Readers of this blog will be familiar with the depressing and alarming story of Ruben Navarro, who died hours after a botched attempt and a “controlled death” and organ harvesting. This occurred under a protocol still not used widely, but on the increase – labeled “donation by cardiac death (DCD).” This appears to be a recent replacement for the term “non heart-beating donation.”

Hootan Roozrokh was charged with felony dependent adult abuse for his role in ordering the administration of massive doses of painkillers and sedatives when Ruben Navarro’s heart kept beating after being removed from a ventilator. As a transplant surgeon, Roozrokh shouldn’t have been in the same room with Navarro until after he’d been declared dead.

Here’s the first few paragraphs of a story on the trial by Leslie Parilla at Sanluisobispo.com:

A San Luis Obispo jury on Thursday acquitted a transplant surgeon of dependent adult abuse in the first criminal case of its kind in the nation.

A jury of nine men and three women decided Dr. Hootan Roozrokh was not guilty beyond a reasonable doubt of felony dependent adult abuse in connection with an attempted organ removal on Feb. 3, 2006, at Sierra Vista Regional Medical Center in San Luis Obispo. Roozrokh was accused of endangering the health of 25-year-old Ruben Navarro by attempting to hasten his death during the failed procedure by ordering large amounts of painkillers.

Navarro died, but not in time for his organs to be harvested; but his death was not in question. The issue was whether the man who suffered from a debilitating neurological condition was given drugs to speed up his death.

Never before has a transplant surgeon in the United States been criminally accused of trying to hasten a patient’s death in connection with an organ removal. Transplant experts across the nation feared the case would discourage potential organ donors and transplant surgeons. Roozrokh’s attorney, M. Gerald Schwartz-bach, said the case already has had that effect.

“It was bigger than me,” Roozrokh said after the court hearing. “And they recognized that.”

Hopefully, the jury decided this case on the basis of “reasonable doubt,” but there are other factors, hinted at in the paragraphs above, that give some cause for concern.

Was the jury worried about a “guilty” verdict on potential organ donations due to the negative publicity? This was certainly a major theme broadcast by transplant advocates and organizational reps over the course of the case.

In fact, it’s clear that the medical profession is relieved at hearing this verdict:

Dr. Brian Liang, a law professor at California Western Law School who specializes in health law and policy, said Thursday that many in the transplant community were relieved to learn of the verdict.

“It’s been a big deal,” Liang said about the case. “I think people, certainly in the medical community, are very happy this particular case is not being seen as the typical situation, and that medical providers are actually very sensitive to how ethically they’re suppose to behave with respect to procuring organs.”

Added Liang: “And people on the other side of things see we don’t have these physician vultures standing over somebody with their scalpels out waiting for the flat-line to happen.”

Liang said the case has already done what the jury wrote about, revising the way rare cardiac-death donations are done.

“The policies were not there and the policies were generally not well defined,” Liang said. “The jury really saw that.” The United Network for Organ Sharing and others have strengthened standards for the procedures since the case was filed, Liang said.

These are nice and vaguely reassuring words from Liang, but short on details. How have policies been defined or redefined? More importantly, what guarantees are there in regard to how policies will be implemented?

In the Navarro disaster, some longstanding policies were violated, with the acquiscence of a room full of medical professionals.

That brings me to another concern in regard to influence on the jury. It’s possible they thought Roozrokh was being unfairly singled out for prosecution. No other medical professionals – nurses who administered the questionable medications, the attending physician, etc. – was charged with a crime. In fact, according to earlier press accounts, they escaped professional sanctions of any kind.

In Barack Obama’s book “Dreams From My Father,” his aunt, warning him of the rush of relations in Kenya that might want something from him, says “if everyone is family, then no one is.”

Similarly, in a situation like the Ruben Navarro case, where every single person in the room shares a degree of guilt, the thinking might go something like this – “if everyone is guilty, then no one is.”

In an interesting article I came across while reading for this entry, I found this fascinating article by Laurel Fletcher and Harvey Weinstein in Human Rights Quarterly (pdf). Here’s an interesting excerpt on the “if everyone is guilty” topic:

Criminal prosecutions serve to highlight the moral claim that individuals and not groups are responsible foracts of violence. The stated claim is that holding individuals accountable for these acts alleviates collective guilt by differentiating between the perpetrators and innocent bystanders, thus promoting reconciliation. In the absence of individual accountability, the fear is that the entire group ofthose in whose name atrocities were committed will be deemed collectively accountable. Dwight MacDonald conceives of collective guilt as “a Hegelian statist approach in which individuals lack will, thought, and conscience except as these are united in the ‘organic totality’ of the state.” As a result, proponents of this view assert that since everyone is guilty then no one is. Consequently collective guilt absolves everyone of responsibility for past wrongdoing. (emphasis added.)

I plan to read this article more carefully when I get back to work next week, it has a lot of interesting information on the environmental and social factors that increase the risk that people will violate their own ethical standards and the law itself in ways they might not if acting on their own.

As far as I know, the research regarding obedience and group dynamics has never been applied to people in a medical setting. Maybe the Navarro case is an indicator that this is an area of research needs to be undertaken – to improve patient safety and quality of care.

That’s not to much to ask, is it? –Stephen Drake