◆2010/05/03 Dominic Wilkinson and Julian Savulescu, "Should We Allow Organ Donation Euthanasia? Alternatives For Maximizing The Number and Quality of
Organs for Transplantation" Bioethics（Online articles） Abstract
I found the article about the Belgian euthanasia coupled with organ harvesting referenced in my critique yesterday of a bioethics journal article urging that very approach. The woman in question was not terminally ill, but in a “locked-in” state, that is, fully conscious and completely paralyzed. She wanted to die?a desire accommodated by her doctors. Just prior to being killed, she decided to donate her organs. From, “Organ donation after physician-assisted death,” (Letter to the Editor) published in the journal Transplantation (21 (2008) 915?no link):
The day before the euthanasia, the patient expressed her will of after-death organ donation. The ethical and legal possibility of combination of the two separate processes, physician-assisted suicide and after-death organ donation was then considered and agreed by the institutional ethical committee president. The intravenous euthanasia procedure was performed according to the regular protocol, in the presence of the patient’s husband, in a room adjacent to the operative room. The patient was in her regular hospital bed. No member of the transplant team was present during the euthanasia. When the patient’s death was declared by three independent physicians after 10 min of absence of cardiac activity, her cadaver was placed on the operative table. The liver and both kidneys were harvested and transplanted according to the regular Eurotransplant organ allocation rules for after-death organ donation. Currently, more than 1 year later, all three recipients are enjoying a normal graft function.
If this doesn’t set off alarm bells about how the sick and disabled are increasingly being looked upon not only as burdens (to themselves, families, and society), but potential objects for exploitation, what will? A disabled woman was killed, even though people with locked-in states often adjust over time to their disabilities and are happy to be alive. Indeed, the book The Diving Bell and the Butterfly-written by?Jean-Dominique Bauby?tells just such a story.
Moreover, agreeing to harvest organs from euthanasia/assisted suicides raises the very realistic prospect that despairing people with terminal illnesses or disabilities (or perhaps, just despair) could latch onto being killed for their organs as a way of bringing meaning to their lives. This is very dangerous territory, made all the more treacherous by doctors, spouses, and a respected medical journal validating the ideas that dead is better than disabled and that living patients can, essentially, be viewed as a natural resource to be killed and mined.
The authors don’t see it that way, of course. They have visions of organs dancing before their eyes:
This case of two separate requests, first euthanasia and second, organ donation after death, demonstrates that organ harvesting after euthanasia may be considered and accepted from ethical, legal and practical viewpoints in countries where euthanasia is legally accepted. This possibility may increase the number of transplantable organs and may also provide some comfort to the donor and his (her) family, considering that the termination of the patient’s life may somehow help other human beings in need for organ transplantation.
Taking the organs was the easy decision. Once you’ve pulled medicine into the forbidden zone of active killing, finding self-congratulatory justifications becomes a most desirable quest.
Some might defend the act by noting the patient’s decision to be euthanized was not made concurrent with her decision to be an organ donor. I don’t see the distinction. Besides, once society accepts that the two can be joined, saving others could easily become a frequent motivation for asking to be killed. Heck, given the number of non voluntary euthanasia deaths in the Netherlands?coupled with the push for “presumed consent” to harvest organs?”choice” itself could one day become moot.
When checking the blog stats this morning, I noticed a huge jump in hits yesterday. It took me a bit to figure out why, since it's been a few days since I've posted anything.
It turns out that NBC Dateline broadcast a story on the death of Ruben Navarro and the trial of Dr. Hootan Roozrokh last night. A bunch of folks found this blog using their search engines. (Ruben Navarro died after an aborted attempt at Donation after Cardiac Death - DCD - in a nightmarish scenario that has been described in this blog and elsewhere.)
The story contains some important updates and leaves many important questions just hanging.
First, though, it's probably most important to share the news that not only was Dr. Roozrokh exonerated by a jury, but Ruben Navarro's mother now sees him as someone who did the best he could in a bad situation.
From the transcript to "A Matter of Time":
After the trial, the California medical board, which had also launched an investigation of Dr. Roozrokh, quietly withdrew it. And Rosa withdrew her lawsuit. And this is rare. Her lawyer attached a letter of apology: "We believe you acted ethically and in good faith society will be best served if you are allowed to apply... your talents as a transplant surgeon and continue saving lives. "
That doesn't mean that what happened with Ruben Navarro was acceptable or that there aren't important questions left hanging that will now never be answered:
Rosa Navarro claimed that she was told that Ruben could only be on a ventilator for five days and then would be taken off; Who told her this? Was it hospital policy? No hospital representative in coverage has confirmed or denied this claim.
