, or will people come to know that the organ donation ambulance has been sent, making them wonder if their relative got a full press of rescue care?" said Arthur Caplan, director of the Center for Bioethics at the University of Pennsylvania in Philadelphia. "This is called violating the dead donor rule -- no organ donation [discussion] raised prior to pronouncement of death."

Emergency medicine experts also have questions about the service but see real benefits as well.

"I am fully in favor of the concept of this ambulance; it may very well make more organs available for transplant and thus improve the lives of many people for every deceased person they transport," said Dr. Richard O'Brien, spokesman for the American College of Emergency Physicians.

"How well it will work out remains to be seen."

Several Ethical Concerns

Maxwell J. Mehlman, director of the Law-Medicine Center at Case Western Reserve University in Cleveland, says he worries the process could cause distress for family members of decedents if it interferes with their grieving process.

"Would it delay family access to the decedent?" Mehlman said. "Would it physically alter the body in ways that were apparent during the funeral -- [for example, during an] open casket? If so, then some families might object, and some courts might regard the program as violating the family's rights."

The issue of how family members react to the service might even begin well before the funeral.

"I can also easily imagine confusion during which a corpse that is dead has procedures done for preservation of the organs and is whisked away, leaving onlookers and family thinking that the person is still alive, when the EMTs know they are dead," said Bill Allen, associate professor of the Bioethics Program at the University of Florida College of Medicine in Gainesville. "What will they tell bystanders?"

Far more troubling is the idea that emergency medical personnel staffing the ambulances could be faced with a dilemma of either doing everything possible to save a patient, or acting with the chief interest of saving organs.

"If it is an ambulance for the living or the dead, you run into an ethical dilemma," O'Brien said. "The ambulance has an obligation to the people of their service area to go back into service after a call, as soon as possible. This sounds like they may be tied up transporting and working on literally a deceased person, and not be available for others."

"Unless there is a plethora of EMS vehicles available where this ambulance serves, which is not the case in many areas, they still should concentrate on treating and transporting patients who have a chance at survival first."

Mehlman adds that some may worry whether the responders on such an ambulance would be under any pressure to stop trying to revive a patient in order to begin saving his or her organs. And at a time when the growing need for transplant organs is met by public concern over how these organs are obtained, such considerations become especially crucial, Allen says.

"One reason some people are unwilling to sign living wills is that they are afraid that will make physicians give up on them sooner than they should in order to get their organs," he said. "Such fears are overwrought in general, but understandable and real."

And high-profile incidents -- such as a recent case in California in which a transplant surgeon was accused of hastening the removal of organs from a donor who did not yet meet appropriate criteria for brain death -- add to such fears.

Division of Responsibility May Be Needed

The key to avoiding potential problems may lie in preserving a singular role for emergency medical responders. This would mean that those arriving at the scene would ideally focus on saving the patient, or saving the organs -- but never both.

"EMTs generally attempt resuscitation and continue that effort until an emergency department physician they are talking to tells them to stop," Allen said. "In such a scenario, the two roles of the rescuer and the retriever -- rather than harvester of a human as a source of organs -- reside in the same person.

"Once this process begins and it is widely known, there will be instances where the EMTs are suspected or accused of giving up resuscitation attempts too soon in order to get a corpse still warm enough to do the procedures for organ harvest."

Despite these concerns, Caplan says groups in Philadelphia may soon follow New York's lead. Other cities may follow.

But even as the popularity of these services rises, Allen says, the implementation of these plans will be far from simple.

"The kinds of issues and the details to implement a program like this successfully may not be insurmountable, but they are considerable," he said. "Doing this is not a no-brainer."