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• Burden of organdonation after euthanasia: better exclude it than reduce it
  Johan PC Sonneveld, Johannes GH Mulder
  Published on: 30 September 2022

• Published on: 30 September 2022

  Burden of organdonation after euthanasia: better exclude it than reduce it

  • Johan PC Sonneveld, anesthesiologist-intensivist Isala Zwolle
  • Other Contributors:
    • Johannes GH Mulder, general practitioner

  Maes et al suggest that the burden of organdonation related issues in organdonation after euthanasia (ODE) patients is well tolerable or may even be neglegible. They present two cases with untreatable psychiatric disorders who requested for euthanasia and expressed their deathwish to combine with postmortal organdonation. The burden relates to the patient, his family and the professionals involved in euthanasia. They propose that all psychiatric patients whom euthanasia is granted should be informed about the possibility of postmortal organ donation(1).
  First, we state that the burden can even be minimized further: it is not necessary for the patient to have his euthanasia performed in the hospital. These patients can be given the sense of dying at home and transported thereafter using an anesthesia bridge to the hospital, as we have shown to be feasible(2).
  Second, it is not fair to use the experience of these two evident highly for ODE motivated psychiatric patients and their families as a reference for comparable euthanasia patients who are unaware of the option of post mortal organdonation.
  But third, of perimount importance, we criticize the opinion that the amount of burden for ODE patients may reach a point to be neglegible. In our opinion this burden should not be minimized, but excluded. The suggestions of Maes et al are motivated by utilistic ethical considerations and the existence of waitinglists for transplantation. The act of organdonation h...

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  Maes et al suggest that the burden of organdonation related issues in organdonation after euthanasia (ODE) patients is well tolerable or may even be neglegible. They present two cases with untreatable psychiatric disorders who requested for euthanasia and expressed their deathwish to combine with postmortal organdonation. The burden relates to the patient, his family and the professionals involved in euthanasia. They propose that all psychiatric patients whom euthanasia is granted should be informed about the possibility of postmortal organ donation(1).
  First, we state that the burden can even be minimized further: it is not necessary for the patient to have his euthanasia performed in the hospital. These patients can be given the sense of dying at home and transported thereafter using an anesthesia bridge to the hospital, as we have shown to be feasible(2).
  Second, it is not fair to use the experience of these two evident highly for ODE motivated psychiatric patients and their families as a reference for comparable euthanasia patients who are unaware of the option of post mortal organdonation.
  But third, of perimount importance, we criticize the opinion that the amount of burden for ODE patients may reach a point to be neglegible. In our opinion this burden should not be minimized, but excluded. The suggestions of Maes et al are motivated by utilistic ethical considerations and the existence of waitinglists for transplantation. The act of organdonation however is a pure altruistic one, and in the face of the ultimate choice to end one’s life incompatible with any utilistic view.
  Any suggestion of organdonation to an euthanasia patient, irrespective of the underlying disorder making him to choose his own death, compromises his freedom of an eventually irrevocable and irreversible choice to end his life.
  Also the treating physician should be free of any coercion during the whole project of ODE and moral pressure beyond the relationship with the (euthanasia) patient; this excludes even the suggestion for a potential organdonation.
  From the first international round table conference on ODE, we became aware of the moral conflicts of healthcare providers experienced in Canada in their practice to ask euthanasia patients to consider organdonation who were not aware of this possibility, which appeared far from a neglegible burden(3). We also know from the practice in the Netherlands that healthcare professionals at the ICU experience an increasing personal burden after multiple ODEs, especially in cases of psychiatric patients.
  Using the donor registry as an opportunity to bring up the issue of organ donation in case of euthanasia does not resolve the intertwinement. It is of note that the donor registry has never been designed to be used in the context of ODE. ‘Shared decision making’ also does not mean that interests of transplant recipients need to be considered by euthanasia patients.
  We conclude that the altruistic deed of an ODE patient should be safeguarded against any external driven interests and coercion, while at the same time healthcare providers shape the conditions that the wish to donate will be fulfilled.
  The awareness of ODE will gradually grow via social media, internet and patient platforms. There is no alternative. Most important is the separation of interests to be hold. In the extremely vulnerability of ODE, society should have no doubts that healthcare professionals, as founded in constitutional legislation, first of all seek anyone’s integrity of life, mind and person. This priority should never be compromised by any interests of others. Intertwinement of these interests may eventually further harm the challenges in ODE and post mortal organdonation in general, than it may help to reduce waitinglists for transplantation.

  1. Maes G, Oude Voshaar R, Bollen J, Marijnissen R. Burden of organ donation after euthanasia in patients with psychiatric disorder. BMJ Case Rep. 2022 Jul 4;15(7):e246754. doi: 10.1136/bcr-2021-246754. PMID: 35787499.
  2. Mulder J, Sonneveld JPC. Organ donation after medical assistance in dying at home. CMAJ. 2018 Nov 5;190(44):E1305-E1306. doi: 10.1503/cmaj.170517. PMID: 30397157; PMCID: PMC6217602.
  3. Mulder J, Sonneveld H, Healey A, Van Raemdonck D. The first international roundtable on "organ donation after circulatory death by medical assistance in dying" demonstrates increasing incidence of successful patient-driven procedure. Am J Transplant. 2022 Mar;22(3):999-1000. doi: 10.1111/ajt.16879. Epub 2021 Nov 6. PMID: 34706144.

