PMID: 10890679

Issn Print: 0090-3493

Publication Date: 2000/06/01


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What can and cannot be learned from the Pittsburgh experience

Baruch Brody

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The acute shortage of solid organs for transplantation has led to a variety of proposals for increasing the supply of organs. One that has attracted considerable attention is the Pittsburgh protocol for harvesting organs through controlled non-heart-beating organ donation. Although there has been much theoretical discussion of the clinical, ethical, and policy issues raised by this protocol, that discussion has not been informed by data about the actual operation of the protocol. The report in this issue by Dr. DeVita and colleagues (1) is therefore welcome. More generally, the Pittsburgh group is to be applauded for their openness in describing their protocol from its initial inception (2) to its actual implementation, despite the fact that this has left them open to criticism (3). Especially in these controversial areas, progress can only be sustained by openness of scientific discussion.
Several crucial things can be learned from this report. The first is that this source of additional organs is unlike to have a tremendous impact on the shortage. In 51/2 yrs, the Pittsburgh group harvested organs from only 16 donors. We are not told whether there was an increase over time or whether the rate was constant, but these results are disappointing from the perspective of a national solution to the shortage of solid organs. Nevertheless, there were real benefits from adoption of the protocol. Some patients on the waiting list were helped to obtain organs, and some families of dying patients were given the opportunity to make something good happen from their loss. These are real benefits, and they provide good reasons for supporting the Pittsburgh protocol, regardless of whether future experience at Pittsburgh or elsewhere supports the view (4) that this protocol can eliminate the current national shortage.
A second and related lesson is that the organs come from a very narrow class of donors, those who suffered severe brain injury but were not brain dead and those who may have been brain dead but on whom testing for brain death had not been performed. It would have been of interest to know how many came from each category and whether those who were not brain dead were expected to become brain dead shortly. Depending on the answers to these questions, the use of the Pittsburgh protocol in this series of 16 may not have increased the pool of donated organs very much, even if it did hasten the donation.
A third lesson is that the details of the implementation of the protocol are very important. By not using phentolamine, the Pittsburgh group showed that one can harvest the organs without getting involved in the controversy (justified or not) raised by the use of that drug (5, 6). Controversial protocols should be drafted to avoid unnecessary side controversies, and the Pittsburgh protocol succeeded on this point. By not being as clear as they should have been, however, about some of the issues of documentation, they left themselves open to the suggestion that the harvesting of organs had begun before the patients were declared dead. They have wisely modified their protocol to make such requirements more precise, and other programs should surely follow their lead.
There is much of value to be learned from the current report, but I am afraid the crucial conclusion that the authors wanted to derive is not fully supported by their data. One of the great debates about the Pittsburgh protocol is the amount of time that should elapse between the determination of pulselessness and the declaration of death by using a cardiopulmonary criterion (7). That criterion of death refers to an irreversible loss of cardiopulmonary functioning.
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