Over-Enthusiastic Organ Procurement?

by Kieran Healy on October 21, 2004

Reading about a case described in the National Review by Wesley J. Smith,[1] Kevin Drum wonders “if there really are serious moves afoot to redefine “death” in order to expedite organ harvesting.” The case in question concerns a Colorado man, William Thaddeus Rardin, who shot himself in the head. His organs were procured for transplantation. In his report on the death, however, the local Coroner, Mark Young, ruled that proper procedure hadn’t been followed, that Rardin’s brain death hadn’t been properly established and so the cause of death was the organ procurement itself. The local Organ Procurement Organization (OPO), Donor Alliance, has strongly rejected this charge.

An answer to Kevin’s question, and some commentary, below the fold.

The OPO says,

The declaration of brain death was clearly documented. Donor Alliance does not accept a case for donation unless the patient is declared dead, and the declaration of death is documented and meets acceptable medical criteria. In this case all acceptable tests for brain death were conducted. Brain death was documented and confirmed, prior to any organ recovery.

This case surfaced on Transplant discussion groups a few days ago. On the face of it, I’d be inclined to believe the OPO. Bear in mind that Coroners are not medical professionals and that organ procurement from start to finish happens fast, within a 24-hour period or less. It might be that the Coroner has an axe to grind about organ donation. It’s also possible, of course, that proper procedure wasn’t followed in this particular case. But it’s hard to say from the evidence we have. So the short answer to Kevin’s question is No—there aren’t serious moves afoot to redefine death right now, despite the existence of the papers Smith cites in his article. But it’s worth making the broader point that death has already been redefined in ways that help make organ donation possible. As Margaret Lock argues in Twice Dead: Organ Transplants and the Reinvention of Death (California 2001), the emergence, definition and successful spread of the concept of Brain Death from the late 1960s to the mid-1980s was bound up with the growth of the transplant industry. In the mid-70s, organ transplantation was often bundled together in public argument with things like stem-cell research, human cloning and genetic engineering. Advocates worked hard—and successfully—to present transplantation as a morally praiseworthy and therapeutic practice.[2] The concept of brain death especially helped them overcome the fears of religious authorities.

Recently, another class of donors has been defined: non-heart-beating donors are not brain dead but have zero chance of survival anyway, because they have sustained a catastrophic gunshot would to the heart, for example, and are in complete and irreversible cardiac and respiratory failure. In such circumstances, waiting the required time to determine brain death will often make the other organs unusable, so death can be declared by this criterion instead.

The waiting list for transplants is larger than the number of cadaveric donors by a factor of about ten. The increasing use of living donors for kidney transplants (they now make up more than half of all kidney transplants) has eased the pressure on the waiting list a little, but living donation isn’t an option for most other organs. As a result, transplant professionals are constantly casting around for new ways to increase the supply. Taking poorer-quality organs, widening the age-range of potential donors, introducing some kind of presumed consent system[2], and offering financial incentives to donor-families have all been mooted. Some (slackening the medical criteria) have been put into practice; others (financial incentives) have been pilot-tested. Further loosening the definition of brain death is another possibility. The main thing standing in the way of most of these proposals is the success of the prior efforts of OPOs to defined organ donation as the “Gift of Life”. In the ‘70s and ‘80s, the problem was convincing people that transplantation wasn’t grave-robbing or defiling the dead for the sake of a gruesome and often unsuccessful medical experiment. Now that transplants are routine, the supply constraints are hitting very hard, but many of the proposed solutions undermine the now widely-accepted idea that donation is a morally worthy gift. How far the existing system can be tweaked without provoking a severe backlash of public opinion is an open empirical question. Cases like the present one suggest that there may not be much leeway.

Notes

fn1. A Senior Fellow at the Discovery Institute. Aren’t those the Creationism / Intelligent Design people?

fn2. This was also the period when Bioethics successfully established itself as an independent field. See John H. Evans, Playing God? Human Genetic Engineering and the Rationalization of Public Bioethical Debate (Chicago, 2002).

fn3. This one is a lot more complicated in practice than it sounds in principle. I hope to have an empirical analysis of cross-national presumed consent practices ready for circulation soon. I might post a link to it from CT when it’s ready.

