HODS Rabbis & Physicians Seminar
Albert Einstein College of Medicine
[Part 4: 13 minutes 58 seconds]
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So we talked about in this conference over the last two days brain death, what organs can be donated from a brain dead individual. An important dimension which you shouldn’t leave tonight without is appreciation of at least the notion of the donation after cardiac death. Some of the myths about donation after cardiac death and some of the real genuine ethical and halachik concerns about donation after cardiac death. So before the neurological criteria for death were established in the 1960’s and 70’s non- heart beating donation was the only source of cadaveric donation. This, many people don’t realize. So the, I forget when what the year of the Harvard criteria was, 68?
Someone from the crowd says 68
68 was the Harvard criteria. So in the early 60’s and 70’s before that criteria became popular organ donation was occurring. It was occurring from cadaveric donation from non-heart beating donors. And the ethics committee of the society of critical care suggests that the required elements of, criteria for the cardiac-pulmonary death are simultaneous and irreversible. So what is cardiac death? I think we all know what cardiac death is; unresponsiveness, apnea, lack of breathing, and absent circulation. Which organs can be procured in donation after cardiac death? Now just to share with you, this is important, (that slide) in terms of terminology, the original terminology was non- heart beating donation the synonym for that has been replaced by donation after cardiac death which is called, like physicians are fond of putting acronyms to everything, it’s called DCD. So DCD refers to donation after cardiac death. Tissue donation, corneas, heart valves, skin and bone, has always been possible from non-heart beating donors. And I don’t suspect you discussed a lot about skin and bone donation, probably more focusing on the vital organs hearts, livers, lungs, and kidneys. You can see you can spend two days on one topic and still have a wealth of information that hasn’t been covered. Just gives you an idea of the complexity of the field of medical Halacha.
Many centers have now established programs for kidney transplants from such donors, a few centers have also moved into non-heart beating donor liver and lung. This, I just want to share with you, this is called the restrict classification, I’m not fond of classifications in general but it’s very straightforward very simple. It tells you the different types of people that can donate after their hearts have stopped beating. And this is essential to differentiate between the very controversial ones and the completely uncontroversial ones and the completely non-halachically problematic ones. So the first one is when a patient is brought in dead from the outside. Somebody who has cardiac arrest outside may or may not have, actually in this case probably has had no resuscitation, successful resuscitation was not picked up by EMS simply presents to the hospital dead on arrival. Number 2, classification 2, is unsuccessful resuscitation. So somebody who is brought in by EMS doing chest compressions working on him for 10 15 minutes but the effort has been unsuccessful. Number 3, and this is perhaps the most controversial and the one that almost everybody identifies with this category of DCD and donation after cardiac death, is awaiting cardiac arrest. Now everyone in this room is awaiting cardiac arrest, shouldn’t be until 120 years. But what is the context here? The context here is, and Rabbi Flaum addressed this and one of the questions was asked about end of life issues and withdrawing of care he discussed the Shvut Yaakov and the Beis Yaakov. The issue here, the context here, are cases where a patient is either on, usually on life support but is not brain dead, no brain death here whatsoever just somebody who is very critically ill, and the family decides or the patient had expressed wishes that they want life support withdrawn. The expectation is, and the expectation isn’t always met, that once life support is withdrawn that patient will sustain complete brain and cardiac death, primarily cardiac death. So in the absence of removal of, this, of the respirator the person could continue for whatever period of time, but the family decided on Tuesday at 3:00 we will be removing the respirator, once we remove the respirator within a relatively short period of time the heart will stop beating, we will notify the transplant team that we are going to be removing the respirator at that time, the transplanting will be on standby. Once death is diagnosed as absence of heart beat, for whatever period of time they choose, then they will come in and transplant the heart. That is the most, one of the issues which is the most contentious and has evoked a lot of discussion in the medical ethical and lay population. Number 4 is cardiac arrest after brain stem death
Question: is it successful?
So I’ll talk about how, what things can be successful, which organs can be successfully transplanted
Number 4 is cardiac arrest after brain stem death. So that’s a case where someone has sustained diagnosed 100% brain death then you remove the respirator from that person, and then their heart stops beating. And that, which may have come up in the discussion, gets something which Rav Shlomo Zalman discussed to some extent about the possibility of removing the respirator from a brain dead individual, allowing their heart to stop and then having the organs transplanted subsequently. There are debates about whether he rescinded or didn’t rescind to that. Be that as it may definitely something that was a theoretical possibility in the position of Rav Shlomo Zalman. In the 4th one which is a new category, cardiac arrest in a hospital inpatient. So that is somebody who is in the hospital for a variety of reasons but has, sustains a cardiac arrest in the hospital. So he’s in a medical environment where they can attend to him immediately after cardiac arrest.
So the reason why this whole category and topic is important is because the halachik organ donor society has 2 options; has an option of heart beating donation and non- heart beating donation. So what is that, what is the practical application of the non-heart beating donation part of that donor card? So obviously the applications are not as broad as the brain death criteria because brain death you can donate a whole host of organs which you may not necessarily be able to donate from a cardiac death. But in cardiac death there are still organs that can be donated, and lives that can be saved.
Categories 1 and 2, so those that come from outside the hospital, are called uncontrolled donation
Categories 3 to 5 are called the controlled donations. So only tissues can be taken from category 1 donors. So someone who is brought in dead from the hospital outside with no EMS, there’s nothing that can be donated from that person except tissues, which includes heart valves, bone, and skin.
