The American College of Physicians reaffirmed that physicians’ foremost ethical duty in organ transplantation is to the donor-patient. The organization outlined updated guidance addressing donation after circulatory death, informed consent, and fairness in organ allocation.
The American College of Physicians (ACP) stated in a recent position paper that the decision to withdraw life-sustaining treatment must remain independent of donation decisions. It reported that in cases of donation after circulatory death, up to half of planned donations did not proceed because death did not occur within the expected time frame—usually 30 minutes to several hours. Some patients survived to hospital discharge, prompting the ACP to recommend communicating these possibilities to families in advance.
Premortem interventions to preserve organs must never hasten death or harm the patient, the paper added. It highlighted ethical concerns with thoracoabdominal normothermic regional perfusion, a technique that restores circulation after declared death while blocking blood flow to the brain, warning that it could blur compliance with the dead donor rule—the principle that organ recovery must not cause death.
Informed consent was another focus. The ACP found that presumed or “opt-out” consent systems yielded only marginal increases in available organs, estimated at 0% to 5%, while risking violations of patient intent. It advised that donation discussions occur only after final decisions about life support or death determination.
The ACP also identified systemic inequities across the transplantation process, citing evidence that Black patients were less likely than White patients to have donor hearts accepted despite similar medical profiles. It recommended using transparency measures, such as an "Access to Transplant Score", to evaluate fairness in both allocation and outcomes. “Patients, families, and communities who mistrust the health system and the organ transplantation system may be particularly attuned to utilitarian conversations that place increasing organ donation above respecting preferences and values of individual patients,” said Matthew DeCamp, MD, PhD, of the University of Colorado Anschutz Medical Campus, underscoring the importance of trust and respect for autonomy in achieving equity.
The organization warned that regulatory metrics and financial incentives should not influence patient care. It noted that 56 organ procurement organizations operate under performance targets that may create conflicting priorities, and that transplant centers’ focus on one-year survival rates could discourage timely use of palliative care among recipients.
The ACP Ethics, Professionalism, and Human Rights Committee conducted literature and policy reviews and sought input from multiple ACP councils before final approval by the Board of Regents. The guidance was grounded in the principles of beneficence, nonmaleficence, respect for autonomy, and justice.
The paper only reflected ethical consensus rather than quantitative analysis. Its recommendations may vary in application across jurisdictions depending on institutional and legal frameworks.
The ACP underscored that ethical stewardship—not procedural innovation—is vital to sustaining trust in transplantation. It called on physicians to uphold transparency, fairness, and patient welfare as the field evolves, ensuring that medical progress remains guided by professional duty and public confidence.
Financial support for the development of this position paper came exclusively from the American College of Physicians operating budget. Dr. DeCamp received compensation from ACP for consulting on and coauthoring the manuscript. All committee members adhered to ACP’s conflict-of-interest policy and procedures as outlined in ACP bylaws.
Disclosure forms are available with the article online.
Source: Annals of Internal Medicine