{ 21 comments }

1

Kate Nepveu 10.21.04 at 4:42 am

I’d be interested in your footnote #3; I did my undergrad thesis on increasing the supply of donated cadaveric organs, with a section on presumed consent. This was in 1999, and I was relying on secondary sources, of course (plus there are sections of it that make me cringe now from what I didn’t consider). My naive conclusion was that it seemed to provide a more favorable environment for increased donation, though it wasn’t a magic cure.

I’m not working in public policy at the moment, but I like to keep somewhat informed on the topic.

2

Vance Maverick 10.21.04 at 6:57 am

The waiting list for transplants is larger than the number of cadaveric donors by a factor of about ten.

You mean the waiting list at the moment is larger than the number of those who die in some time period? Or larger than the number of those who, at any given moment, are recently enough dead to be valid donors? Or do you mean that new patients arrive ten times as fast as new donors?

3

Kieran Healy 10.21.04 at 7:07 am

Sorry, I was unclear. I mean that, for example, last year there were about 85,000 people on the waiting list for some kind of transplant and about 6,000 cadaveric donors were procured. In the last 15 years or so, the waitlist as grown from about 18,000 to 85,000 while the number of cadaveric donors has grown from about 4,000 to 6,000. Typically about 3-4 organs are procured per cadaver.

4

VJ 10.21.04 at 9:55 am

Don’t have a URL but it made NPR last week. Seems to be an inexperienced coroner who was not up on the latest medical procedures. The donor was indeed ‘flat-lined’ and met none of the usual criteria for being here. (Nail bed test, eye ball scratch etc.) But it does make for good copy, and will scare the bejeebers out of 100’s of otherwise decent donor prospects. Nice going for the usual media suspects! (We don’t need the facts, sensation always worked for us).

5

Kristjan Wager 10.21.04 at 10:53 am

A Senior Fellow at the Discovery Institute. Aren’t those the Creationism / Intelligent Design people?

Yep, that’s them alright, though many of them probably would make clear that they have absolutely no connection to the Creationists – they say that they don’t advocate any specific designer, just a designer (which is of course nonsense, they are Creationists in a new package).

6

Nash 10.21.04 at 3:15 pm

“Bear in mind that Coroners are not medical professionals “

That is simply not universally so. In Franklin County, Ohio, the previous Coroner was an M.D., a pathologist, specifically. I’m unsure about the current one. While it’s not a requirement for election, it’s not a barrier to service either. Do you know for a fact that there are not jurisdictions where an MD is actually required?

7

adoherty 10.21.04 at 5:05 pm

According to the US Center for Disease Control (CDC), coroners in Ohio must be doctors who have practiced for at least two years.
http://www.cdc.gov/epo/dphsi/mecisp/ohio.htm

8

Mark 10.21.04 at 5:19 pm

I’d like to chop this story off at the knees, and harvest it’s organs, to mix metaphors –

Firstly, Those reading this thread should be aware that the position of Coroner here in Colorado is an elected position, and requires no medical background or training. In this case, I believe, the Coroners medical experience is based entirely around a period of employment as a paramedic.

Secondly, heres the report on this incident:

Montrose – Montrose County Coroner Mark Young was reckless and mistaken when he declared that a Montrose suicide victim died from having his organs removed for transplant.

That was the finding of a committee of coroners, physicians, district attorneys and organ-donor specialists who studied medical records and looked into Young’s actions in declaring the death of William Rardin a homicide.

“There was no deviation from acceptable medical standards. … There was no homicide by removal of organs,” Montrose District Attorney Thomas Raynes said during a news conference Tuesday at Montrose Memorial Hospital.

Raynes called the news conference to reveal the findings of the seven-person team that met Friday in Denver to determine whether the removal of organs from Rardin on Sept. 28 was done properly.

