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NEAL CONAN, host
New York City is about to start an ambulance service for organs. The Rapid Organ Recovery ambulance is designed to preserve the organs of the newly deceased so that they'll be available for transplant. There are long lines of people waiting for parts and kidneys, and proponents say this service will save lives. Critics worry that it might divert resources from the treatment of the living and raise questions about whether EMTs and doctors gave every effort to save a patient's life, or moved too quickly to harvest organs.
If you're waitlisted for an organ, if you work on an ambulance or in an emergency room, we want to hear from you, 800-989-8255. Email email@example.com. You can also tell us your story on our blog at npr.org/blogofthenation. We begin with Dr. Richard O'Brien, an emergency-room doctor at Moses Taylor Hospital in Scranton, Pennsylvania, and a spokesman for the American College of Emergency Physicians, with us on the phone from Scranton. Nice to have you on the program today.
Dr. RICHARD O'BRIEN (Attending Emergency Physician, Moses Taylor Hospital; Former Chair Public Relations Committee, American College of Emergency Physicians): Thank you very much. Great to be here.
CONAN: And how would this Rapid Organ Recovery ambulance service work?
Dr. O'BRIEN: I'm not from NYC, but from what I understand is it's a specially trained ambulance crew that would go out and try to procure the newly deceased and make it possible for organ transplant to happen quicker.
CONAN: And they would then work even as the transport is under way to ensure that those organs would be available for transplant.
Dr. O'BRIEN: Well, when you think about it, there is an awful lot of delay in organ transplantation, and like you said, there are many, many, many people on the list, something like 99,000 right now, waitlisted for organ transplants. The idea, the concept, is very interesting and you can understand why a lot of people would be behind it.
CONAN: But there is also a shortage of ambulances in many places. Couldn't these vehicles, some would argue, be put to better use to serve the living?
Dr. O'BRIEN: That's one of my personal concerns. When an ambulance picks up a patient or several patients at a disaster, they're out of service for the rest of their area, whatever area they serve. And if you can consider someone being picked up as deceased, that ambulance conceivably is out of service for the living in that area. And unless they have special arrangements for coverage, you know, you wonder whether this is going to be taking care of the deceased-versus-the-living situation, and that becomes a huge ethical dilemma.
CONAN: And there's another situation, let me put it to you. A mass-casualty incident, a bus crash, a train wreck, that sort of thing, lots of injured people who need help. Yet also, sadly, lots of otherwise healthy people who got killed and whose organs might be very good for transplant.
Dr. O'BRIEN: That is the case, and obviously, if you're sitting in a hospital somewhere, waiting for a new kidney, you have a completely different view of it then you have if you dial 911 because you have chest pain. But I think the balancing act is where the ethics come down and obviously, the emergency medical services works for the living. And they have to go and help those that are salvageable first.
CONAN: Joining us now is Arthur Caplan. He's director of the University of Pennsylvania's Center for Bioethics. He joins us from Audio Edit Studios in Chicago, Illinois. And it's good to have you back on the program.
Dr. ARTHUR CAPLAN (director , Center for Bioethics, University of Pennsylvania): Hey, Neal. How are you?
CONAN: And we've referred some of the ethical issues brought up by Dr. O'Brien. Nevertheless, I know you also have some other concerns.
Dr. CAPLAN: There are a couple of other concerns here. It's a tough call on this one. One is, who are you going to take as a potential organ donor? Are you going to take anyone who is newly dead that you think might be a source of organs? Or are you only going to take people who have a donor card, or who someone says, yeah, I think they wanted to be an organ donor?
There are some number of Americans who don't want to do this. There are some number of Americans who, on religious grounds, don't want to do this. There's going to have to be some very careful thought going to who it is that is put in that ambulance just for the purposes of getting their parts to the hospital. A second issue is, when you're in the ambulance, we're going to have to do things to you. We have to put lines in you. They may put certain preservative fluids into you.
I think some Americans are going to say, you know what? I don't want them touching me. I didn't give my consent. They're doing this without knowing whether I want to be an organ donor, whether I want this done at all. I worry that we're going to have some pushback here. Traditionally, people who are organ donors and have these things done to them, it comes after either their card is found that they want to do it or the family says OK. But in this case, you have procedures begin done to a person without any consent and that's a tough area to be in, in American medicine this days.
CONAN: Yet, Dr. O'Brien, the other side of that equation is that, well, you're also losing opportunities and your losing time.
Dr. O'BRIEN: This is true, and the way that I look at it, the best way to keep the organs alive is to keep the patient alive, and obviously, we err on the side of trying to save the patient. That's what we all do and that's what emergency medical services is set up to do. That's the unique thing about this New York City idea, this unique ambulance, that ideally, the sole purpose of this particular crew would be to get a newly deceased person as a patient.
CONAN: Dr. Caplan, there are also - these are sort of the internal concerns about harvesting of organs, people who fear that, well, some people's interest is, in fact, in harvesting their organs, not keeping them alive.
