By John Lichfield in Paris
France may have to reconsider its medical definition of death after a heart-attack victim came alive in the operating theatre as doctors were about to remove his organs for transplant.
The patient, whose identity has not been revealed, recovered after a long period in intensive care and is now able to walk and talk.
The 45-year-old man owes his life to the fact that surgeons authorised to remove organs for transplant operations were not immediately available. Under experimental rules adopted in France last year, to make more organ transplants possible, the man had already reached the point where he could be officially regarded as dead. Similar rules – allowing the removal of organs when a patient's heart has stopped and fails to respond to prolonged massage – already apply in several other European countries, including Britain.
The case occurred at the Pitié-Salpêtriere hospital in Paris in January but was not revealed at the time. The organisation that runs state-owned hospitals in the Paris area – Assistance Publique-Hôpitaux de Paris (AP-HP) – referred the case to its ethical committee on transplants. A summary of the committee's debate, which came to no firm conclusion, has now been published on the AP-HP website. "This situation [illustrates] the questions that remain in reanimation ... and what criteria can be used to determine that a reanimation has failed," says the report.
The ethical questions raised are complex, as the committee acknowledges that doctors – and the state – have an obligation to the 13,000 people waiting for transplanted organs in France. Last year 231 of these patients died because organs did not become available. It was for this reason that France introduced experimental rules allowing the removal of organs in nine hospitals from so-called "stopped heart" patients.
The 45-year-old at the centre of the controversy collapsed close to the La Pitié-Salpêtriere hospital. Efforts were made to revive him at the scene, and more elaborate procedures continued at the hospital for 90 minutes. As surgeons were preparing to remove his vital organs, the man began to breathe unaided. His pupils moved and he showed signs of pain. His heart started to beat again. After several weeks during which he was gravely ill, the man can now walk and talk. He has yet to be told that doctors were ready to remove his organs.
Otherdoctors have seen similar incidents, according to the ethics committee report. "During the meeting, other reanimators ... spoke of situations in which a person whom everyone was sure had died in fact survived after reanimation efforts that went on much longer than usual," the report said. "Participants conceded that these were exceptional cases, but ones that were nevertheless seen in the course of a career."
Le Monde said doctors had feared the new transplant rules would confront them with cases of this kind. They believe the existing rules are imprecise and could undermine public support for the removal of organs for transplant. They are pushing for the issue to be discussed as part of a consultation next year on a proposed, new law on medical ethics.
Professor Alain Tenaillon, the organ transplant specialist at the French government's agency of bio-medicine, told Le Monde: "All the specialist literature suggests that anyone whose heart has stopped and has been massaged correctly for more than 30 minutes, is probably brain dead. But we have to accept that there are exceptions.... There are no absolute rules in this area."
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