Young announced last week that Rardin, 31, was not brain- dead when his heart, liver, pancreas and kidneys were removed after he had shot himself in the head Sept. 26.

Medical personnel at Montrose Memorial Hospital determined Rardin was mortally wounded, and his body was flown to St. Mary’s Hospital in Grand Junction for the organ removal.

Young had said that Rardin was pronounced dead at Montrose Memorial and again at St. Mary’s, but Raynes said physicians at Montrose consulted with physicians at St. Mary’s and determined that the detailed tests for brain death and an official declaration of death would be made at St. Mary’s.

Rardin was tested and pronounced dead that same night. Young was contacted less than two hours later and officially released Rardin’s body for organ removal, the committee’s investigation showed.

Before his organs were removed, the team’s investigation found, routine clinical observations of brainstem activity – gag-reflex tests, eye- movement observations, etc. – were performed and an apnea test that measures gases in the bloodstream was done.

9

Lindsay Beyerstein 10.21.04 at 7:54 pm

Not only is the coroner of Montrose County not a doctor, he made his ruling without consulting the doctors in question, or leading medical experts. He asked the local DA instead.

Young, a part-time coroner who makes his living as a paramedic, said he consulted with District Attorney Tom Raynes and determined that the declaration of brain death did not meet “acceptable medical standards” in finding that Rardin was legally brain dead after he’d shot himself in the head.

Rocky Mountain News

10

Lindsay Beyerstein 10.21.04 at 8:02 pm

Not only is the coroner of Montrose County not a doctor, he made his ruling without consulting the doctors in question, or leading medical experts. He asked the local DA instead.

Young, a part-time coroner who makes his living as a paramedic, said he consulted with District Attorney Tom Raynes and determined that the declaration of brain death did not meet “acceptable medical standards” in finding that Rardin was legally brain dead after he’d shot himself in the head.

Rocky Mountain News

11

bellatrys 10.21.04 at 10:01 pm

This has been a popular meme among conservatives for as long as I can remember (circa 1975) and goes along with the claims that the Evil LiberalAtheistFeministFags are going to take kids away from their parents, sterilize those with more than two children, and enforce mandatory Free Sex as they forbid all practice of religion. This will be matched with mandatory euthanasia (a new development of this is “under UN aegis”, combining the dreaded Blue Helmets into the conspiracy mythos – it’s better than the Illuminati, you can work in *everyone*) of the elderly and disabled, whose organs will then be harvested and given to rich liberals.

The amount of flakiness varies, but it was a staple of editorials in the Wanderer, the Remnant, and Triumph magazine, of which the Wanderer is still around, and the authorship of the others has morphed around until some of them are writing for Crisis and so forth.

Then there is Thomas Sowell, who thinks that poor people ought to be allowed to sell their spare organs to the rich, combining Free Enterprise tropes into it all.

They don’t *make* enough tinfoil in a year to cover the intellectual heirs of Ford and Sears…

12

HP 10.21.04 at 10:54 pm

This story provides a gruesome complement to the issues in this thread. Parents in Utah refuse to take their dead son off life support, even though his tissues have already begun to decay. Further, they want the hospital to release their “son” (read: decaying corpse) into their custody so they can apply holistic treatments at home.

It puts me in mind of M. Valdemar. And a Happy Halloween to all.

13

HP 10.21.04 at 10:55 pm

This story provides a gruesome complement to the issues in this thread. Parents in Utah refuse to take their dead son off life support, even though his tissues have already begun to decay. Further, they want the hospital to release their “son” (read: decaying corpse) into their custody so they can apply holistic treatments at home.

It puts me in mind of M. Valdemar. And a Happy Halloween to all.

14

HP 10.21.04 at 10:56 pm

This story provides a gruesome complement to the issues in this thread. Parents in Utah refuse to take their dead son off life support, even though his tissues have already begun to decay. Further, they want the hospital to release their “son” (read: decaying corpse) into their custody so they can apply holistic treatments at home.

It puts me in mind of M. Valdemar. And a Happy Halloween to all.

