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Ethical and Organizational Issues in Adopting a Pediatric Protocol for Controlled Donation After Circulatory Determination of Death

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Ethical Issues in Pediatric Organ Transplantation

Part of the book series: International Library of Ethics, Law, and the New Medicine ((LIME,volume 66))

Abstract

Despite two decades of ethical and clinical debate, controlled donation after circulatory determination of death (cDCDD) remains a controversial practice, especially in pediatrics. While debates continue both nationally and internationally, it can be challenging for pediatric hospitals to build agreement on a cDCDD policy among their own constituents. After briefly reviewing the state of the larger debates, this chapter describes organizational steps involved in developing a cDCDD policy for one deeply divided pediatric hospital community. Tracing the experience of a large, tertiary-care teaching hospital and transplant center, the chapter reports the work of a multidisciplinary task force that developed an empirical evidence base and an ethical “constitution” for a cDCDD program, as well as a protocol for pediatric cDCDD. The chapter highlights a number of philosophical and practical issues considered in this process, including questions about the compatibility of a cDCDD program with the overall mission of the hospital. Also described are organizational measures aimed at forging a transparent, legitimate policy in a context of partial stakeholder agreement and persistent controversy.

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Notes

  1. 1.

    “Based on anecdotal reports, … basic science reports [studies of laboratory rats and pigs], and existing guidelines at pediatric transplant centers, it appears that a period of not less than 2 min of asystole, apnea and unresponsiveness is sufficient to declare death in a pediatric population. Therefore, although the IOM did not specifically evaluate the appropriate interval for death determination in a pediatric population, we believe their recommendation for 5 min in adults can reasonably apply to pediatric death determination, although a somewhat shorter time interval may be acceptable as well” (emphasis added) [15, p. 1829]. In the first italicized phrase, note the curious use of de facto hospital guidelines as evidence of a scientific basis for pediatric standards.

  2. 2.

    The abbreviation “DCD” is retained in direct quotations from sources in which the practice is referred to as “donation after cardiac death”.

  3. 3.

    acirculation—absence of circulation.

  4. 4.

    At the time, the Hospital was known as Children’s Hospital Boston (CHB), rather than the current BCH.

  5. 5.

    Unless otherwise specifically noted, the referenced Task Force proceedings and findings are documented in the Task Force Final Report or in other unpublished documents, including protocols and consent forms. All are available from this author at charlotte.harrison@childrens.harvard.edu.

  6. 6.

    This research excluded patients under 3 months of age. A subsequent BCH study focused on the potential scope of donation among infants [33].

  7. 7.

    This member felt that these donation-related measures would “compromise the human dignity of the patient and therefore cause […] harm”; however, she determined that “these reservations, based on personal spiritual beliefs and values, should not prevent the Task Force as a whole from proceeding” to try to design a protocol that met the Foundation Conditions [31, p. 56–57]. In consensus decision-making, a member’s decision to “stand aside” represents his or her determination that it is better for the group to proceed with its decision, without his or her support, than to be left without a decision [34]. After standing aside at the end of Phase I, this BCH Task Force member participated actively in Phase II. Her views are represented in the votes and comments reported below.

  8. 8.

    The complete text of the Foundation Conditions is reproduced in a 2008 report [20].

  9. 9.

    The Task Force made no specific recommendation as to how or with whom the consultation should be conducted. In the year following issuance of the final report, the Harvard Community Ethics Committee was formed, as a policy-related resource for all of the Harvard-affiliated teaching hospitals (http://www.medicalethicsandme.org). The BCH consultation with regard to cDCDD would become the first hospital submission to this group.

  10. 10.

    The process also took place at a time when there was no national requirement in the US for transplant hospitals to offer cDCDD. That requirement was first published for public comment in August of 2006 [30]. During the comment period, the co-chairs of the BCH Task Force submitted a letter detailing specific pediatric concerns and urging that two measures be undertaken: first, a delay in implementation of the proposed requirement solely with respect to pediatric institutions, and, second, the convening of a national consensus conference on pediatric cDCDD [31]. A report recording the OPO Committee’s discussion of these proposals, together with comments from other hospitals, highlights some of the struggles of pediatric institutions at the time in confronting the ethics of cDCDD [30].

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Authors and Affiliations

  1. Boston Children’s Hospital, Boston, MA, USA

    Charlotte H. Harrison

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  1. Charlotte H. Harrison
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Correspondence to Charlotte H. Harrison .

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Editors and Affiliations

  1. Department of Family and, The Hospital for Sick Children, Toronto, Canada

    Rebecca A. Greenberg

  2. Dept. of Pediatrics, Winnipeg Regional Health Authority, Winnipeg, Canada

    Aviva M. Goldberg

  3. Department of Philosophy I, University of Granada, Madrid, Spain

    David Rodríguez-Arias

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Harrison, C.H. (2016). Ethical and Organizational Issues in Adopting a Pediatric Protocol for Controlled Donation After Circulatory Determination of Death. In: Greenberg, R., Goldberg, A., Rodríguez-Arias, D. (eds) Ethical Issues in Pediatric Organ Transplantation. International Library of Ethics, Law, and the New Medicine, vol 66. Springer, Cham. https://doi.org/10.1007/978-3-319-29185-7_8

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