Donor Organs Are Too Rare. We Need a New Definition of Death.
A person may serve as an organ donor only after being declared dead. (Until then, transplant surgeons are not allowed even to interact with a dying patient.) This common-sensical rule underpins organ donation in the United States and many other countries.
Most donor organs today are obtained after brain death, defined by most state laws as a condition of permanent unconsciousness with no spontaneous breathing, no response to pain and no primitive reflexes — in other words, devastation of the whole brain. Organs obtained this way are often relatively healthy, because brain-dead patients can continue to circulate blood and oxygen.
Brain death is rare, though. In New York State, with a population of 20 million, there are on average fewer than 500 cases suitable for organ procurement and transplantation each year.
Far more often, people die because their heart has permanently stopped beating, which is known as circulatory death. However, precisely because the blood has stopped circulating, organs from people who die this way are often damaged and unsuited for transplantation.
The need for donor organs is urgent. An estimated 15 people die in this country every day waiting for a transplant. We need to figure out how to obtain more healthy organs from donors while maintaining strict ethical standards.
New technologies can help. But the best solution, we believe, is legal: We need to broaden the definition of death.
Consider how things currently work. In the procedure known as donation after circulatory death, a typical donor is in an irreversible coma from, say, a drug overdose or a massive cerebral hemorrhage, and the heart is beating only because of life support. The donor is still not legally brain-dead; he or she might have, say, a gag reflex or other primitive functions.
In such cases, with the blessing of the family, a donor is brought into an operating room and life support is carefully withdrawn. If, as is expected, the removal of life support results in stoppage of the heart, surgeons will wait long enough to determine that the stoppage is permanent — to be confident of death — but not so long that vital organs get damaged. This period is typically about five minutes. Then the surgeons remove the organs.
But even a few minutes of a stopped heart often results in damage to the organs. This deprives potential recipients of healthy organs and thwarts the wishes of donors to have their organs used to help others.
Fortunately, there is a relatively new method that can improve the efficacy of donation after circulatory death. In this procedure, which is called normothermic regional perfusion, doctors take an irreversibly comatose donor off life support long enough to determine that the heart has stopped beating permanently — but then the donor is placed on a machine that circulates oxygen-rich blood through the body to preserve organ function. Donor organs obtained through this procedure, which is used widely in Europe and increasingly in the United States, tend to be much healthier.
But by artificially circulating blood and oxygen, the procedure can reanimate a lifeless heart. Some doctors and ethicists find the procedure objectionable because, in reversing the stoppage of the heart, it seems to nullify the reason the donor was declared dead in the first place. Is the donor no longer dead, they wonder?
Proponents of the procedure reply that the resumption of the heartbeat should not be considered resuscitation; the donor still has no independent functioning, nor is there any hope of it. They say that it is not the donor but rather regions of the body that have been revived.
How to resolve this debate? The solution, we believe, is to broaden the definition of brain death to include irreversibly comatose patients on life support. Using this definition, these patients would be legally dead regardless of whether a machine restored the beating of their heart.
So long as the patient had given informed consent for organ donation, removal would proceed without delay. The ethical debate about normothermic regional perfusion would be moot. And we would have more organs available for transplantation.
Apart from increased organ availability, there is also a philosophical reason for wanting to broaden the definition of brain death. The brain functions that matter most to life are those such as consciousness, memory, intention and desire. Once those higher brain functions are irreversibly gone, is it not fair to say that a person (as opposed to a body) has ceased to exist?
Understandably, some will worry that doctors will prematurely pronounce a patient irreversibly comatose when in fact the patient is not or there is genuine hope for recovery. This is rare, but it can happen (as recently documented by The Times), and when it does, it is a catastrophe.
That sort of concern, however, is about practicalities such as whether doctors are following protocol properly and whether external pressures are creating perverse incentives for doctors and other medical workers to be careless. These are critical issues, to be sure. But it remains possible (and common) to responsibly determine whether someone is irreversibly comatose, and in such cases a judgment of brain death is merited, as the law should be revised to reflect.
In 1968, a committee of doctors and ethicists at Harvard came up with a definition of brain death — the same basic definition most states use today. In its initial report the committee noted that 'there is great need for the tissues and organs of the hopelessly comatose in order to restore to health those who are still salvageable.'
This frank assessment was edited out of the final report because of a reviewer's objection. But it is one that should guide death and organ policy today.
Sandeep Jauhar (@sjauhar) is the author of 'Heart: A History' and a cardiologist at Northwell Health, where Snehal Patel and Deane Smith are the directors of the Center for Heart Failure, Transplant and Mechanical Circulatory Support.
The Times is committed to publishing a diversity of letters to the editor. We'd like to hear what you think about this or any of our articles. Here are some tips. And here's our email: letters@nytimes.com.
Follow the New York Times Opinion section on Facebook, Instagram, TikTok, Bluesky, WhatsApp and Threads.
Hashtags
Try Our AI Features
Explore what Daily8 AI can do for you:
Comments
No comments yet...
