Issues related to non-heart-beating organ donation.

ABSTRACT

Since the enactment of the Transplantation of Human Organs Act, 1994, the brain dead person remains the primary source of organs legally obtained for transplantation purposes in India. With the increasing demand of organs for transplantation purposes, non-heart-beating donors can help meet this need. However, the process of retrieving organs in non-heart-beating donors is more complex and raises ethical and legal as well as medical issues. This essay discusses some of these concerns. Since the enactment of the Transplantation of Human Organs Act, 1994, the brain dead person remains the primary source of organs legally obtained for transplantation purposes in India. However, the demand for organs always been high and continues to grow, and potential donors are few, so the supply of organs remains limited. Therefore, alternative sources have been sought, including the retrieval of organs from individuals declared dead according to cardiopulmonary criteria, that is when cardiac function ceases. Such individuals are known as non-heart-beating donors (NHBD) (1). The NHBD is defined as one who sustains cardio-respiratory arrest and whose organs are retrieved after irreversible cessation of cardiac and respiratory function (2). In contrast, a conventional heart-beating donor is one who sustains irreversible brain insult and whose death is based on neurological criteria. The concept of NHBD is not new. When organ transplant programmes first started, all organs were retrieved from patients immediately after cardiorespiratory arrest (3). However, with the recognition of brain death, the use of NHBD has decreased considerably. The modified Maastricht classification of NHBD identified five categories of potential donors. A more practical classification may be “uncontrolled” or “controlled” NHBD depending on whether cardiopulmonary function ceases spontaneously or after medical therapy is withdrawn. Donors from categories 1, 2 and 5 have been classified as uncontrolled donors whereas those in categories 3 and 4 are described as controlled donors (3). It is proposed that NHBD could contribute to an increase in the number of solid organ and tissue donation for transplantation purposes. The solid organs that are suitable for transplantation purposes include the kidneys, liver, lungs and pancreas, and tissues such as corneas, bone marrow and pancreatic islet cells (1, 3-6). The results of transplantation of kidneys are encouraging (7, 8) and the recipients of NHBD kidneys have a five-year survival that is the same as those who received a conventional heart-beating donor kidney (2). It is estimated that the introduction of an NHBD programme would have the greatest impact on the cadaveric organ pool compared to cadaveric donations (9). However, the retrieval of organs for transplantation is more complex in NHBD due to time constraints, medical concerns about organ damage owing to “warm ischaemia” and the ethical and legal issues involved therein.