  Answer by Marijnissen et al,

  We thank Sonneveld and Mulder for their thoughtful comments and an opportunity to provide additional explanation to our paper 1. Sonneveld and Mulder argue that the burden of ODE should be fully excluded instead of being reduced as much as possible. In our opinion, however, excluding the patient burden completely in these delicate situations is impossible.
  Nevertheless, somewhat paradoxically, the authors suggest that the burden of ODE can be reduced based on the possibility of letting people say goodbye to loved ones at home, after which they are transported to the hospital under anaesthesia. This assumption that saying goodbye at home will reduce burden however does not apply automatically for all patients and their loved ones. For example, the described opportunity has been openly discussed with the first patient some weeks prior to the ODE was performed and afterwards with the family of the second patient. However, they considered the burden of performing this procedure at home higher than saying goodbye in the hospital, as they preferred to accompany their loved ones to the ODE procedure in the hospital as well as when they actually die. This reflects, however, very personal views, which should always be considered and why in our opinion shared decision making is so important.
  Sonneveld and Mulder also nuance our conclusion ‘that the burden can be minimal after ODE’ is based on two patients highly motivated for ODE’. Case-reports present by definition highly selective cases, but are important for the discovery of new ideas, for education in rare diagnoses or exceptional situations, and, as in our case, to challenge widespread believes.3 We wanted to inform other health care professionals about the possibility of organ donation after euthanasia in these patients, and its positive consequences – arguing that ODE is not necessarily or merely a burden to every patient.
  We are a bit surprised that these authors feel it is better that patients are informed about ODE through social media than by their physician, who knows them best and who can provide correct and nuanced information. The report of the limited round table conference only advertises ODE with anesthesia initiated at home (ODEH) and talks about a ‘patient ‐driven process’, but how can this be patient-driven if the patient is not aware of the possibility of this procedure? Furthermore, by only focusing on avoiding an act in the interest of the transplant waiting list (which is not the way we see ODE), the authors forget to act in the interest of the dying patient by ignoring potential altruistic motives. Physicians are responsible to provide information about all possibilities a patient has, making shared decision possible – only then we can speak of an “irrevocable and irreversible choice to end his life” and “integrity of life, mind and person”. We however do not challenge that informing a patient about ODE is a very sensitive matter, because of which the registration as an organ donor might be a good starting point for this patient-physician discussion. Recently, a Dutch medical disciplinary committee judged that informed consent is also necessary when physicians decide not to perform a surgery, which demonstrates that withholding a medical act causes a burden for both patients and relatives. In other words, irrespective of whether patients chose for ODE or not, the burden of ODE can never be fully excluded. Nonetheless, more research is needed on the best way to introduce and implement ODE, probably especially in a patient with a psychiatric disorder, to minimize the burden.
  Our case report on the burden of organ donation after euthanasia in patients with a psychiatric disorder was not aimed to state that the burden of ODE is low in general. Instead, it was meant to give the perspective that a doctor may do the patients short when he or she avoids discussing ODE based on the assumption that it may be too burdensome for them. Nonetheless, we fully agree that the burden for professionals working at the ICU can be substantial and this burden also involves professionals informing patients about the possibility of organ donation during a trajectory for euthanasia 4. We fully agree with the authors that patients should always be prevented from feeling pressure to donate their organs. To this end, our protocols (and laws) state that both procedures should independently be performed by different teams. The best way and timing of discussing all possibilities with patients is probably highly personal and require further study how to optimize the procedures of ODE from both a patient and doctors’ perspective beyond expert opinion.

  References
  1. Maes G, Oude Voshaar R, Bollen J, Marijnissen R. Burden of organ donation after euthanasia in patients with psychiatric disorder. BMJ Case Rep. 2022 Jul 4;15(7):e246754. doi: 10.1136/bcr-2021-246754. PMID: 35787499; PMCID: PMC9255367.
  2. https://www.ama-assn.org/delivering-care/ethics/withholding-information-...
  3. Vandenbroucke JP. Observational research, randomised trials, and two views of medical science. PLoS Med. 2008 Mar 11;5(3):e67. doi: 10.1371/journal.pmed.0050067.
  4. Mulder J, Sonneveld H, Healey A, Van Raemdonck D. The first international roundtable on "organ donation after circulatory death by medical assistance in dying" demonstrates increasing incidence of successful patient-driven procedure. Am J Transplant. 2022 Mar;22(3):999-1000. doi: 10.1111/ajt.16879. Epub 2021 Nov 6. PMID: 34706144.

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  Conflict of Interest:
  None declared.

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