What happened to the medical chart containing the minute by minute recording of Ruben Navarro's vital signs that night? Why was nurse Carla Albright, the transplant coordinator who had a heavy hand in this mess, never called as a witness?
Was Ruben Navarro really dying? Dr. Roozrokh himself noted how hard his body rallied to continue to live even after ventilator removal and the administration of morphine and ativan. Was Rosa Navarro misled in some way?
It's frustrating that as I read the transcript over, almost everyone involved in the story seems more concerned with this story's negative impact on organ donation than the particulars of Ruben Navarro's death. It would be nice to see some indication that some of the professionals felt a little worse about that.
--Stephen Drake
Posted by Not Dead Yet at 12:39 PM
Ruben Navarro's death is "old news" by internet standards. He was a man with adrenal leukodystrophy whose path to death included an alleged attempt to kill him by a transplant surgeon. Five medical professionals stood by while transplant physician Hootan Roozrokh ordered massive doses of ativan and morphine for Navarro. One of those physicians was Navarro's attending physician. A sixth medical professional, a nurse, administered the injections that Roozrokh ordered. Roozrokh is now facing felony charges of dependent adult abuse, administering a harmful substance and prescribing controlled substances without a legitimate medical purpose.
For the full story of Navarro's life and death, please read Diagnosis: Murder by Cilla Sluga for the most comprehensive investigative reporting on the life and death of Ruben Navarro.
Ruben Navarro's "medical lynching" occurred under the heart beating cadaver donor protocols. Unlike the more common organ harvesting done when someone is declared "brain dead," the organs are removed shortly after a person undergoes cardiac arrest. This protocol is somewhat controversial, but many thoughtful people support it as ethical if it is done properly. Wesley Smith, for example, laid out his reasoning about the practice in this essay.
Whether it's ethical or not, the practice has at least two big problems that don't exist within the more common practice of harvesting after pronouncement of brain death:
In the case of brain death, physical functions can be maintained while arrangements are made to harvest organs after removal of artificial ventilation, minimizing time pressure;
The new protocol opens up potential "candidates" for organ harvesting who are not dead or dying at all. Ruben Navarro, for example, could have gone on indefinitely on a ventilator and may even have achieved some level of recovery if he had not been disconnected from his ventilator.
Meanwhile, there are several important issues demanding discussion, but no bioethicist or journalist we can find is discussing them (thanks to Cilla Sluga as a source for more than one of these important questions):
Was Ruben Navarro really dying? In the wrongful death complaint brought by Navarro's mother, she claims the hospital told her that the hospital had a limit of five days for coma patients being on a ventilator? Could Ruben Navarro have experienced some level of recovery if he'd been given longer than five days? Is this claim true? How did she come to believe that? What does that mean about her "consent" to having his ventilator removed?
Can we trust the coroner's report? Cilla Sluga reports that a betadine solution administered into Navarro's intestines is toxic when taken internally. Navarro lived for hours after the alleged overdoses of ativan and morphine. Did the betadine kill him?
Why was no one else in the room charged with a crime? The medical professionals in that room all had a duty to prevent harm from being done to a patient. How did the medical review boards come to a decision that neither the attending physician nor the nurse who administered the injections did nothing wrong? Could they tell us what the heck they did right? What does this tell us about the medical profession's ability to police itself and discipline its members for misconduct?
Right now, the news coverage has died down on Navarro, but it will flare up again, and more than once. Look for it to flare up again around September 12, when transplant surgeon Hootan Roozrokh will be arraigned.
So far, transplant advocacy organizations, bioethicists, and transplant recipients have made themselves heard in the coverage. That's exactly what they should be doing in terms of advancing their respective interests.
Ruben Navarro, though, was a member of the disability community, and our voices have been absent. We need to claim our place in this story. The nightmarish treatment of Ruben Navarro resonates with some of the worst nightmares that many of our brothers and sisters talk quietly about.
