17 August 2007

Clearly Wrong? Well, I Should Think So

My thanks again to reader Jay P., who urged me to begin posting on the organ donation issue. It seems Providential, as Father would say, because the media is increasingly covering the subject. Here is a disturbing story with a Homer-esque headline, from The Tidings, the LA Archdiocese's newspaper, if you can believe it:

Botched organ harvesting: 'Clearly wrong'
By R. W. Dellinger

On the face of it, and supported by additional facts dribbling out from police reports and court records, the newest transplant case to hit the front pages of newspapers seems surreal - like a bizarre comic scene from a sequel to Mel Brooks' "Young Frankenstein" movie.

Here is what the reports allege:

Dispatched by the California Transplant Donor Network on February 3, 2006, San Francisco transplant surgeon Dr. Hootan Roozrokh and a colleague entered the operating room at Sierra Vista Medical Center in San Luis Obispo at 11:20 p.m. They got to the O.R. even before the Sierra Vista doctor, who was supposed to be in charge of removing the patient from life support and verifying that his heart had stopped beating, arrived.

Their mission? To harvest the organs of one Ruben Navarro.

Five days earlier, on January 29, after the 25-year-old disabled man had been found unresponsive at a long-term care facility, he was taken to nearby Sierra Vista, put on life support and admitted to the intensive care unit. Rosa, Navarro's mother, gave her consent for organ donation at some later date.

On that late February night, nurse Jennifer Endsley asked the visiting physicians why they were in the operating room before staff supervisor Dr. Laura Lubarsky was present. In response, all Endsley received was cold stares before being totally ignored.

When Dr. Lubarsky arrived around midnight, Dr. Roozrokh told respiratory therapist Mark Winekoff to remove the patient's breathing tube. According to the police report, when Winekoff looked at Dr. Lubarsky she motioned to do as he was told.

After a few minutes, the transplant surgeon supposedly instructed another nurse to give Navarro 100 milligrams of morphine and 40 milligrams of Ativan, a sedative. Some 18 minutes later, Dr. Roozrokh ordered the dosages to be repeated, saying they needed more "candy."

The surgeon is also accused of administering Betadine into the patient's stomach through a feeding tube. The antiseptic is part of a sterilization procedure done to the bodies of organ donors after they're dead.

But Navarro didn't die. And after more than 30 minutes had passed, when the organs were no longer viable, the transplant doctor and his colleague abruptly left the O.R. and hospital.
The patient, who was frothing from the mouth and shivering, was taken back to the I.C.U. He died seven hours later on February 4 at about 8 a.m.

At the end of July, some 18 months after Ruben Navarro died, felony criminal charges were filed against Roozrokh, the 33-year-old transplant surgeon, for prescribing excessive amounts of drugs to hasten Navarro's death to harvest his organs. It's believed to be the first time in the United States such serious charges were leveled against a doctor involved in harvesting organs.

The district attorney's office of San Luis Obispo County accused Roozokh of abusing a dependent adult, administering a harmful substance and prescribing controlled substances without a legitimate medical purpose. If convicted on all counts, the physician could receive up to eight years in prison plus a $20,000 fine.

Donation after cardiac death

To understand the Ruben Navarro case, it is necessary to understand "donation after cardiac death," which requires knowing some recent medical history, according to Professor James Walter, chair of the Bioethics Institute at Loyola Marymount University.

In most of the 1960s and earlier, before their organs could be harvested, patients had to undergo cardiac death - the complete and irreversible cessation of cardiac and respiratory function. In short, their hearts had to stop beating.

But in 1968, doctors at Harvard Medical School developed a brain-based definition of death, which became the gold standard for transplantation into the 1990s. To be declared brain dead, patients had to have irreversible cessation of all brain function, including any brain stem activity.

Then in the '90s, transplant surgeons reintroduced "DCD," donation after cardiac death. Instead of waiting until a patient's brain was declared dead, transplant surgeons could start harvesting organs soon after his or her heart stopped. Many of these cases involve patients who after suffering catastrophic brain trauma are left with only minimal brain stem function and need life-supporting ventilators to breathe.

Nearly 100,000 people are on the nation's waiting list for heart, lung, liver, kidney, pancreas or intestine organ transplants. More than a dozen die every day. In a feature story earlier this year, Forbes magazine reported on Internet organ brokers who charge in the range of $140,000 for a kidney and $290,000 for a heart.

Which begs a question: Under these horrific supply-and-demand pressures, is it any wonder that enterprising transplant surgeons might want to speed up the dying process of patients?
"It seems to me in the Navarro case that several of the guidelines were simply broken and just overlooked," LMU's Walter says. "According to any kind of protocol for transplantation and harvesting of organs, there has to be two sets of medical teams: one that cares for the patient during the dying process, and the second is those who harvest the organ. Dr. Roozrokh was evidently the one who prescribed the 200 milligrams of morphine and 80 of Ativan, which is inappropriate. He should have never had done that."

Another issue, the bioethicist points out, concerns the withdrawal of life support. Withdrawing support to harvest organs is wrong, he says. The only intention should be to remove life support because it no longer benefits the patient. Moreover, it can't bring the patient to any level of suitable quality of life the patient would want.

