You Won’t Get a Piece of Me

After you read what I’m about to say, you may find me a selfish person. But before you judge me, at least listen to what I have to say in this article, something I’ve wanted to say for awhile, but since the majority of society is against this, I was reluctant to speak on it. Nevertheless, I feel that as a doctor, I am in a special position to write about the subject of organ donation, as I have witnessed first-hand the death of patients and the subsequent process of donating their organs to an anonymous recipient.
Hopefully organ donation will be obsolete by the time I die, so that I may never have to make this decision in reality. Some people think that the decision to donate their organs requires absolutely no thought at all. After all, why wouldn’t you donate organs to save (maybe even) 6-7 lives, since you are dead and never coming back anyways? Let me describe my view on this.
A potentially self-centered statement: I will NEVER consent to donating my organs after I die. In fact, I am much more likely to donate either a kidney or a piece of my liver to a HLA-matched family member while I am alive then to give these organs to an anonymous recipient after I’m dead. Let me explain several reasons why, from both an ethical standpoint and an experiential standpoint. I won’t get too much into the altruism of donating organs, and I applaud those who would do such a thing. I honestly think though that many potential organ donors would rescind their wish to donate after they die if they had seen and learned what I have.
Organ donation is quickly becoming big big business. All of medicine and peripherally-related enterprises are big business, generating a mass amount of revenue, since the entire premise is to make people live both longer and with better quality of life, stemming from mankind’s survival instinct and drive to avoid pain and suffering, respectively. Both medicine and non-transplant surgery’s goal is to fix broken tissues and organs, or to delay the time it takes for them to break. This works to a certain extent, but it has been the dream of medically-inclined men to replace organs and tissues since the beginning of time. It has not been possible until recently. This is the main driver for the business of organ donation.
The process of creating and/or growing organs is a little ways off via genetic engineering techniques. Xenotransplantation, the process of transplanting organs from other species into humans, has also not panned out very well. Therefore, in the meantime, we must rely on donation of organs from other human beings until either of the aforementioned processes is more perfected.
Given this, and humankind’s desire to constantly extend life, human organs are in high demand these days, and will remain so for some time given rising incidence and prevalence of disease. Simple economical principles dictate that where demand exists, those who control and mediate the supply will benefit (i.e. profit). Since ethical principles forbid exchanging your organs for anything of monetary value, an attempt is made to make altruism the only factor involved in deciding to donate your organs. However, as stated, the mediators of this business control the supply and in turn, they benefit. Granted, the organ donation business is also largely motivated by altruism, and many organizations are non-profit. But since the demand for organs always outweighs the supply (for many reasons-ethical, medical, etc.), a system is setup in which certain people may skip mediating agencies and directly arrange donation to a desperate recipient, often for monetary gain (more for living-related donors, although also for families of deceased donors). There is no doubt that this exists, as there have been numerous reports of such transactions occurring, although it is uncommon. The process itself is regulated not only by ethical principles, but also by law, and this tends to reduce this problem. Therefore, I cannot dump on the whole organ donation business over this one specific fact, but nonetheless I feel I must state this as a background to my further objections over organ donation.
I feel that a lot of my main objection over organ donation is in the process of organ procurement itself. I think this stems from some technical aspects of the procurement process as well as a specific attitude of people in general and organ donation societies to the following sentiment: “After all, they’re dead!” Let me explain these issues in more detail.
Unfortunately, the time immediately after death is crucial in organ procurement. Once the heart and lungs stop, and the whole person is considered dead, the individual organs themselves only begin to die. Lack of blood supply and resultant lack of oxygen begins a process in which cells first become ischemic, and subsequently begin to necrose (put simply, decompose). Some organs degrade faster than others, but the point is, that the faster an organ is procured after the death of the whole person (cardiorespiratory arrest, as brain-dead people can at least have artificial ventilation and cardiac support), the more likely that the organ is viable in the recipient. Means such as freezing the organ may buy some time, as the tissues composing the organ become less metabolically active at a lower temperature.
