A San Francisco surgeon named Hootan Roozrokh has been indicted for attempting to hasten the death of Ruben Navarro in order to harvest his organs. According to authorities, Roozrokh ordered unnecessary doses of morphine and Ativan to be administered when Navarro didn’t die as expected after the removal of life support in an attempt to hasten his death. When Navarro still didn’t expire, the transplant procedure was terminated. In a horrible scene, Navarro reportedly died eight hours later frothing from the mouth and shivering.

The story made international headlines and raised a potent question: How could such a horrible scene have happened in a modern American hospital?

Answering this question requires a brief explanation of the arcane procedures that govern cadaver organ procurement involving people who die from irreversible cardiac/pulmonary arrest. For ease of discussion, let’s call this “heart death.”

Due to the growing organ shortage, in recent years transplant centers have begun adopting protocols to govern heart death organ procurement. Sometimes called the “Pittsburgh Protocol,” the procedure permits the patient’s treating medical team to withdraw life support. Then, several minutes after the patient’s heart stops, a different medical team steps in and removes the organs.

The Pittsburgh Protocol is controversial: First, it permits organ procurement from patients who might be capable of being resuscitated. Second, it harvests organs from people who are not “brain dead.” Finally, some worry that catastrophically ill patients on life support could be treated more as organ farms rather than as fully human beings. Of these, only the third seems to be cause for significant concern.

Let’s first examine the concern about procuring organs a few minutes after the lungs stop breathing and the heart stops beating. The crucial question here is irreversibility. Heart death in this circumstance is considered irreversible precisely because no CPR will be attempted and it is deemed nigh-on impossible for a person’s heart to restart spontaneously after several minutes without beating. Moreover, after so much time without oxygen, the brain has ceased all function and the now declared dead patient will be totally unaware.

True, some critics say, but there is no doubt that a heart dead patient’s brain will contain living neurons when the organs are removed. Yes, but so too do patients “declared dead by neurological criteria,” as brain death is more accurately phrased. In fact, the term “brain dead” is misleading in this regard precisely because it implies that every cell in the cadaver’s brain is dead, when the term actually means that the whole brain and each of its constituent parts have irreversibly ceased to function as a brain .

The concern that potential heart death donors like Navarro will be treated as mere organ systems is supposed to be prevented by iron-clad ethical rules. For example, medical decisions regarding the patient are not to be made with an eye toward organ donation. Of perhaps even greater importance, once the decision has been made to withdraw life support and donate organs, the medical team in charge of the organ procurement should have no contact with the patient until after death.

All of these (and other) ethical rules appear to have been violated in the Navarro botched organ donation. According to reporting in the San Luis Obispo Tribune , based on interviews, unsealed court documents, and the police report:

  • Before the transplant team arrived, Navarro’s intensive care doctor wrote in his patient’s chart and notified a transplant nurse that Navarro was not a good candidate for organ donation. If true, the donation protocol should never have proceeded.
  • Roozrokh, the primary organ procurement surgeon, took over Navarro’s care before he was declared dead by a treating doctor, an especially egregious ethical violation.
  • When Navarro didn’t go into cardiac arrest after removal of his respirator, the organ donation should have been called off. Instead, Roozrokh allegedly ordered the patient injected with drugs to make him die.

The Navarro case is our worst nightmare about organ transplantation. To prevent erosion in the public’s confidence, steps need to be taken to ensure that the procurement system operate ethically, consistently, and competently. One positive and long overdue step toward that goal would be the establishment of legally mandatory national standards to govern all organ procurement-whether from heart dead or brain dead donors. Blithe “trust us” assurances about the general safety, integrity, and beneficence of organ transplant medicine-true though they may be-are no longer good enough.