15

HP 10.21.04 at 10:57 pm

This story provides a gruesome complement to the issues in this thread. Parents in Utah refuse to take their dead son off life support, even though his tissues have already begun to decay. Further, they want the hospital to release their “son” (read: decaying corpse) into their custody so they can apply holistic treatments at home.

It puts me in mind of M. Valdemar. And a Happy Halloween to all.

16

HP 10.21.04 at 11:00 pm

Apologies to all for multiple post. Multiple 500 errors, and I and double-checked several times before resending. Such a stooge.

17

NancyP 10.22.04 at 4:56 am

That is truly sad about the child. But perhaps not unprecedented. Every once in a while, there is a report of a person who has left a dead spouse or child in situ (bed, usually) in the house for an extended period of time, months or years.

18

Mrs. Coulter 10.23.04 at 4:12 am

Strangely enough, this was the plot of a Law and Order episode that aired in 1997, titled “The Harvest”.

19

Mrs. Coulter 10.23.04 at 4:15 am

Eeek, let me correct myself. The L&O episode is “Harvest”. “The Harvest” is an episode of Buffy the Vampire Slayer.

20

Gweipo 10.25.04 at 5:09 am

I thought of doing a case study once on China and the modernization of their body parts industry. It’s an ingenious industry, since they get the inventory for free – they sell the body parts of prisoners.

Ten years ago, everyone in China and Hong Kong knew that the best time of year to get body parts was around Chinese New Year, since it’s an ancient Chinese custom to have executions around holidays (troublemakers are much quieter after they’ve been executed, plus watching it is good family fun, as it used to be in England). But, of course, this didn’t always fit the customers’ schedules. There were executions around other holidays too, but the Communist Party generally liked to save executions up for special days, and that didn’t always fit the market.

So, they added “just in time” executions, where for an extra fee you could have a prisoner with the right blood type killed to order. Of course, the best selection and prices are still around major holidays, if you’re looking for a bargain.

And they’ve also added quality controls. It used to be that they shot prisoners through the head, since most of the saleable organs were lower down. But if there was a special order for the corneas, they would shoot the prisoner in the chest instead.

Either way, valuable inventory was damaged, so they’ve started using lethal injections and have even begun carrying out death sentences in vans, making it easier to get the donor to the hospital to harvest the organs. They used to do it in stadiums, in front of those holiday crowds, but that made quality control more difficult.

In other words, they have developed a thriving industry that has followed the dictates of business schools – just in time inventory, greater quality controls, modern technology all around. And the ingenious part is that they get the inventory for free. They’ve traditionally made the family of the prisoner pay for the bullet used to shot the person through the head (but I don’t know if the family now has to pay for the needle). Families certainly don’t get a share of the large fee charged for the organs.

Doctors in New York have reported having more and more Chinese patients that bought their organs in the “People’s Republic”. But it’s not for the rest of us – they only sell to Chinese.

I guess this is my own gruesome complement to this thread.

21

Robert Walraven 10.26.04 at 10:54 pm

Current updates on the issue at hand.

MontrosePress October 26, 2004 stated that “Young amended Rardin’s death certificate Friday to indicate he died from a suicide after Dr. James P. Kelly, a Denver neurologist whom he asked to review the case, determined Rardin was pronounced brain dead according to accepted medical standards.”

The article followed by saying that, ” Kelly also noted in his report that doctors did not adequately document their brain death diagnosis.”

As stated in this stream and various articles, Mr. Young is an elected official performing in the duty of his office with the tools at hand to him, and with the outset of the controversy that occured brought in an expert to help finalize this case.

It is admirable that a person, no matter what the critics would have you believe, would stand by any person, alive or partially so, to ensure that ‘all’ procedures have been followed correctly. That is what is at issue here, not about the harvesting or not harvesting of organs, just to prevent what has happened and has been documented in the past of organs being taken prematurely.

I am glad that we have at least one elected official who does not sit back and just “rubber stamp” the documents placed in his department.

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