Given this consideration, it is critical for a newly-deceased organ donor to present to the OR for harvesting of organs ASAP, if the organs are to even survive outside the human body and subsequently be transplanted into another human being. Whereas this is an unfortunate fact of organ donation, I feel it is one of the main driving factors in everything which is wrong with the organ donation process.
Warning: Here come my rants and raves about the horrors of organ donation. Imagine your parents are about to find out that you have died rather suddenly without warning, say in a car accident. You are rushed to the hospital, but are DOA (dead on arrival). Your personal effects are removed from your dead body, and it is noticed on your driver’s license that you have directives stating you would like to be an organ donor upon death. Let the circus begin.
Likely, the organ donation agency is called even before your parents are (TIME IS OF THE ESSENCE of course since somebody else is very sick and waiting for your organs, and your organs are starting to die NOW)! Your parents are called next, and they arrive 20 minutes later, completely distraught. I happened to be in the ER trauma unit when your body arrived, and I am trying to help your parents cope, offering support services such as a chaplain, etc. However, within 3-4 minutes of your parents just arriving to the hospital, I leave and direct an organ donation representative into the room. In the middle of this complete shock of losing you, your parents are gently asked if it was your wishes to graciously donate your organs to those who need them (of course, it doesn’t matter what they say, since you had previously specified that as your wish).
The staff may give your parents 5-10 minutes to visit with your body, say final goodbyes before seeing you again at your funeral, and then the organ donation representatives send a team in to take your body away for harvesting of your organs. Again, time is of the essence. Is that how you would like your distraught parents to experience the time immediately after your sudden death, with the topic of organ donation one of the first things to come up? Imagine if you hadn’t specified or told them of your wishes concerning organ donation, and they were left with making that choice, having to make a decision within minutes of arriving to the hospital.
I must ask about donation to newly-deceased patients’ families all of the time. It is usually #2 or #3 on my list of things that I must ask as required by Minnesota state law (another is addressing autopsy). Although I am almost always extremely uncomfortable in addressing it (especially if the death was unexpected), I cannot imagine what it would be like to be on the other end of that conversation. “You’re telling me my son (daughter, mom, dad, grandma, grandpa) just died and you’re asking me for their organs”? To be fair, many family members have no problem with this, and some actually like to answer that question, indicating that their loved one would have wanted to help save another life. However, that is only the beginning of this horrible process. I’ll describe the rest in a bit, after I detail other potential scenarios of how this can play out.
Brain death is a “special” kind of death in a way, part in due to the introduction of our own technology. A lot of times, brain dead people are young, and the brain death is due to some massive and final event such as a traumatic head injury or sudden stroke or brain hemorrhage. Brain dead people can be kept “alive” in the sense that machines can breathe for them if their brainstem is taken out. Alive in the sense that the patients’ families may consider them to be alive, because they are breathing and their heart is beating, but brain dead people are not alive. Their brain has lost all function, including rudimentary reflexes. Brain dead criteria is extremely strict, as rigorous tests must be performed to determine that even the most rudimentary brain functions have been lost.
Brain dead people are usually excellent organ donation candidates, as they tend to be younger and their main organs can continue to be preserved almost indefinitely with artificial life support. The ethics of the care and withdrawal of care from brain dead vs. nearly brain dead patients are particularly difficult. Nearly brain dead patients are those that have some rudimentary reflexes left, and thus do not meet specific criteria for “brain death”. Although futile, their lives can be prolonged by their families for years on end, with no “meaningful” function apparent. I will not go into my feelings on these ethical difficulties, whether to remove life support or not. However, problems come up when the subject of organ donation is approached. To be perfectly honest, although a lot of doctors claim to continue to treat these patients as they would any other with completely normal function, subconsciously, they do not. They see the futility of keeping a person alive who will never awake, who will never have quality of life. An ethical dilemma ensues. Even though it is the specific health-care proxies’ decision whether or not to remove artificial life support, this type of futile patient has viable organs. They are an “organ transplant candidate”. They can save others’ lives.
