Dilemma 4

Is it ethical to continue life support in brain-dead patients so others may live?

I was working in a trauma room. A patient was brought in who had been shot through the head. Although he had vital signs, he was hemorrhaging rapidly through the wound. There was wide destruction of his brain tissue; much of it had spilled out on the stretcher. My immediate reaction was, “This poor person has died.” Any intervention at that point seemed futile. Then another doctor who was present ordered blood. I was shocked and asked, “Why?” The doctor replied, “Perhaps he will be an organ donor.”

We aggressively resuscitated a person who was demonstrably beyond saving with large volumes of blood, ventilator support and other means on the chance that we would find a family member in time to ask if he would be a donor. Was it right to treat the patient in front of us—who was functionally dead and moments from being without vital signs—as a potential source for an organ harvest?

If the two physicians agreed that the patient could clearly not be saved, it would be ethically acceptable to stop treatment, according to Mark R. Mercurio, M.D., HS ’85, co-chair of the Yale-New Haven Hospital Bioethics Committee and associate clinical professor of pediatrics, who also co-directs a bioethics seminar series for pediatrics residents. “However,” he adds, “that does not mean that continuing aggressive treatment with the goal of enabling possible organ donation was unethical.”

According to Mercurio, there are several ways of looking at the question. The patient-centered approach is perhaps the one most widely favored by medical ethicists. It holds that in the absence of any knowledge of the patient’s wishes, decisions should be guided by his or her best interest. To determine this, physicians must weigh the relative benefits and burdens imposed on the patient by a particular course of action. “Pain should always be considered as a potential burden,” he says. “Also, perhaps his family will be left with a much larger financial burden, which might be viewed indirectly as a burden to him.”

It may also be valid to consider the interests of others, including family members or society at large. While it may seem wrong to treat the patient just to serve someone else’s interests, keeping the patient alive for a period of time while important information is gathered might be appropriate. “Some ethicists feel that we do not need to restrict the analysis to the patient,” Mercurio states, “but can consider the interests of others affected by those decisions as well. Perhaps his family will draw some measure of comfort from organ donation, and just as their cost may be perceived as his cost, their consolation may be seen as a benefit to him.” Such an analysis could, he suggests, be expanded still further to incorporate potential organ recipients or even a much wider set of people. “It seems the questioner sought adherence to a patient-centered ethic, but perhaps the other physician thought it reasonable to consider the interests of others. Ultimately it is a matter of opinion, not medical fact, which approach is more appropriate.”

Mercurio concludes that while the physicians may not have been ethically required to continue the treatment, “I do think it was ethically permissible for them to do so, at least until the patient’s status as a possible organ donor could be clarified. If they learn that he had not chosen to be an organ donor, and the family did not choose that for him, at that point I would then recommend ceasing further efforts to maintain vital signs.”

One final point: “When the correct course between two options is not clear, it seems to me the wiser choice is the one that is potentially reversible when more information becomes available,” says Mercurio. “This would also favor attempts to maintain vital signs until the patient’s and family’s wishes regarding organ donation could be clarified.”