Kidneys can be used from category 2 donors which is an unsuccessful resuscitation, which means if someone has a cardiac arrest rachmona litzlan (G-d forbid) at home gets an EMS comes you know shortly after the cardiac arrest and they brought him to the hospital with EMS performing resuscitation and it’s unsuccessful resuscitation and the person is diagnosed as cardiac dead in the emergency room, kidneys can be harvested from that person. So that’s an important thing even so if you don’t accept in theory the concept of brain death as halachik death there are still options which are not oft exercised, but options to serve as a donor as well. All organs except the heart can be potentially used from category 3, 4 and 5. So that means lungs, livers, kidneys, and heart, and I don’t know if this came up in discussion in medical discussion but for hearts it’s the shortest longevity time once they’re removed from the body, it’s only about 4 hours. So those still aren’t being transplanted. So these are guidelines which the UNOS has put forth; they say “it is ethically acceptable and appropriate to recover organs after cardiac death”. This is the important line, “the use of DCD donors presents certain risks in terms of the perceptions of the public and of health professionals”. And that’s the issue specifically of removing life support and then doing the organ transplant. “These risks are shared not only by the clinicians employing such protocols, but ultimately by the transplant system as well. Transplant professionals involved in DCD protocols must be sensitive to such issues and concerns.” So what are the halachik issues, and with this we’ll close…
Question: What could be good for a heart, you said?
Rabbi: None, none of them are good for heart. Maybe…
Question: But you said they call in a team and they say that at 2:00 they’re going to stop the, take the person off life support.
Rabbi: Oh yeah I’m sorry 3 can be good for heart, I apologize, right 3 can be good for all organs.
Another man: You said there’s a four hour
Rabbi: Yeah a 4 hour time limit. But even that, as well see in a…actually we won’t get to it but I’ll share with you briefly, hearts is debated whether they should use it because hearts need to be profused the longest. So people are very hesitant to harvest hearts even when they’re standing at the bedside and the patient is pronounced dead, and there’s a debate about whether the success rate from those is as good as a heart donation from a non-heart, from a brain dead donor.
So what are the halachik issues? So if the patient is brought in dead then you invoke the classic issues really similar to the autopsy issues, the famous Noda B’Yehuda and also the Chasam Sofer as well in this, whether you can violate the prohibitions and obligations that relate to the dead body in order to save a life, in order for פיקוח נפש (saving somebody’s life). So we have an obligation to burry, we have a prohibition desecrate, we have a prohibition to derive benefit from the body, but we have an obligation to save somebody’s life, so those you would engage in that discussion and that’s a relatively straightforward discussion which has been discussed for century upon century that for פיקוח נפש (save someone’s life) you could violate the body. Now you probably would want to do it in the least halachikally least offensive fashion, so have a surgeon very delicately remove the kidney and transplant the kidney, but it could theoretically be done. And I should hasten to add here I haven’t seen very specific discussions in the פוסקים (halachic deciders) about these issues so my halachic analysis is really a clarification of halachic issues. פוסקים (halachic deciders) have not discussed very extensively modern application of halachik donation after cardiac death. Unsuccessful resuscitation all the same, but the main issue is awaiting cardiac arrest; it’s these patients in whom life support has been removed voluntarily. And I’m actually just in the interest of time, I’ll, rather than read through these slides, I’ll just say one phrase for each one of these slides. The main issue is, well there’s two issues, one is would Halacha allow the treatment to be withdrawn? So if it’s a patient that’s a Jewish patient that observes the Halacha, would Halacha allow treatment to be withheld or withdrawn, the respirator to be removed? So the answer to that question is it obviously depends on the circumstance. In the overall majority of the cases life support generally or respirators generally are not removed. Rav Chaim David HaLevi, as Rabbi Flaum mentioned in his discussions, is famous for saying that one could remove a respirator. They are working in ארץ ישראל now to create respirators that have timers to facilitate the halachikally appropriate way to stop the respirator without physically removing the respirator and not necessarily have to reinstitute or reinitiate the respirator. So there could theoretically be circumstances where it would be halachically permissible to have a patient for whom life support or respirators could be removed and a surgeon could come in and do the transplantation. But what is the potential halachic problem? The problem is that to facilitate transplantation after the heart stops, the transplant community gives certain medicines or puts in or does certain procedures on the individual before they die, before they’re diagnosed as dead. So they’ll give them a medication called Heparin to stop from blood clots, they’ll give them, they’ll put in the big tube the big plastic tube into the arteries or vain so they can provide whatever fluids are needed. These things could potentially be halachically objectionable because they can, hast, theoretically hasten the death of the individual without being of any specific benefit to the individual. And just to close, this is a…2 more slides…this is showing the percentage of donation after cardiac death which has increased, it’s just the pink part, it’s increased from 1995 to 2004, so there’s definitely been a push and that’s because there simply aren’t enough organs being provided and there are thousands of people that are, 96 thousand people probably on the list currently and many people dying every day on that list so there’s been a big push to increase donation after cardiac death. And this is just an evaluation, as you said about whether hearts can be donated, it’s an ongoing analysis and assessment in the community about whether these organs are as viable and transplant as well and the success rate is as good, and like everything else in the world of medical Halacha it needs ongoing discussions with the physicians and the doctors which has been the objective of this wonderful conference over the last few days. And this is just one issue of a two day conference to give us a great appreciation of the complexity and the beauty of Halacha not only in its diversity but in its ability to approach the most interesting current up to date and complex topics in the world of science and Halacha. Thank you very much.