Organ Donation in the Unrepresented Patient-Ethical Challenges and Opportunities for Improvement

In the United States, if an individual not on the donor registry dies by neurologic criteria (DNC), has no documented advance directives, and has no identified next of kin-so called unbefriended patients-current law permits hospital administrators to authorize organ donation on behalf of these patients in a process known as administrative authorization. On the one hand, organ transplantation is a public good that improves human life, and demand for organs vastly outstrips current supply; procurement from unrepresented individuals could help to increase the pool of available organs. On the other hand, administrative authorization, though legal, is fraught with several ethical concerns. Given that as many as 1 in 10 patients admitted to the ICU may be unbefriended, the question of how best to approach organ donation is of material interest. Between 2020 and 2024, 5 unrepresented patients were admitted to our trauma ICU, suffered DNC, and were considered for organ procurement. In this viewpoint, we argue that administrative authorization for organ donation on behalf of unbefriended individuals violates the principles of autonomy and justice and raises significant concerns regarding potential conflicts of interest. We challenge the ethical basis of two counterarguments often offered by proponents of administrative consent. Finally, we introduce the concept of a time-limited trial of continued organ support after death by neurologic criteria as a potential alternative to administrative consent based on our center's experience.