Related Articles
Yahoo
40 minutes ago
- Yahoo
Trump's anti-DEI order sparks new federal funding guidance in Washington County
PORTLAND, Ore. () — Washington County has approved guidelines aimed at helping officials maintain critical funding amid President Donald Trump's anti-diversity, equity and inclusion policies. One of several established that entities with DEI practices would no longer be eligible for funding from the U.S. government. After several months of talks centered on how to preserve federal grants and other financial support, the Washington County Board of Commissioners voted to approve guiding principles during a meeting on Tuesday. CDC delves into bubonic plague case detected in Oregon in early 2024 The new guidance states that leaders will continue to operate 'in a transparent and open manner' while complying with federal, state and local regulations, among . Earlier in June, the its February 2020 commitment to DEI practices in response to the executive order. following pushback from several residents who argued leaders of the diverse county shouldn't adhere to the Trump administration's demands. However, County Administrator Tanya Ange noted that officials rely on $135 million in federal funding annually — and July through August is typically the period in which grants and contracts are renewed. Senior Medicare services administered through the Oregon Department of Human Services and overdose prevention programs managed by the Oregon Health Authority are among the resources that are currently 'at risk' as local officials wait to learn whether funding has been secured, according to Ange's . Despite uncertainty surrounding which resources will remain accessible in the county, some community members are arguing the new guidelines are too vague to ensure the protection of all residents. 'Simply changing the wording may not be enough to get the federal funds that we need, or maybe the wording is enough, but the resolution you pass is ambiguous enough to open the door for these funds to be made available for purposes they were not intended for — for not serving the under-resourced members of our community,' one testifier said. Ritz-Carlton in Portland sold back to lender to 'strengthen' struggling property District 1 Commissioner Nafisa Fai proposed an amendment that would have changed the guidelines to include language about Oregon's sanctuary state status, and to affirm that all Washington County residents would still have the right to access resources despite discrimination. When no other leaders voted to second the proposal, a decision that was met with 'boos' from attendees of the public hearing, District 4 Commissioner Jason Willey said legal counsel had already advised the county against changing the resolution. Copyright 2025 Nexstar Media, Inc. All rights reserved. This material may not be published, broadcast, rewritten, or redistributed. Solve the daily Crossword
Medscape
an hour ago
- Medscape
PCPs Guide to Prescribing Blood Thinners for AF
As a primary care physician (PCP), you're often the first healthcare professional that will identify cardiac issues, including atrial fibrillation (AF). Individuals with AF face a fivefold risk for stroke. Therefore, these patients are often prescribed blood-thinning medications (anticoagulants) to slow blood clotting, according to the American Society of Hematology (ASH). Up to six million Americans have AF, the risk for which increases with age. The ASH says there are 450,000 hospitalizations each year because of AF. It's very important to check on your patient's response within the first few months of taking blood thinners. In fact, patients with AF who took low doses of oral anticoagulants experienced a higher incidence of bleeding episodes during the first 3 months of treatment, according to a study published in Blood Advances . When Should PCPs Prescribe Anticoagulants? PCPs should consider prescribing oral anticoagulants when they are the principal caregivers for patients with AF, acute deep venous thrombosis, or acute pulmonary embolism, according to R. Michael Benitez, MD, a cardiologist at the University of Maryland Medical Center and a professor of medicine in the Division of Cardiovascular Medicine at the University of Maryland School of Medicine in Baltimore. The decision to prescribe an oral anticoagulant must be based upon the patient's risk without anticoagulation weighed in context with the patient's risk for significant bleeding, he said. How Can Physicians Best Communicate the Rationale for Anticoagulant Therapy? When describing AF, PCPs can explain to patients that the upper chamber of heart is 'wiggling' and not effectively contracting and when blood is not being effectively moved forward, it tends to clot, said Benitez. Physicians can also share that a clot as small as 2 mm is large enough to cause a major stroke if it were to break loose from the inside of the top chamber and be pumped with the blood to the brain, suggested the cardiologist. 'The oral anticoagulant greatly reduces the risk of the formation of these blood clots and subsequent stroke,' Benitez said. 'Stroke is a terrible event that, if survived, often changes a patient's life permanently and significantly. In the setting of atrial fibrillation, anticoagulation greatly reduces the patient's risk of stroke.' Regarding deep venous thrombosis, physicians can explain that a blood clot in the leg veins could break loose and be pumped through the right side of the heart to the lungs. 'This event, pulmonary embolism, can cause critical illness or even death; the risk can be greatly reduced through the use of oral anticoagulants,' said Benitez. What Are Important Directives Regarding Usage? PCPs should stress that daily use is critical to the success of the drug in preventing stroke. 'In the case of the new direct oral anticoagulants, such as apixaban or rivaroxaban, the drugs both work very quickly but also wear off very quickly,' said Benitez. 