Saving the living has always been the No. 1 priority for a New York City ambulance crew. But a select group of paramedics may soon have a different task altogether: saving the dead. The city is considering creating a special ambulance whose crew would rush to collect the newly deceased and preserve the body so that the organs might be taken for transplant.
The "rapid-organ-recovery ambulance," still in the early planning stages, could raise a host of ethical questions and strike some families as ghoulish. But top medical officials in the Fire Department and Bellevue Hospital say it has the potential to save hundreds of lives.
Generally in the U.S., only people who die at hospitals are used as organ donors, because doctors are on hand with life-support machinery and other equipment to preserve the organs and remove them before they spoil. Surgeons have only a few critical hours before kidneys, livers and other body parts suffer damage that renders them unusable.
Dr. Lewis Goldfrank, the director of emergency medicine at Bellevue, said the ambulance project could spark an "amazing transformation" by substantially increasing the pool of donors. The system would be one of the first of its kind in the U.S., although similar ambulances have operated successfully in parts of Europe, he said.
The transplant ambulance would turn up at the scene of a death mere minutes after regular paramedics ceased efforts to resuscitate a patient. The team would begin work almost immediately, administering drugs and performing chest compressions intended to keep the organs viable.
Sometimes, those steps would be taken before getting approval from a relative and without knowledge of the departed's wishes regarding organ donation.
Any organ removals would be done at the hospital only. And no organs would be removed without getting the family's express consent.
But experts in medical and legal ethics said they still see potential for trouble.
"Starting this process without knowing whether the decedent wanted to be a donor could be a problem," said Maxwell Mehlman, director of the Law-Medicine Center at Case Western Reserve University in Cleveland.
Distraught relatives could be unnerved by the site of a transplant team arriving so soon after a death. Some might have a religious objection to organ donation, and be enraged to learn that a body had been moved and injected with fluids.
Other families might also — rightly or wrongly — question whether the paramedics curtailed their lifesaving efforts because a patient had valuable organs.
"A lot of people don't trust the medical system to begin with, and in the city, you have additional class and race issues to deal with," said Arthur Caplan, a professor of bioethics at the University of Pennsylvania. "I could very easily see a family saying, 'If it was a white, rich person, that person would have been saved. But instead you've sent the meat wagon.'"
Doctors working on developing a pilot program say they realize the sensitivity of the issue and are building precautions into the system, which would start with just one ambulance.
The project's ethics consultant, Nancy Dubler, director of the division of bioethics at Montefiore Medical Center, said there would be an "absolute barrier" between the medical personnel involved in the lifesaving effort and those working on the organ recovery team.
Paramedics responding to an emergency would not be told whether there was a transplant crew waiting in the wings, and would have nothing to do with that process.
A separate supervisor would make the call on whether to dispatch the organ-recovery ambulance, and that team would be barred from arriving until five minutes after a formal declaration of death.
Only cardiac arrest patients who die of natural causes would be considered candidates for the program.
The organ-recovery team would also travel with a counselor who would make every effort to get a family's consent before the body was moved or touched.
"That's a tricky conversation," acknowledged Dr. David Prezant, the Fire Department's chief medical officer. He said grieving relatives might expect to be asked about organ donation at a hospital, but are certain to be caught off guard if the topic is broached in the field.
The city has received a $1.5 million, three-year grant from the federal government, but there is no set date yet for when the ambulance might begin operating.
Researchers say their next step is to consult with lots of New Yorkers, including religious leaders and members of the Manhattan neighborhood around Bellevue where the ambulance would operate.
"If everyone isn't comfortable with the answers, we won't be moving forward to a pilot phase," Dubler said.
Goldfrank estimated that 22,000 people die at home each year in the U.S. who might be able to donate organs through such a program, although he added that it would probably only be workable in big, dense cities.
Opinion surveys in the U.S. routinely find that a majority of Americans are willing to donate their organs. In New York, more than 1.4 million people have signed an organ donor registry maintained by the state.
"Several hundred people die every month waiting for organs," said Dr. Richard O'Brien, an emergency physician at Moses Taylor Hospital in Scranton, Pa., and a spokesman for the American College of Emergency Physicians. "This could be a way to make organs more reliably available to people who desperately need them."