"So that's an ethical issue," he observes. "It seems in this case the withdrawing of the life support was to harvest the organ, not because the ventilator was no longer beneficial to the patient."

But the overriding issue for Walter is whether the large dosages of morphine and Ativan were given to ease Navarro's suffering or to quicken his death. "If the intention is to speed up the dying, then that's inappropriate," he notes. "The intention should never be to speed up death. That would be inappropriate morally and legally."

Vulnerable populations

Wanda Teays, who chairs the philosophy department at Mount St. Mary's College and teaches bioethics, was particularly struck by Rosa Navarro's plea that her son hadn't died with dignity and that she didn't have the chance to say goodbye to him. But the professor also thought it significant that the young man was physically and mentally disabled, and was from a working class background as well as being Latino.

"There are a lot of people on the organ waiting list, and there are desperate people out there," she points out. "So with desperate people willing to cut corners or worse, we've got a recipe for the vulnerable of the world being sacrificed. And whenever you talk about vulnerable populations, you've got the issues of race and class, and then here you've also got disability."
Teays believes the contrast between Dr. Roozrokh and Dr. Jack Kevorkian is important. The latter - known as "Dr. Death and recently released from prison - acted alone, often in his own van, helping suffering and terminally ill people willingly end their lives.

But when the transplant surgeon took an unresponsive Ruben Navarro off life support and ordered massive doses of a narcotic and sedative, he was in Operating Room 3 of Sierra Vista Medical Center. Moreover, at least six other health care workers stood by, including the patient's attending physician, a supervising staff doctor, a respiratory therapist and nurses.
"There's something brazen about the doctor having that large of an audience," she notes. "But his hubris and lack of respect for the patient didn't go unnoticed."

Teays commends the nurses who stepped forward to express their outrage -staffers like Jennifer Endsley who told investigators she recalled saying, "I don't think this is right."
The academic thought it was "really good" many news outlets ran the Sierra Vista piece as their lead story. And the fact that felony charges were filed, she believes, "raised the flag" that it's not okay to sacrifice any human being for the benefit of others.

"We got a human face on a very important bioethical issue," Teays stresses. "And by using a photo of Ruben Navarro being held by his mother, we get the whole sense that here are these people like you and I. And we could be the ones lying there getting the morphine.

"It means," she stresses, "we just always have to be vigilant now."

'Do no harm'

Ken Zanca, who teaches religious studies and philosophy at Marymount College in Rancho Palos Verdes, also is glad to see how many laymen and professionals were shocked when they heard about what happened to Ruben Navarro.

"When you talk about the 'slippery slope,' the slippery slope in one sense can be the desensitizing of people to wrongdoing," he explains. "We just get used to it, and then we don't notice the incremental decline. But here there's outrage, and this to me is healthy.

"People are seeing this for what it was, and the wrongs are not being fudged. Even people who support physician-assisted euthanasia, they're not saying the ends justify the means in this case. Because here the ends were wasted organs, on top of the destruction and the suffering of this poor victim."

Two major ethical issues pop out at the professor. First is the physician's sacred oath to do no harm. He's convinced that the alleged facts of the case clearly indicated that Dr. Roozrokh was giving morphine and barbiturates "directly for the purpose" of not easing pain, but to hasten death. "To me that seems a patent and self-evident contradiction of the Hippocratic principle," he says.

The second issue has to do with consent. When Rosa Navarro agreed to organ donation, Zanca notes, she didn't consent to speeding up her son's death. "That's another violation of an ethical code," he says. "In the absence of informed consent on the part of the patient, then his custodians must be fully informed of what is going on and the consequences. And they weren't."
Like his colleagues, Zanca is also bothered by the legal point that a transplant surgeon can't be directly involved in the patient's care while alive. He does not understand how the patient's attending physician okayed the transplant procedure, especially the administration of morphine and Ativan. He says it's "staggering" to think that your own doctor would not be your strongest defender against such an illegal procedure.

"I've studied medical ethics questions for quite a while, and most of the cases are excruciatingly complex and involve all manner of need for ethicists to be involved with the science before they make any type of ethical assessment," says Zanca, who holds a doctorate in Christian medical ethics from Fordham University. "Ethics is a reflective discipline that has to catch up with science very often.

"But of all the cases, this one is so abundantly clearly wrong," he adds. "I mean, it's not even an issue. There are so many basic legal as well as ethical principles that have been violated that I see no gray area here at all. This one stinks like a fish that's been left out of the refrigerator too long."


thetimman said...

Dr. Hootan Roozrokh?

Latinmassgirl said...

Two years ago at a Catholic hospital, my husband was insulted and shocked that he had to give his consent to be resucsitated if something happened before his "simple" gullbladder surgery .

When there was a complication with the anethesia and had to be put on life support for two days, I was chilled to think that if he had answered "no support" he would be dead!

When the doctors can go against their oath and let someone die simply because they do not want life support, or to harvest an organ, then there is a definite ethical problem.

paramedicgirl said...

Every time I post on organ donation, I get a bunch of hate mail from the medical profession internet bloggers who say they can't believe a paramedic would be advising against being an organ donor. (We actually have posted on the same two stories.) I've been told to stick to religion and leave the business of organ donation in the hands of the grim reapers - oops, I mean "organ procurement coordinators."