Ethics Argued in Hoag’s Use of ‘John Doe’ Heart

From the beginning, paramedics, police and hospital officials knew him only as “John Doe.”

Called to a Circle K market in Costa Mesa at 5 a.m. Tuesday, paramedics found a young Latino man lying unconscious on the sidewalk.

He had dark brown hair, brown eyes and a mustache and was wearing a gray shirt, blue jeans, white tennis shoes and white socks, Costa Mesa Police Lt. Rick Johnson said. He was 5 feet, 8 inches tall and weighed about 145. He is believed to have beent 18 to 23, carried no identification and only $9.14 in his pocket.

Police ran the usual checks--running his fingerprints through a state identification system, looking to see if his description fit anyone in their missing-person files, asking possible witnesses at the Circle K whether anyone knew who he was. No one knew anything about him, Johnson said.

At 11:40 a.m. Wednesday, “John Doe” was declared legally “brain dead” by doctors at Hoag Memorial Hospital Presbyterian, who decided that his heart could help someone else.

Seven hours later, Hoag surgeons removed the heart, implanting it in the chest of a 58-year-old Fountain Valley doctor with congestive heart failure who had waited 4 1/2 months for a donor.

While taking the organs of an unidentified body for transplant is legal in California under certain circumstances, experts said it is a relatively rare occurrence and one that focused attention Thursday on the ethical issues of such a procedure.

Police are still investigating “John Doe’s” death--treating it now as a possible homicide--and are preparing a composite drawing to seek help in identifying him. The young man, they said, had a fractured skull. Otherwise, his life is a mystery.

“We have to assume at this time (that) because nobody is screaming and yelling about their little Tommy, that he is a transient. We don’t know much about him,” Johnson said.

The circumstances of this heart transplant were very unusual, police and medical ethicists said Thursday.

Usually, when a person’s heart or other organs are donated, either he or his next of kin must have signed a consent form for donation. But under the Uniform Anatomical Gift Act, a hospital may authorize the donation of organs if no relatives are available.

There are several qualifiers, however: There must be a “diligent search” for next of kin that lasts at least 24 hours. Local missing-persons records must be checked. The patient’s “personal effects” must be examined. Anybody visiting the patient or reporting the death must be questioned.

Hoag public affairs director Gail Love said Thursday that the hospital complied fully with the law.

Search for Next of Kin

As required, Hoag asked Costa Mesa police to search for next of kin, Love said. Hospital staff members looked through the man’s clothing and found nothing that could identify him. And although they watched constantly to see whether he had visitors, no one came, she said.

So, after consulting with Hoag attorneys and officials from the regional transplant network in Los Angeles, the hospital authorized his heart to be taken for transplant.

Costa Mesa detectives said they did not know that injured man was dead, or that he was being considered as a heart donor, until about 2:30 p.m. Wednesday.

“We didn’t find out about the transplant and that he might not make it until we got to the hospital yesterday afternoon,” Costa Mesa Police Detective Dan Hogue said.

The detectives were surprised at the news, Detective Sam Zuorski said. “So much to say, ‘Wait a minute. What’s going on here?’ ”

But, Zuorski added, “Evidently this was all worked out between the hospital and the coroner’s office.”

Supervising Deputy Coroner Richard Plows confirmed that his office had authorized the transplant. After the police check of fingerprints came back with no name, “The decision was made to transplant,” he said.

Ethicists Divided

Medical ethicists interviewed by The Times on Thursday were divided about whether removing an unidentified man’s heart was appropriate.

The removal “bothers me,” said Arthur Caplan, director of the Center for Biomedical Ethics at the University of Minnesota in Minneapolis.

“Organ donation rests on a fragile ethical foundation, and people may have doubts. Will they (doctors) treat me aggressively if I am sick?” Caplan said.

“If I had my druthers, I might forgo the few organs that might be available by doing this, because of the cost it takes in public trust.”

Sister Corrinne Bayley, director of the Center for Bioethics at St. Joseph Health System in Orange, also said she has doubts.

“Some might say, because the patient was dead, he had no more rights,” Bailey said. “However, that’s not how we act. . . . Normally we wouldn’t do that sort of thing without consent.”

She added: “One option is to not take the heart--to not do it because we don’t have consent. The other is to do it and say we presume consent.”

Also concerned about the transplant was a Hoag nurse who telephoned The Times to complain that she and several other Hoag staff members were “upset about the transplant.”

The nurse said she was concerned that Hoag may have been “in a rush to get a transplant to compete” with UCI Medical Center, which performed the county’s first heart transplant nearly two weeks ago.

Finding Victim’s Relatives

“Was there really a concerted effort made to find this kid’s relatives? There was nothing on the news,” she said.

Nor did anyone unhook “John Doe” briefly from his respirator to take and circulate a snapshot of him, she said.

But Father John Golenski, a consulting ethicist at UC San Francisco Medical Center, said that taking the unidentified man’s heart for transplant was probably appropriate.

“If we have no expression of wishes, we suppose people by nature have altruistic motives and would have decided they would have been a donor,” Golenski said.

Still, he said, ‘You have to make a reasonably thorough attempt to find the family. . . . You have to really look.”

Golenski said he had advised surgeons in Salt Lake City on a similar case 18 months ago. In that case, surgeons at Latter-day Saints Hospital convened a hospital ethics committee before deciding to remove a transient’s heart for transplantation. There was no subsequent criticism of that decision, Golenski said.

Vicki Michel, an associate professor at Loyola Law School in Los Angeles and a member of the Los Angeles County Bar Assn.’s bioethics committee, generally agreed with Golenski.

“The idea is that if the need for the organs is great enough, and if the benefit to an individual and society is great enough, there is the feeling that most people, if asked, would agree to donate the organs,” Michel said.

When families are asked about organ donation, they usually agree, Michel said.

But usually no one thinks about the issue in advance, she added, “because people are hesitant to contemplate their own deaths.”