Dr. CAPLAN: Sad to say, that is a worry that a number of Americans have. If you looked around, Neal, and said, what's a major hindrance to getting people to sign donor cards? A lot of people will tell you they worry that, if they carry a card ,they fear they are not going to be treated aggressively if they get sick and go to the hospital, tends to be people without health insurance, tends to be poor people. But it's a very real fear that a lot of folks have.
Now, if you tell them, you know, we don't have health insurance for you, and if you get sick, the only place you can go is in here. But we're sending a special ambulance out to your neighborhood if you're newly dead. We'll make sure you get into the hospital in that case. You can see where a little tension might go.
CONAN: Does this, as a practical matter, Dr. O'Brien, how often does this tension emerge?
Dr. O'BRIEN: I have never seen it in 20 years of clinical emergency medicine. We do not check to see whether you are an organ donor or not when we come out to get you. I did two years of life flight as a helicopter doctor, and believe me, I never looked in a wallet. I never asked about organ donation. I tried to see viable patients.
I personally was at the scene of two plane crashes, and you try to see the most viable patients you can, the ones that you can help. And you get them to the hospital. You get them to the trauma center. That is a very real fear, I understand that, but it is not a reality. I have never, ever, ever seen anybody treated any different way, as if they were an organ donor or they weren't. They were all treated...
Dr. CAPLAN: I don't think there's any evidence, Neal, that the fear is grounded, even when you get to the hospital. I think there's no reason whatsoever to suggest or hint that, somehow, if you're carrying a card that says you want to be an organ donor, people are going to give up on you because they want the parts for someone else.
But as a fear, as a concern, it is very, very real of a part of many. And, you know, the other issue is, as I said, you've got about a quarter of the population with no health insurance, and they're having a hard time getting basic healthcare. But here comes the special ambulance that says, well, your parts are worth something to others, and we can make money installing them in others. We'll make sure to get those.
CONAN: We're talking with Dr. Richard O'Brien, an emergency room physician at Moses Taylor Hospital in Scranton, also a spokesman for the American College of Emergency Physicians. And with us is Dr. Arthur Caplan. 800-989-8255, if you'd like to join us.
We want to speak to people who are maybe on the waiting list for transplant or maybe those who work in emergency rooms or on ambulances. Give us a call. Again, it's 800-989-92655. Email us, firstname.lastname@example.org. And we'll go to Lorraine, Lorraine's with us from Scottsdale, Arizona.
LORRAINE (Caller): Hi.
LORRAINE: I want to really echo the sentiment of Dr. O'Brien. I was a paramedic - I'm retired now - for 20 years and that really never happened. The paramedics on a fire engine or ambulance come and their whole chief goal is to save your life. And again, we don't check any of those things and I just never, ever, even in the worst accidents and circumstances, even though we knew maybe that that patient would die, we just never stopped short of going the whole way and doing the best we could do to save that life.
And I can't imagine that anyone in emergency service now, in New York or in any state, would fall short to say, oh, let's just save these organs. And it also occurs to me that the paramedics and firemen and people on the scene, they might be the ones that would be calling the ER doctor in the emergency room and saying, what about and should we discuss this ambulance? Or should we be a part in retrieving that special emergency medical service...?
CONAN: And Lorraine, given your experience as a paramedic, do you think this specially designated ambulance to collect the newly dead for organ transplants, do you think that could work?
LORRAINE: I think it could work, but I think there would have to be some significant regulation. And I think there would have to be specific circumstances that that would be OK. Also I think that's - you're never very far from a trauma center nowadays. I mean, everywhere is pretty close, except for the very farthest rural areas, and by helicopter, those are reachable as well. So it seems to me that getting them to the facility that could then administer all that care might be a better route that maybe would alleve (ph) some of the fears of the general public.
Dr. O'BRIEN: Can I jump in here, Neal?
CONAN: Go ahead, Dr. O'Brien.
Dr. O'BRIEN: Also, let's echo the fact that I don't think a paramedic or EMT or a doctor or nurse an ambulance service would ever check the insurance status of a patient.
LORRAINE: Never. Absolutely not. It just ever happens. I mean, I suppose, in a story, it could, and on television, but in real life that is just not how it works.
Dr. O'BRIEN: Emergency medical (inaudible)...
Dr. CAPLAN: Neal, let me jump on here.
CONAN: Go ahead.
Dr. CAPLAN: Let me jump in. I don't think the issue is emergency medicine being picky, so to speak, about insured or noninsured. Although there are certainly private ambulances out there that tend to want to avoid people who can't pay. That is a reality. But I think what I'm talking about is the perception.
If you're a poor person in a community and somebody says, you don't have health insurance, but you can get, if you do die, a special ambulance will come out here. And by the way, don't worry about the ambulance being diverted, as often happens in my city of Philadelphia, having to choose between two or three places because they are full just won't take anybody anymore. The special ambulance, if you're dead, that's going to get right in and you're going to get special attention.
