you are an intensivist in an institution that performs solid organ transplantations . in an effort to provide patients and families with increased opportunities to donate their organs ,
the institution has recently developed a policy for donation after cardiac death ( dcd ) . with the new dcd policy , organ donation
is offered to patients and their families in a controlled setting when death occurs immediately following the withdrawal of life - support . based on your understanding of organ donation , you are aware there are certain medications ( for example , inotropes to maintain tissue perfusion ) and certain management practices that may allow the donated organs to have better outcome .
you wonder about the ethics of starting interventions that will have no benefit to the dying patient but will benefit the organs that are about to be donated .
jason phua and tow keang lim what medications and interventions are started in potential donors before death for the sole purpose of making the organs more viable in dcd , and how do they affect organ function ?
firstly , inotropes and vasopressors are crucial for the preservation of organ perfusion in patients in shock .
the majority of potential donors are hypotensive before cardiac death , and hypotension worsens graft function .
secondly , anticoagulants such as heparin decrease the risk of thrombosis after the circulatory arrest and the negative consequences on organ function . to maximize effectiveness , heparin
thirdly , vasodilators such as phentolamine may enhance organ blood flow and lower the incidence of delayed renal graft function .
more controversial practices are the administration of thrombolytics and antemortem cannulation in preparation for the administration of cold preservation solution . although rarely performed in europe , these practices are endorsed by major american and canadian transplantation and ethical guidelines [ 3,7 - 9 ] . indeed
, most american dcd centres consider heparin administration at the time of withdrawal of life - sustaining treatment as the current standard of care .
the acceptability of these practices should be evaluated according to beauchamp and childress ' four moral principles . as far as beneficence
is concerned , none of these practices benefit the donors , at least not physically , since they will die regardless of the treatment provided .
most of the opposition to these practices , however , stems from the second principle of nonmaleficence .
there is concern that anticoagulants and thrombolytics may cause bleeding and that vasodilators may cause hypotension  and therefore hasten death .
nevertheless , there is no evidence that heparin leads to sufficient bleeding after the withdrawal of life - sustaining therapies to cause death .
the guidelines , however , do state that heparin should only be used in patients with low bleeding risks , and phentolamine should only be used in patients without significant hypotension . the most important moral principle in dcd , however , is arguably that of autonomy .
if the potential donor or his / her designate gives informed consent for these organ - preserving measures with a clear understanding of their possible side effects , who are healthcare professionals to object ?
critics point to the lack of large randomized controlled trials to validate these measures . as the data available
are very suggestive , however , while we await these trials ( which may never be performed ) the onus is on us to institute these measures to prevent any organs from going to waste .
this is all the more crucial when one considers the last moral principle of justice , and the fact that these organs are a scarce resource . to conclude
, we believe that starting certain medications and interventions such as inotropes , vasopressors , heparin and phentolamine in potential donors for the sole purpose of making the organs in dcd more viable is an acceptable practice , provided they are used in patients with a low risk for side effects and that informed consent is provided .
david a zygun and christopher j doig the ethical principle of the ' rule of double effect ' provides moral justification for the provision of certain forms of care at the end of life that result in death .
a practical example of this principle is the use of narcotics for pain relief , although respiratory depression and death are potential consequences .
application of this principle requires all four conditions to be met : the act must not belong to a category of acts considered evil ; the good effect ( for the patient ) , and not the bad effect , must be intended ; the bad effect must not be a means to the good effect ; and there must be a proportionally good reason for bringing about the bad effect . this principle has also been used to justify antemortem interventions in dcd , but do these interventions meet these necessary elements ?
the benefit of dcd is primarily to organ recipients and society [ 13 - 15 ] .
this is evident in the published literature , where the common justification for dcd is to increase the supply of organs .
furthermore , the organ most likely to be recovered in dcd is the kidney , which will result in significant cost savings to healthcare systems by removing a patient from dialysis .
although there are some data that families may gain benefit from dcd , such as avoidance of delayed regret for missing the opportunity to donate organs   or the desire that donation will ease their grief , these reasons are also not for the benefit of the patient .
is there potential harm to the donor ( a hastening of death as a primary consequence ) ?
most dcd donors are individuals with neurological injury , and heparin poses more than a theoretical risk of precipitating or exacerbating intracranial haemorrhage and hastening death .
phentolamine , a potent vasodilator , may precariously decrease blood pressure and hasten haemodynamic collapse in any icu patient , and would be particularly harmful in a patient with impaired cerebral autoregulation .
there are other interventions that might also be considered , such as intravenous fluid administration to maintain urine output ( would this be acceptable if the patient has concomitant hydrostatic pulmonary oedema ? ) .
simply , none of these interventions would be reasonably provided outside the setting of dcd , all are credibly associated with potential harm to the dying patient , and the perceived benefit of dcd may be directly gained through the harm caused ( a more rapid death ) .
the principle of ' double effect ' is suggested as an appropriate ethical framework to support antemortem interventions in dcd donors .
the requisite elements of this principle are not met , and this principle can not be used as a moral justification . as such , antemortem interventions with a risk to harm
the patient violate the moral duty to ' first do no harm ' , and should not be condoned . finally , invoking the principle of double effect places this principle in jeopardy as a reasonable justification for many appropriate interventions in palliative care treatment ; if this principle is brought into disrepute , it may be harmful to palliative care patients , society and the practice of medicine .
jason phua and tow keang lim some argue that by facilitating a successful dcd such antemortem interventions benefit the donor by fulfilling his / her wishes , benefit the donor 's family by easing their grief , and benefit the recipient .
we propose that instead of focusing on this doctrine , these interventions should be evaluated according to beauchamp and childress ' moral principles .
we reiterate that any bad effects of heparin and phentolamine must not be exaggerated without medical evidence .
these interventions benefit dcd by improving organ viability , not by causing ' a more rapid death ' .
david a zygun and christopher j doig violation of the principle of beneficence has been acknowledged . with nonmaleficence ,
absence of evidence of harm does not equal proof of absence of harm ; the incidence of harm from heparin is credible and has not been systematically examined .
a standard of practice to use heparin without good clinical evidence of benefit and lacking measurement of potential harm is not a credible argument .
most potential dcd candidates are not competent to consent . families as proxy are not acting in the patient 's autonomous interest in consenting to treatment that will not benefit and may harm the patient , irrespective of benefit of family or another third party ( society , organ recipient ) .
importantly , the statement ' they will die regardless of the treatment ' is not factual .
finally , justice requires an equal share of not only benefits , but also of burden .
given premortem intervention requires the dying patient to solely bear the burden ; justice can not be elicited to support such interventions .
 several hospitals have been developing programmes for organ donation after cardiac death . 
 such programmes offer options for organ donation to patients who do not meet brain - death criteria but wish to donate their organs after withdrawal of life - support . 
 these programmes also increase the available organ pool at a time when demand exceeds supply . 
 given that potential donors are managed in intensive care units , intensivists will be key components of these programmes . 
 donation after cardiac death clearly carries a number of important ethical issues with it . in the present issue of critical care 
 two established groups debate the ethical acceptability of using medications / interventions in potential organ donors for the sole purpose of making the organs more viable . 
 such debates will be an increasingly common component of intensivists ' future practice . 
The scenario
Pro: Antemortem interventions to improve organ viability in donation after cardiac death are acceptable
Con: The intended unintended and the principle of double effect
Pro's response: Involve Beauchamp and Childress' moral principles, not the doctrine of double effect
Con's response: The four tenets  out of tune
Abbreviations
Competing interests