To put it bluntly, Ruben Navarro would probably have been rejected out of hand as eligible for being a recipient if he had needed a transplant. It makes the circus of horrors accompanying the rush to make him a donor all the more appalling.
It's time to get louder.
It's especially important in California where legalization of assisted suicide is being pushed. Part of the "push" includes glowing promises about "safeguards" and "oversight" - the same kinds of safeguards and oversight that "protected" Ruben Navarro.
For some ideas on what to get loud about, check out this archived episode of WBAI's "The Largest Minority." Cilla Sluga and I discuss the Navarro case.
--Stephen Drake
Addendum: I was just alerted that the archived audio of a show I did last week is now available. Thanks to host Geoff Langhorne of "disRespect disability awareness radio." Disabled Los Angeles Man Put Down for Organs ? can be now be heard online or downloaded.
On a winter night in 2006, a disabled and brain damaged man named Ruben Navarro was wheeled into an operating room at a hospital here. By most accounts, Mr. Navarro, 25, was near death, and doctors hoped that he might sustain other lives by donating his kidneys and liver.
But what happened to Mr. Navarro quickly went from the potentially life-saving to what law enforcement officials say was criminal. In what transplant experts believe is the first such case in the country, prosecutors have charged the surgeon, Dr. Hootan C. Roozrokh, with prescribing excessive and improper doses of drugs, apparently in an attempt to hasten Mr. Navarro’s death to retrieve his organs sooner.
A preliminary hearing begins here on Wednesday, with Dr. Roozrokh facing three felony counts relating to Mr. Navarro’s treatment as a donor. At the heart of the case is whether Dr. Roozrokh, who studied at a transplant fellowship program at the Stanford University School of Medicine, was pursuing organs at any cost or had become entangled in a web of misunderstanding about a lesser-used harvesting technique known as “donation after cardiac death.”
Dr. Roozrokh has pleaded not guilty, and his lawyer said the charges were the result of overzealous prosecutors. But the case has sent a shudder through the tight-knit field of transplant surgeons ? if convicted on all counts, Dr. Roozrokh could face eight years in prison ? while also worrying donation advocacy groups that organ donors could be frightened away.
“If you think a malpractice lawsuit is scaring surgeons off, wait to see what happens when people see a surgeon being charged criminally and going to jail,” said Dr. Goran B. Klintmalm, president of the American Society of Transplant Surgeons, who added that he considered the case unprecedented.
David Fleming, the executive director of Donate Life America, a nonprofit group that promotes donations, said the case had “given some support to the myths and misperceptions we spend an inordinate amount of time telling people won’t happen.”
Mr. Fleming said about 18 people a day die in the United States waiting for transplants. That has created a tremendous demand for donor organs, and over the years the medical community has established strict protocols to govern organ harvesting.
Transplanting organs from patients whose hearts have stopped, or cardiac-death donations, began to go out of vogue in the late 1960s and early ’70s after medical advances like life support and subsequent changes in the legal definition of death made donations from those declared brain dead more efficient. But health officials have encouraged cardiac-death donations in recent years.
There were 670 cardiac-death donations through the first nine months of 2007, the most in any year this decade, according to the United Network for Organ Sharing, which oversees organ allocation. Over the same period, there were 12,553 brain-dead donations, according to the network.
In brain-death donations, the donor is legally dead, but machines keep the organs viable by machines. In cardiac-death donations, after the patient’s ventilator is removed, the heart slows. Once it stops, brain function ceases. Most donor protocols call for a five-minute delay before the patient is declared dead. Transplant teams are not allowed in the room of the potential donor before that.
Cardiac-death donations can make some doctors and nurses skittish if they have not previously witnessed one, said Dr. Robert Sade, the former chairman of the American Medical Association’s Council on Ethical and Judicial Affairs.
“It all works exactly the same, the cuts and the procedure,” Dr. Sade said. “But the circumstances are quite different.”
Several days after Mr. Navarro was hospitalized at the Sierra Vista Regional Medical Center here, a decision was made to remove his ventilator. According to the criminal complaint, Dr. Roozrokh ordered excessive doses of morphine and Ativan, an anti-anxiety medicine, both of which are used to comfort dying patients. In the most shocking accusation, the complaint said Dr. Roozrokh introduced Betadine, a topical antiseptic, into Mr. Navarro’s system; Betadine, the complaint said, is “a harmful substance that may cause death if ingested.”
