Maastricht 3 procedure: let's remain cautious to its ethical issues!

Abstract

Few debates or studies have been reported since organ donation after circulatory death (Maastricht 3) has been instituted in France in 2014. An intensive care physician will however be submitted to an intimal conflict of interest: he/she will have to separate his/her desire to help future organ receivers without affecting the decision of withdrawing/withholding end of life treatment in their own patients. This occurs in a particular uncomfortable context of uncertainty concerning specific prognosis of comatose patients. Any modification in the end of life decision process during the instauration of Maastricht 3 – i.e. patient admission policy, sedation practices, different modalities of ventilation weaning etc. – could be the reflect of an utilitarian conception of this procedure. The search for patient surrogate consent may also be blurred by an important social desirability bias and culprit, for both of which an adequate evaluation is unlikely to occur in the particularly stressful time scale of the end of life process. Several solutions may be debated including the highlighting of philosophical tensions between consequentialist and deontological conception of care, an urgent need for debate in each institution in which Maastricht 3 is considered, a restriction of Maastricht 3 to the most severe anoxic comatose patients, an independent retrospective control of cases of patients included in the Maastricht 3 program. While the shortage of deceased donor organs for transplantation could be more efficiently solved by an increase in the acceptability of organ donation after brain death, organ donation after circulatory death is questioned about an irreversible crossing of ethical limits, the one which precisely guaranties a meaningful commitment of health care professionals in the care of their patients.