'This means that even missing just 2-3 days is enough for the blood to again clot normally. It is essential that the drugs be taken daily to prevent stroke.' In the case of warfarin, the effect of the drug is more prolonged. While missing a single dose is unlikely to markedly change the degree of anticoagulation, it's still best to remind patients not to miss doses and take this daily as prescribed, according to Benitez. What Side Effects Should Be Discussed? It is extremely important with warfarin — and to a lesser degree with direct oral anticoagulants — to always make certain that there is no drug-drug interaction that might affect the degree of anticoagulation when new medications are introduced, such as antibiotics, said Benitez. Other side effects to bring to a patients' attention are minor bleeding (such as gum bleeding with dental flossing) or nose bleeds that stop easily, which don't require immediate medical attention. However, your patients should self-monitor bleeding episodes and know a course of action if injured. 'If bleeding will not readily stop then medical attention is needed, and patients who incur major injury or trauma are likely to be taken to an emergency facility where it is important for the staff caring for them to know what anticoagulant they are taking, the dose, and when they last took it,' Benitez said. 'Reversal agents are now available to normalize blood clotting.' Your patients may be concerned with food that could interact with these medications. Benitez said there are no significant food interactions or dietary restrictions. But when prescribing warfarin, some nutritional guidance is warranted. 'With warfarin, which is a vitamin K antagonist, it is essential that the patient limit their intake of food containing vitamin K, as it is essentially an antidote or reversal agent for the anticoagulant,' he said. Some sources of vitamin K are well-known, such as leafy vegetables like spinach, kale, and other greens. However, there are many other dietary sources rich in vitamin K that may not be as obvious, such as cauliflower and soy products, Benitez said. 'It is important for the patient to familiarize themselves with vitamin K-containing foods and to keep the intake of them low and steady from day to day if they are taking warfarin,' he said.
Yahoo
an hour ago
- Yahoo
Could a single shot at birth shield kids from HIV for years?
There's potentially exciting news from a trial conducted in monkeys: A single shot of gene therapy given to newborn monkeys appears to shield them from HIV, the virus that causes AIDS, for at least three years. Of course, studies conducted in animals don't always pan out in humans. But scientists say that if it does, it could save the lives of babies and children still imperiled by HIV. The study authors estimate that more than 100,000 children worldwide (largely in subSaharan Africa) are believed to contract HIV soon after birth, primarily via breastfeeding with an HIV+ mother. "Nearly 300 children are infected with HIV each day," said lead author Dr. Amir Ardeshir, associate professor of microbiology and immunology at the Tulane National Primate Research Center in New Orleans. "This approach could help protect newborns in high-risk areas during the most vulnerable period of their lives." His team published its findings July 30 in Nature. It noted that the new work hinges on the notion that in the first few weeks of a primate's life -- humans are primates, too -- the body's immune system is naturally more tolerant of "invaders," including gene therapies. The research focused on a tried-and-true form of HIV-fighting gene therapy. It works by programming cells to continuously produce HIV-fighting antibodies. The gene therapy was piggybacked onto a harmless adeno-associated virus (AAV) to help deliver it to the muscle cells of newborn rhesus macaques. Muscle cells were chosen because they are particularly long-lived, Ardeshir's team explained. The gene therapy instructs these cells to produce broadly neutralizing antibodies, or bNAbs, which are capable of neutralizing multiple strains of HIV. It's not the first time bNAbs have been used in gene therapy to fight HIV. However, in prior trials repeat injections were required to keep the immune system vigilant. In the new trial, "we turn these muscle cells -- which are long-lived -- into micro factories that just keep producing these antibodies," Ardeshir explained. When such an approach is used in older monkeys, however, the animals' robust immune systems turn against the therapy, shutting it down. That didn't happen when Ardeshir's team introduced it during a macaque's first few weeks of life. All of the monkeys who got a single shot of bNAbs therapy soon after birth were shielded from infection with HIV for at least three years, with no need for a booster. Tulane researchers said that's roughly the equivalent of a treatment that could ward off HIV in humans deep into adolescence. If the gene therapy was delivered even a bit later -- 8 to 12 weeks after birth -- the young monkey's more developed immune system swung into action to fight it, eroding its effectiveness. Giving the shot soon after birth seemed key, Ardeshir said. "This is a one-and-done treatment that fits the critical time when these mothers with HIV in resource-limited areas are most likely to see a doctor," he noted in a Tulane news release. "As long as the treatment is delivered close to birth, the baby's immune system will accept it and believe it's part of itself." Will it work in human babies? That's not entirely clear, since it's possible infants might be less amenable than monkeys to therapies that are delivered via AAV, the team said. The monkey trial also used only one strain of simian-human immunodeficiency virus, which is similar in some ways to HIV but may not reflect the variety of circulating strains of HIV strains. Still, the research team is hopeful. Giving families a one-shot preventive tool to protect their children would be especially useful in areas where access to repeat medical treatments can be tough, the researchers said. "Nothing like this was possible to achieve even 10 years ago," Ardeshir said. "This was a huge result, and now we have all the ingredients to take on HIV." More information Find out more about HIV and AIDS at the U.S. Centers for Disease Control and Prevention (CDC). SOURCE: Tulane University, news release, July 30, 2025 Copyright © 2025 HealthDay. All rights reserved.