Mr. Navarro died about eight hours later of what the coroner ruled was natural causes. In the end, however, because his death was not more immediate, his organs had deteriorated too much to be usable for transplant.
Prosecutors have charged Dr. Roozrokh with felony counts of dependent adult abuse, mingling a harmful substance (Betadine) and prescribing a controlled substance (morphine and Ativan) without medical purpose.
The doctor’s lawyer, M. Gerald Schwartzbach, said that Dr. Roozrokh, 34, who moved to Wisconsin from Iran when he was a toddler and excelled as a collegiate swimmer, did “nothing that adversely affected the quality or length” of Mr. Navarro’s life.
“Dr. Roozrokh is a brilliant young surgeon, who has dedicated his life to saving lives,” Mr. Schwartzbach said. Neither the police nor prosecutors would comment on the case.
Mr. Navarro was diagnosed with adrenoleukodystrophy, a neurological disorder, when he was 9. “He would walk like he was drunk,” said his mother, Rosa, a Guatemalan immigrant. “And when he would play, he would fall like Bambi.”
By his early 20s, however, Mr. Navarro’s mental and physical condition had deteriorated to a point where he was placed in an assisted-care facility.
On Jan. 29, 2006, Ms. Navarro received a call from the facility that her son had been found unconscious, in cardiac and respiratory arrest, but that he had been revived and transported to Sierra Vista. His brain had been damaged from lack of oxygen.
Several days later, Ms. Navarro says she was told by a doctor at the hospital, whose name she did not know, that her son would not recover and that he would be disconnected from life support.
Ms. Navarro, a machinist from Oxnard, Calif., who is on disability, said she did not have enough money to stay another night near her son. She said that shortly after leaving the hospital, she received a call from the California Transplant Donor Network, a nonprofit organization. On a tape recording made by the network, Ms. Navarro agreed to donate her son’s organs, saying she did not want him “to suffer too long.”
Late on Feb. 3, a transplant team including Dr. Roozrokh arrived at the hospital.
According to a police interview with Jennifer Endsley, a nurse, the transplant team, including Dr. Roozrokh, stayed in the room during the removal of the ventilator and gave orders for medication, something that would violate donation protocol. Ms. Endsley, who stayed to watch because she had never participated in this type of procedure, also told the police that Dr. Roozrokh asked an intensive care nurse to administer more “candy” ? meaning drugs ? after Mr. Navarro did not die immediately after his ventilator was removed.
Mr. Schwartzbach said he would address the accusations in court. “I think a great many people, lay and medical, will realize they have been significantly misinformed,” he said.
Several months after the incident, federal health officials cited the hospital for a series of lapses, including failing to grant temporary clinical privileges to Dr. Roozrokh, who was under contract with the donor network. Last February, the United Network for Organ Sharing reprimanded the California Transplant Donor Network for breaking “established protocol” in the case. The donor network declined to comment.
Ms. Navarro has filed a civil suit against Dr. Roozrokh, the donor network and other doctors in the operating room, and has settled a lawsuit against the hospital. A spokesman for the hospital, Ron Yukelson, said a plan to correct the problems had been accepted by federal health officials.
Ms. Navarro said she remained angry about the way her son’s life ended.
“He didn’t deserve to be like that, to go that way,” she said. “He died without dignity and sympathy and without respect.”
A San Luis Obispo jury finds him not guilty of trying to hasten the death of a 25-year-old potential organ donor.
THE REGION
December 19, 2008|Steve Chawkins
Grappling with ethical questions about organ transplants, a San Luis Obispo jury on Thursday acquitted a surgeon accused of trying to speed a potential donor's death.
The case against Dr. Hootan Roozrokh, believed to be the first of its kind in the United States, was watched intensely by doctors and other professionals involved in transplant surgeries. Experts had feared that a conviction would turn away potential donors, their families and even some of the doctors who harvest organs.
During the two-month trial, Roozrokh was cast by prosecutors as a predator who crossed ethical boundaries in a failed attempt to acquire organs from a dying 25-year-old patient.
The defense contended that Roozrokh acted only with compassion toward Ruben Navarro, a comatose 70-pound man afflicted with a painful, wasting neurological disease.