This can be extremely dangerous if these sentiments enter into the minds of those healthcare providers who are directly involved in the care of such a patient, either consciously or unconsciously. Care can be compromised. The physician may not work as hard in providing the adequate care the patient needs. They may subconsciously influence the family members concerning the fact that their loved one can save many lives by allowing withdrawal of life support and subsequent organ harvesting.
But who can blame them? In front of them is a perfectly good waste of human organs. Whereas these sentiments are common, they can lead down a very slippery slope. Where do we draw this line? There are people on both sides of personal and societal human interests, the family wishing to hold onto the hope that their loved one may one day respond to a novel therapy or that a miracle may happen, and the organ donation representatives and health-care team thinking about the sick who can benefit from this patient’s organs.
These arguments are hard to work through, but I think they illustrate how a major dilemma was introduced into the morality and ethics of humankind when transplantation technology was made available to them. I simply take the side against organ donation personally, because I see the organ donation representatives and their inherent biases against the deceased and their families.
Let us go back to the actual process of organ procurement. We have detailed how organ donation is addressed within minutes of a person dying, required by law. As stated, I think this is awful. It is as if I am coming to you and saying, “Oh yeah, I’m sorry about your family member dying, but now that he is dead, can we have his organs?!? They would save soooo many lives, wouldn’t he want that?” Is that not a loaded question in the first place? Since this article addresses a controversial viewpoint I hold, suffice to say I am the only one you or I know that would actually tell the organ donation representative to shove off! But even uncomfortably so in my case, as there is such pressure to donate, and to avoid disdain for being selfish.
Who else besides me would dare to say no to donate a deceased loved one’s organs to save others’ lives? If I say no, would they ask why? And my answer to this question would be exactly the point I have been trying to make, that they should not have asked me in the first place when I am in such utter grief having just learned my loved one has died. It is neither the place nor time to do so, but as we had previously outlined, if organs are to be viable in transplantation, that inherently the question needs to be addressed soon after one has died, as time is of the essence.
Let us move to the actual process of the harvesting. Does anybody even know what this is like when they decide to donate? Maybe they should watch a video of it first. An argument to this would be again, “who cares, you’re dead!” But imagine if your family watched your organ harvesting live within hours of learning you are deceased.
I have only witnessed one or two organ harvesting surgeries, and one corneal harvesting. Suffice it to say that the experience alone turned me off to ever consenting to donate. In scouring the internet for physicians with a similar viewpoint to mine, I found a post by an anesthesiologist in a debate on organ donation, the exact quote as follows:

“I am an Anesthesiologist on call, and my team was responsible for maintaining the brain dead patient's blood pressure, temperature and so on... The 17 year old beautiful young boy who had fallen and hit his head lay there on the OR table at once pristine and peaceful, then the next 30-60 minutes looked like a dead carcass on the African Serengetti, a victim of mindless tigers looking for spare parts. I have seen many procedures in my life but nothing, NOTHING is as DISGUSTING as the organ harvesting procedure. A vertical incision is made from crotch to throat, the Rib Cage is spread wide open and as quickly as possible, the organs tied off and removed, the BEATING heart stopped and grabbed out like Jack the Ripper, the Liver, Kidneys, Pancreas thrown on Ice and taken out in an Igloo cooler. Once this horrific process is done, It DOES NOT STOP! The next wave of Vultures fly in and take scalpels and cut out the EYES! Then all flesh was removed around the chest with nothing but bare RIBS exposed! The Once beautiful rosy cheeked 17 year old reduced to a pale Carcass. Absolutely the worst image I have ever witnessed. And who decides how the organs are used? Not the family, Not the Dead Patient. Why should One young boy be mutilated so another can live a few extra years? Society tries to extend the life of humans for whatever cost, the whole time I realized what really frightened me was the fact that I too will also be dead like that boy. He just made the transition tonight. Listen up....you all will die someday. Yes, you will! and instead of trying to prolong the inevitable why don't we accept that our time has come, and in so many instances self induced (ie..alcohol, smokes) So maybe you will get lucky and receive this kid's heart or maybe you will die waiting. anonymous Doctor.”