We have a country that has tremendous disparities in the access not to ambulance care, not even sometimes to the ER, but just generally getting to the hospital. I suspect you're going to see some pushback from some folks who are going to say, you let me in the hospital when I am newly dead for my parts. How about you let me in the hospital when I'm just sick?
CONAN: Yeah. Lorraine, thanks very much for the call.
LORRAINE: Thanks so much.
CONAN: We're talking about New York's new organ recovery ambulance service. You're listening to Talk of the Nation from NPR News. And let's go to Laura, Laura with us from Columbus, Ohio.
LAURA (Caller): Hi, I work in neurology and I have been called to the ICU on multiple occasions and to make a decision regarding brain death. And I have been pushed by the organ-procurement people to make a call regarding brain death before it was possible, and I was greatly concerned that the organ-procurement people were contacted before I was.
CONAN: So they were already in the room, ready to go, as soon as soon as you and then you came in to see if the person was actually dead.
LAURA: Exactly. And they had the charts and approached me and said, hurry up, we need these organs.
CONAN: There's, of course, no doubt that they do need those organs. There are thousands of people waiting for them.
LAURA; Exactly, but I think it's inappropriate that they are there pushing me, because I am supposed to be...
CONAN: The patients' advocate.
LAURA: Yes the patients' advocate, or even to be neutral. And I have been very pressured, very, very hard, and it's awful awkward that the families are asking me, who are those people? So they weren't aware of any of this going on. And I totally understand that there's a need for the organs, but I just feel that there's too much pressure in some situations to make - to be the patient's advocate or to be neutral on this, you know, as a physician.
CONAN: Arthur Caplan, that's sort of outside the structure that we were talking about in terms of emergency rooms and ambulances, but nevertheless the same kinds of ethical conflicts.
Dr. CAPLAN: Same kinds of ethical conflicts. So the moral principle in America is operated by trying to help those who need organs for transplant is that you have to be announced dead by people independent from those who come to get the organs and you don't want to cross what's called the dead-donor rule, or if you rule the dead donor alive.
People shouldn't be present from organ procurement until somebody is pronounced dead. One of the difficulties from the ambulance situation is the people who are going to have to do the pronouncing now, out in the field of death, are probably the people that are going to involved in taking the human body back for purposes of procurement. So the line gets blurry.
That's why I'm much more comfortable if this system was set up to say, we're only going to start with people who have a donor card where we find it, or we're going to ask people, survivors or family members, if they think the person might have wanted to be an organ donor. I get nervous if we're just going to start this bringing everyone in and doing procedures on them. I think you're going to build some distrust and pushback that way.
CONAN: Dr. O'Brien, as a practical matter, is that possible? Is it preferable?
Dr. O'BRIEN: It's certainly preferable to involve the family. In fact, if you go to one of the websites where you can become a donor, organdonor.gov, it will say you should tell your family what your wishes are, fill out one of these cards, and in many states, the family will have to sign some sort of permission slip to allow procurement of organs.
It is obviously preferable for the family to be involved in the decision and to know fully what's going with their deceased person or their nearly deceased person. And I can really feel for that physician who had to make the call on brain death, because sometimes the call is not that easy to make. And you as an independent physician should not be pushed one way or another.
And I completely agree with Dr. Caplan. We're concerned that the decisions will be made quickly, and again, very serious policies and procedures have to be followed to the letter. And I agree that perhaps people that are known organ donors should be the first person that are looked at with this ambulance service.
CONAN: Laura, thanks very much for the call.
LAURA: Thank you.
CONAN: Appreciate it. Finally, let me ask you, Dr. O'Brien, this is not yet in effect, though it's going to be in effect for New York City fairly soon, as I understand it. Philadelphia and other places are also looking at it. Do you think this is going to become more widespread?
Dr. O'BRIEN: I think that remains to be seen, but obviously, a situation like this will work better in a large city. It would never work in a small town. Scranton, Pennsylvania, perhaps not. But when there are a fair number of deaths per hour, you would have more potential organ donors. And when you think that 17 people a day die waiting for organs in the United States, hopefully that number will be reduced tremendously if this can be done ethically and in a regulatory fashion where everyone is satisfied.
CONAN: Thanks very much for being with us today. We know you're busy.
Dr. O'BRIEN: Thank you, sir.
CONAN: That's Dr. Richard O'Brien, an emergency room doctor at Moses Taylor Hospital in Scranton, Pennsylvania, a spokesman for the American College of Emergency Physicians. Live with us by phone from Scranton. And Arthur Caplan, as always, thank you for your time today.
Dr. CAPLAN: Thanks very much.
CONAN: Arthur Caplan is director of the University of Pennsylvania's Center for Bioethics. He was with us today from Audio Edit Studios in Chicago, Illinois. Tomorrow. We'll broadcast from the Newseum again. Join us for Philip Gourevitch on his new book about Abu Ghraib. I'm Neal Conan. This is Talk of the Nation from NPR News, in Washington. ..COST: $00.00
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