By Sarah Arnquist

Prosecutors in a small town on California’s Central Coast are making history. For the first time in the United States, they brought criminal charges against a transplant surgeon, alleging he prescribed excessive amounts of medication in an attempt to hasten a disabled man’s death and harvest his organs. The case cleared its final pretrial hurdle Wednesday and will now go before a jury later this year.

San Francisco surgeon Hootan Roozrokh faces one felony charge of dependent adult abuse, for which the maximum punishment is four years in prison. Roozrokh, 34, has pleaded not guilty and his attorney, M. Gerald Schwartzbach said his client looks forward to clearing his name at trial.

The Roozrokh case has attracted much national attentionand raises worrisome questions about whether the transplant community is pressing too hard to increase the nation’s organ supply, thereby creating situations ripe for blurring ethical boundaries, such as this one.

It also exemplifies many people’s worst fears about organ donation: That a surgeon will consider comatose patients solely a source for organs and accelerate their death to save other lives.p>

Many fear this case will have a chilling effect on transplant surgeons, hospitals and patients regarding organ donation. When nearly 100,000 peopleare waiting for organs, this is awful publicity for the transplant community.

“The idea of extending elder or dependent adult abuse charges to medical care is a sensitive one,” said Dr. Brian Liang, a law professor at San Diego’s California Western Law School. “You don’t want a chilling effect on physicians doing the right thing.”

The details

Here’s what witnesses said happened on Feb. 3 and 4, 2006 in operating room No. 3 at a community hospital in San Luis Obispo, Calif., after 25-year-old Ruben Navarro’s mother agreed to donate his organs. (Rosa Navarro has also filed a wrongful death suit against all the parties involved.)

The California Transplant Donor Network the Organ Procurement Organization responsible for coordinating donations in Northern California – dispatched a team from San Francisco to travel four hours south to San Luis Obispo and recover Navarro’s organs.

Roozrokh, and fellow Kaiser Permanente surgeon Arturo Martinez were part of the team. Roozrokh, who was born in Iran but grew up in Wisconsin, was less than a year out of his transplant surgery fellowship at Stanford University Medical Center. He has not spoken to the press.

Navarro, who suffered from a debilitating neurological condition since childhood, had been comatose in the hospital for four days. His doctors determined he had suffered irreversible brain damage, but still had minimal brain function and so was not legally brain dead. That’s key to this case because it meant Navarro was a candidate for donation after cardiac death.

Donation after cardiac death

About 95 percent of organ donations from dead donors in the United States come from brain dead patients. There is no time rush in these cases. The donor can be dead for days or even weeks before the donation takes place, allowing the family plenty of time to say goodbye and prepare for donation.

The other 5 percent are donations from donors, who like Navarro are not brain dead but are being maintained on ventilators and die only after being removed from the ventilator and their hearts stop beating. This is called donation after cardiac death.(This type of donation is rare today, but it was the only type of donation available until a legal definition of brain death was created in the early 1980s.)

In cardiac-death donations, time is of the essence. When these donors are removed from life support, their primary doctor will declare death and then wait for five minutes to be sure the patient doesn’t spontaneously wake up. The removal of life support may be done in the operating room, but the transplant team is not allowed near the patient until after death is declared.

Now, timing becomes important. The patient must die within an hour of being removed from the ventilator or the organs do not retain enough oxygen to be viable for transplantation.

After Navarro was removed from the ventilator, he continued breathing on his own. Prosecutors allege that Roozrokh tried to accelerate Navarro’s death by ordering 130 milligrams of morphine and 60 milligrams of Ativan in less than an hour. The ICU nurse said she gave more medication at the direction of the transplant nurse.

Donation after cardiac death is ethically and legally acceptable only if strict guidelines are followed. Roozrokh violated those protocols when allegedly he assumed care for Navarro before his attending physician had declared his death. It’s undisputed that Roozrokh prescribed medications for Navarro, although witnesses disagree on the amounts.

Alan Weisbard, a University of Wisconsin professor of law and bioethics, is among the experts who have voiced concerns that the zealousness to procure organs may cause physicians and procurement teams to overstep boundaries intended to protect patients.

Donation after cardiac death leaves a very narrow margin of error in this domain, and it is rather clear in this case that relevant lines were crossed,” Weisbard said.

Navarro didn’t die until eight hours after being removed from the ventilator. His organs were never used, and the coroner determined he died of natural causes. (He was cremated and an autopsy was never performed).

Several doctors have expressed amazement that Navarro, who weighed about 80 pounds, did not die shortly after given the alleged medication doses. That’s the key to Roozrokh’s defense. His lawyer claims Navarro had a high tolerance to pain medication, and Roozrokh’s actions prevented Navarro from experiencing and pain or discomfort on his “pathway to death.”

“Nothing this man did. Nothing this man said adversely affected the quality of Mr. Navarro’s life,” Schwartzbach said in court, gesturing to Roozrokh.

Blurring ethical lines?

No transplant surgeon in the world has ever been in similar circumstances, Roozrokh’s lawyer said while arguing for the case to be dismissed.

The hospital had no cardiac-death donation protocol, and none of the hospital staff involved had ever been trained in the procedure. Navarro’s attending physician didn’t understand why she had to be there, and  Martinez, a veteran surgeon, did not intervene when Roozrokh ordered medications. Roozrokh and the transplant nurse had each only seen the procedure done once.

Also, no national standard for donation after cardiac death existed at that time. The United Network for Organ Sharing, the nonprofit that contracts with the federal government and overseas regional organ procument organizations, adopted national standard a year after this incident occurred.

Knowing all this, the Transplant Network sent an inexperienced team to recover Navarro’s organs. The surgeons do not have a financial incentive to recover organs. They get paid either way. The Transplant Network, however, is rated by its procurement rate.

Most doctors agree that Roozrokh violated the organ donation protocol when he wrote a prescription for Navarro. Surgeons should not, and in some states, legally cannot care for a patient whose organs they will procure. Whether that professional breach constitutes a criminal act will be up to a jury, which may have a difficult time pointing the finger at Roozrokh because undisputedly the entire system failed that night.

PHOTO CREDIT San Luis Obispo Tribune