RESPONSE: A Solemn Responsibility

Dr. Han writes a thoughtful perspective on the opioid epidemic and its evident impact on organ donation. While I too share his discomfort knowing that many of the overdose deaths are preventable, this narrative is not new. Suicides, homicides, car accidents, and other potentially preventable traumas have always been a component of organ donation—relatively young and healthy individuals whose premature deaths provide life to others through transplantation. This intractable reality does not, however, create an ethical conundrum. At the point when organ donation becomes possible, there is nothing more that can be done. The calculus of beneficence and nonmaleficence Dr. Han recognizes as part of the ethical framework for organ allocation is not in regard to the donor; that patient has died. There is no difficult ethical issue to resolve for that patient. There is only the opportunity to provide something positive from the tragedy that has already occurred.

What makes the opioid epidemic different is that the medical field itself holds some responsibility. The conundrum Dr. Han identifies is not at the moment of death. It is far upstream at the moment of prescribing. It is at that point in time the patient is “at the intersection of beneficence and nonmaleficence.” The opioid epidemic should give physicians ethical pause, not for its impact on organ donation, but for how our communities have gotten to this appalling place.

It is important to understand that even in New England, with a dramatic and heart-breaking increase in the percentage of organ donors who died from the result of an overdose (a 254% increase from 2012 to 2016), the actual number of organ donors who die in this manner is relatively moderate (from 26 in 2012 to 92 in 2016) (1). These data highlight that the overall 56% increase in organ donation in New England over the same time period (from 217 organ donors in 2012 to 338 in 2016) is not solely attributable to overdose deaths, but also to improvements in authorization rates, donation after circulatory death, ex vivo perfusion, and other strategies. And those of us serving the donation community share in the hope that this horrific epidemic will conclude.

In organ donation and transplant, every tragic death is framed as an opportunity to give life. This circumstance is the unapologetic reality of the field, regardless of how the death occurred. But this circumstance does demand unique acknowledgment and respect. Donors are not a source or a supply of organs; they are people who have made the lifesaving legacy of donation one of the most vibrant examples of human interconnectivity. They give to others they do not know, but know are in need. Dr. Han has already experienced what a privilege it is to work in this field and bear witness to the best of humanity even in the worst of circumstances. Honoring those who have died in the grip of the opioid epidemic by maximizing the benefit for those who may live through transplantation is not an ethical conundrum, but rather a solemn responsibility.

• 2018 American College of Cardiology Foundation