Jurors found Roozrokh not guilty of dependent adult abuse, a felony that carries a prison sentence of up to four years. In a handwritten note read in court by San Luis Obispo Superior Court Judge Martin Tangeman, the jury said the case highlights the need for well-defined ethical standards in the transplant procedure known as "donation after cardiac death."
Those standards "will be an important part of Ruben's legacy, and for that we pay him our respects and owe him our thanks," the jurors said.
On the night of Feb. 3, 2006, Navarro was close to death at Sierra Vista Regional Medical Center in San Luis Obispo. He had suffered a heart attack days earlier at a nearby care home. His mother had given permission for organ donation, and a team that included Roozrokh flew in from San Francisco on behalf of a regional transplant network.
Roozrokh, who had just completed a Stanford University fellowship months before, was to supervise a donation after cardiac death, a procedure that had never been performed at the 165-bed hospital. In most transplants, the removal of organs occurs only after a patient is declared brain-dead. In donations after cardiac death, a patient's brain is irreversibly damaged but still functioning minimally. With a family's consent, the patient is removed from life support and, once the heart has stopped, the patient is declared dead, and organs may be removed minutes later. Many experts say, however, that organs are usable only if they can be retrieved within 30 minutes after the machines are turned off.
According to prosecutors, Roozrokh ordered up excessive doses of the painkiller morphine and Ativan, an anti-anxiety drug, so that Navarro would die within that crucial half-hour. As it turned out, he died eight hours later and Roozrokh did not remove any organs.
"He prescribed drugs with abandon," Deputy Dist. Atty. Karen Gray said in her closing argument, "drugs that depress respiration and depress blood pressure in a patient who was already hanging by a thread."
That a transplant surgeon would have anything to do with a potential donor's care was an appalling breach, Gray said, echoing a concern expressed by many experts in the field. She acknowledged, however, that hospital staff members were unclear about exactly what they should be doing during the unfamiliar procedure.
"Everybody there didn't know their roles," Gray told the jury. "That's why he was able to come in and take charge. They didn't know enough to stop him -- but he knew better."
In his testimony, Roozrokh said that the operating room staff was so confused that he had just one ethical choice: Step in to ease what pain and terror Navarro might have been silently experiencing.
He admitted at one point calling the medications "candy," a joke he said he regretted.
In court, hospital staffers offered differing accounts of how much medication was ordered by Roozrokh, although prosecutors pegged it at 200 milligrams of morphine and 80 milligrams of Ativan in about an hour. Expert witnesses sparred over whether that amount was harmful.
Defense attorney M. Gerald Schwartzbach lashed out at nurses for not keeping proper records, at a transplant coordinator for not clarifying the staff's responsibilities and at the attending physician, Dr. Laura Lubarsky, for "abdicating her responsibilities" and not ordering pain medications.
Lubarsky, who testified after receiving immunity from prosecutors, said the transplant coordinator had told her that she was only to observe and to declare death when it occurred.
Schwartzbach called the prosecution "shameful." "It has not made this county or this nation a safer place to live," he told the jury. "It's made it a more frightening place to die."
Roozrokh still faces a hearing before the Medical Board of California.
Although some experts said the highly publicized case reflects deeply held fears about ghoulish transplant physicians, it has not dampened organ donations, according to Bryan Stewart, a spokesman for OneLegacy, the nonprofit organization that secures donations in Los Angeles and six other counties.
"We've seen consent rates at hospitals go up and up," he said. "People realize this is an extremely isolated, completely out-of-the-ordinary case."
Still, it has underscored flaws in the system, said Arthur Caplan, a University of Pennsylvania ethicist.
"At the end of the day, we've got increased pressure for more organs," he said. "There's a growing waiting list; there are more centers competing for donors; and it's a very lucrative procedure for hospitals. It's against that backdrop that the story of a doctor being sent out to come back with organs unfolds."
Even before the verdict, the case sent a powerful message.
"It certainly highlighted the potential of extreme problems that could occur without having the proper policies and procedures in place," said Dr. John Fung, a Cleveland transplant surgeon who testified as a defense witness.
Many hospitals and transplant organizations try to build a wall between medical professionals who care for dying patients and those who are on hand to procure their organs. Transplant teams do not administer medication and sometimes are not allowed in the same room as donors before they die.
But Caplan said he worries about how the rules translate into reality, especially in smaller medical centers.
"Who does what and when is not always clear," he said. "Are we training hospitals and staffs to know what to do?"