This is one person’s viewpoint of course, but I have talked to a lot of physicians, who witness this end of the organ donation process, and they are equally horrified about the whole process. From my (?biased) view, these organ donation people are absolute vultures. From what I have seen, they do not seem to care much or be appreciative of the deceased who donates. They only care about the end-point, that somebody else was able to live because they helped procure organs for them.
My viewpoint may change one day of course if I was in somebody else’s shoes, say for example if myself or someone I knew needed an organ to survive. I have even had some unusual encounters with patients that need a transplant to survive. Granted, they are in dire circumstances, and one should not generalize, but I have even seen patients praying that someone young (the most viable organs are from young healthy people) would have an accident and die so that they can receive their organ. Because organ donation exists, it creates this extreme demand, which can only come about if somebody in fact dies and donates their organs. I am not sure I would rather have the option available at all, as I think if I needed an organ, I would have wished that organ transplantation had never ever been developed in the first place. Death would seem far more preferable than the extreme ups and downs, anxiety, and unnatural thoughts of waiting for somebody to die to give me an organ.
On a quick side note, on the recipient's side, the entire transplant-waiting list process is also troublesome and rife with corruption. I have heard stories of V.I.P.’s (i.e. rich people, CEO’s, high-ranking governmental officials) mysteriously “jumping” to the top of the list to receive a specific organ. I will not even begin to start a debate on this. It is absolutely horrible to think that such things occur, but they do. Do you think if the president of the United States needed a heart transplant that he would actually be made to wait on the transplant list like everybody else, fairly and squarely?
I have also witnessed “games” being played with the health-care system and the transplant list for recipients. For example, when I was in the cardiac intensive care unit, we would occasionally admit heart transplant candidates that were awaiting a new heart. In the U.S., the candidates at the top of the list are divided into UNOS (United Network for Organ Sharing) status Ia and Ib. Status Ia candidates are at the top of the list, and are next to receive a heart transplant if a match is found. One of the main criteria in order for a patient to be moved from status Ib to Ia involves placement of a swan-ganz catheter (an invasive hemodynamic monitoring catheter placed in the neck) with continuous monitoring, and as well, initiation of an IV inotropic agent (an intravenous medicine which augments the heart’s pumping function for those with heart failure). The IV inotropic agents most commonly used include milrinone and dobutamine.
To my astonishment, I learned that it is quite common for transplant physicians to “manipulate” these criteria so that patients can be moved from Ib to Ia status. This occurred twice while I was in the CCU over 1 month. Patients were admitted in “heart failure”, saying that they required an IV inotropic agent, although in actuality they would be as stable as they had been when they were status Ib, with no actual change in their clinical status. We then were instructed to place a swan-ganz catheter in the patients’ neck (a procedure with potentially fatal risks, since it is floated through the heart chambers and subsequently up into the pulmonary vessels), and start the patient on an inotropic agent, and they would then be moved up to status Ia, sitting in the hospital and waiting for news that a heart is available for them. Even more blatant was the fact that we were instructed to start the dobutamine (the inotropic agent) at the lowest dose physically possible (since the patient didn’t really need it), practically just a “whiff”. There our patients sat, sadly and anxiously awaiting their new heart, but they never got it. They racked up 2 weeks in the CCU and a lot of anxiety. Are these games fair to those other people who are on the list and await a heart fairly?
As I've detailed, I have a lot of problems with this entire system of organ donation. After seeing what I have seen, I refuse to donate my organs after I die. You may still think that that is selfish, but you have not been in my shoes. Again, I have luckily never had anybody close to me need an organ transplant, and if I did, that life-changing event may change my perspective. But the moral and ethical dilemma of whether or not to donate your organs after you die is indeed a man-made one. There is certainly nothing "natural" about transplanting an organ belonging to one human being into another, but technology has made it a problem to consider for all of us after we die. All I know is that those who work for organ donation agencies seem like vultures to me after I have seen the way in which they latch on to a newly deceased patient's family so that they can "help" somebody else by securing their organs. Couple that with the obvious corruption that I have both heard about and witnessed first-hand involving which people actually get appropriated organs, and you may begin to understand where I am coming from.