Brain Death & Organ Transplantation Ethical, Legal & Social Issues

- Dr.Sunil Shroff, Dr.Sumana Sundaram

• Money or organ exchange
• Organ Donation & Loan Sharks
• Destitute Donation
• Gracious Act with Aftershocks
• Hang or Harvest
• Marriage Squabbles
• The Belligerent Family

Case 1: Money or Organ Exchange

40 years old on 2 wheeler with unprotected head injury. On the spot GCS 12/15 rapidly progressing to 4/15 on arrival to casualty. Emergency craniotomy failed to improve patient's condition. On day 3 GCS was 2/15 with total absence of brainstem function on 2 examinations 6 hours apart.

Patients has a young wife and a son who is 8 years old. Wife is told about brain death. After some hesitation ICU Social Grief Counselor talks to wife about possible organ donation. She first refuses but subsequently agrees on her own accord. Preparations are made for retrieval surgery. 30 minutes before surgery wife desires money in exchange of organs! Every one is surprised and taken aback!!

Questions for Panel members and Audience:

1. How does one proceed ?
2. When told that this is not legal and not right she withdraws her demand for money, would you still proceed withretrieval surgery?
3. Should there be provision in THO Act for indirect benefits to donor families and if so what?

What actually happened -

The hospital authorities decided to abandon efforts to retrieve organs as they felt the wife was too emotionally disturbed to take a decision about organ donation.

Some of the doctors were upset with the decision, but in the interest of the cadaver programme majority went with the decision of the hospital authorities.

There was some sympathy with how the wife felt about livelihood and future of her minor son.

Case 2: Organ Donation & Loan Sharks

A 30 years old female from lower middle class wants to donate her one kidney. On being dissuaded - She says that her family has borrowed Rs.50,000/- from a loan shark and if they don't pay the loan he is threatening to harm the family? She wishes to be compensated for this amount after donation?

Questions:

1. The case goes to authorization committee and committee is made to believe that she is a servant working in the house and donation is out of true affection for her master. False story discovered by hospital social worker. What action should be taken by hospital authorities?
2. Authorisation committee having cleared the case, the recipient requests that doctors should proceed with surgery otherwise wants to appeal to high court. How do you tackle situation?

What actually happened -

The hospital authorities and the ethical committee decided not to proceed with this transplant in the circumstances that were revealed.

It wrote a letter to authorisation committee in confidence informing about the outcome. No other action was taken. Some of the treating doctors were not happy with the decision.

Case 3: Destitute Donation

A 17 years old unmarried girl from a destitute home is admitted to local hospital in a state shock. There is a vague possibility of an early abortion 2 weeks previously but no evidence is available. Her condition gradually worsens and she slips in a state of irreversible coma requiring ventilatory support. She is declared brain dead after 3 days of ICU care. The social worker in-charge of destitute home is keen that the hospital should proceed and retrieve her organs?

Question:

Are there any legal problems envisaged if organ donation takes place?

What actually happened?

The hospital authorities felt there was no legal problem. The history of abortion was not substantiated by clinical findings, hence it allowed organ donation to proceed.

On Laparotomy incision however she was found to have ascites associated with multiple nodularity, a diagnosis of Tuberculosis was made. This had alluded the clinicians pre-operatively. Retrospectively it was felt she had slipped into a state of irreversible coma followed by brain death from this condition. Only eyes were retrieved.

Case 4: Gracious Act with Aftershocks

Six members of a family involved in an RTA are brought to a local hospital. The husband and wife are admitted to ICU with head injury.

Two members of the family are declared dead after failed resuscitation in casualty. The eldest son - 24 years and his sister - 26 years escape with minor scalp injury.

On day 5 the mother is declared brain dead and the father recovers and is shifted to the ward, however he is not in the best of mental state.

The son and daughter request the doctor not to disclose details to the father about their mother's condition. They also wish to donate her organs before the ventilators are switched off. Organ donation proceeds successfully.

After about 8 months the hospital receives a legal notice from lawyer. The father sues the hospital for taking organs of his wife without his consent and making money in exchange of organs, he also demands a veiled compensation to settle the case out of court.

Questions:

1. Were the doctors right in proceeding with the organ donation without consent of husband?
2. Has the case any legal implications?

What actually happened -

The retrieved organs were shared among three different hospitals. The lawyers were consulted and it was decided to send a polite reply to the husband explaining about the circumstances and how the organs were shared among different hospitals and the renewed lease of life it had given to five different people. The THO act copy was also enclosed to clarify that it was illegal to demand any compensation for organs.

The consent was perfectly legal under the circumstances as the son was the only legal next to kin available at that time. No reply was received and the case died a natural death.

Case 5: Hang or Harvest

18 years old female recently married was brought to casualty in an unconscious state on a Saturday morning during the last general elections weekend. She had been married for 18 months. She was hypotensive (70/50) and unresponsive. She was found by relatives hanging in the bedroom. Resuscitated and ventilated for 2 days. She was declared brain dead on day 3. Family members agreed for organ donation.

Questions:

1. Will you proceed with the request to harvest the organs?
2. What are medico-legal implications if any?

What actually happened -

Under the Indian Penal Code - Any cause of death in a women that is unnatural and that which happens within seven years of marriage should be considered a homicide unless proved otherwise.

The request for organ donation was put on hold and the Police were contacted. The Forensic dept was consulted and they informed that if the Tahasildar or Magistrate of the area consented, organ donation could still proceed if the organs were not required for Forensic purposes.

Repeated attempts at contacting the authorities failed due to General Elections and efforts to obtain organs were abandoned.