Life and death and the organ donor.

The following article is a much abbreviated version of Dr. Shea's original paper. The original may be found on our website under section "Health," together with a11 the proper references.

Editor

Tn an essay published in the American monthly Catholic World Report, March 2001, Bishop Bruskewitz, of Lincoln, Nebraska, and others, point out that the debate about when a person should be considered dead with complete certainty has not been resolved. They suggest that the Pope, in his address to the International Congress of the Transplantation Society in August 29, 2000, may have been misinformed that there were "clearly determined parameters, commonly held by the scientific community" which allow a clinician to declare a person "brain dead" and, by implication, actually dead. The Pope explained that "the use of these parameters, if rigorously applied, does not seem to conflict with the essential elements of a sound anthropology".

The New England Journal of Medicine of April 19, 2001, published an article which stated that the consensus in regard to the equation of "brain death" with death is not free of metaphysical, cultural, legal, and medical controversy. This, it says, has led to the idea that death is a malleable concept that can be adjusted for utilitarian purposes and that, in turn, has made many people ambivalent about organ donation.

The World Report article stated that: 1) no published set of brain death criteria has ever been vigorously applied, and that 2) the word "seem" has been deleted in one published Italian translation by accident.

Some people have interpreted the Holy Father's address as a tacit unconditional approval of organ transplantation. The truth, the World Report states, is that the Pope's speech sets forth stricter guidelines, which are currently being violated, misinterpreted, or ignored, and that these facts call for an urgent "clarification of this important matter of doubt,"

The situation in Canada

In regard to the current debate about the ethics of organ donation, it is interesting to note what a review in the Canadian Medical Association Journal, March 20, 2001, had to say; in the article "Bioethics for Clinicians: 24 brain death," Dr. Neil M. Lazar et al state that

1) brain death is defined as "the absence of all brain functioning demonstrated by profound coma, apnea, and absence of all brain-stem reflexes."

2) "brain death" as a criterion for determining the death of a person "is perhaps justification in the context of organ donation and transplantation."

3) "when death occurs is not simply an agreement about medical or biological criteria, but is also a social formulation".

Note that the article uses medical and biological criteria to define "brain death", but then adds "social formulation," to determine the "death of a person", or to justify the removal of organs and their transplantation. In other words, while Pope John Paul II rightly requires medical and biological criteria "commonly held by the international scientific community" as criteria to declare a person dead. Dr. Lazar et al. think "social aproval" could also be a measuring stick." My question: since when has "social approval" ever established the truth of matters which can only be determined by medical, biological, or moral reasoning? One current example is abortion which--as everyone knows--is done for social, not medical, reasons. That is why many people, including the Church, condemn such reasoning as fraudulent.

The true task of biologists is to face the task of establishing with precision when death occurs. The problem for moralists is the degree of certainty with which this can be established.

Historical background

The idea of "mental death" not marked by loss of respiration and heartbeat but by other criteria was stated in Germany in 1920. In that year, a book was published which promoted the concept of 'live human non-persons'. This concept was a key to the use of euthanasia by the Nazis in order to kill off the psychotic, retarded, demented, and other so-called 'useless eaters'. The same concept was later professionally accepted in the West. The specific purpose of this article is to ask whether "brain death" is actual death.

The biological and philosophical debate

Before one can responsibly declare a person dead, one must define and use biological criteria which accurately indicate the death of a human organism. Traditionally the cessation of the heartbeat and of respiration were regarded as sure signs of death. But medical science has progressed.

Before the middle of the twentieth century, resuscitation of patients when near death was a rare occurrence. Then appeared respirators, electrical heart stimulators, and various medications. These allowed such patients to be resuscitated. Some returned to consciousness but others who did not were still kept alive. Today many doctors have come to regard these unconscious patients as 'clinically dead' and therefore a legitimate source of organs for transplantation purposes. Are these unconscious people deemed to be in irreversible coma, alive or dead? Some physicians were not too troubled by this question. In 1969, for example, Dr. Cooley, a transplant surgeon in the U.S., stated, "The clinician can become too preoccupied with the rights of the recipient". Dr. Christiaan Barnaard of South Africa, who had performed the world's first heart transplant there in 1968, stated in 1969 that "there is no need to wait for conventional death; ... so why wait until the heart stops beating when you know that the patient is going to die?"

The Harvard Criteria 

At about the same time, in 1968, medical researchers published the Harvard Criteria for Irreversible Coma. The committee that published the criteria held that any organ that no longer functions, nor has the possibility of functioning again, is, for all practical purposes, dead. Provided the body temperature is not below 32.2C. and provided that nervous system depressants are absent, the criteria include:

1. A total unawareness of and unresponsiveness to externally applied stimuli--pain, touch, sound, light and inner need.

2. No spontaneous movements or breathing.

3. No reflexes except those mediated by the spinal cord.

4. A flat electroencephalogram.

The problem with point one is that physicians cannot prove that an unconscious patient is unaware of 'inner need'. How can one tell if a patient is not experiencing thalamically mediated pain that the person cannot express? Incidents have recently been reported where patients under anaesthesia have experienced the pain of surgery because, for some reason, they did not respond adequately to anaesthesia.

The Harvard group stated that the judgment that these criteria are present is solely a medical issue; that the physician in charge consult with other physicians directly involved in the case before the person is declared dead; and that the decision to declare the person dead be made by a physician not involved in the case. They recommended that the patient be declared dead before any effort is made to turn off a respirator.

The reason given for the advice is that it would provide a greater degree of legal protection to those involved. They also said that when the above criteria have been fulfilled in the above fashion, function at the cerebral, brain stem, and often spinal levels is abolished, and that the terms 'irreversible coma' and 'brain death syndrome' may be applied and that the patient may therefore be declared 'brain dead'.

The Committee's 1968 definition implied that brain death should be regarded as death because it inevitably leads to death; and that the person in irreversible coma is, for all practical purposes, if not in reality, dead. Untold semantic confusion has followed this oxymoronic notion.

Further controversy

Although agreement on the criteria to be used in determining whole brain death is fairly standard, controversy still surrounds the definition of just what whole brain death is. The definition of whole brain death as equivalent to death raised two other important questions:

1. Do these established criteria in fact indicate the 'irreversible absence of all brain function'?

2. Does brain death, thus defined, indicate the death of the human organism?

Response to question 1:

Many individuals who fulfil all the tests for whole brain death do not have permanent cessation of functioning of the entire brain. The actual physiological status of the brain-dead person remains a problem. Many of these individuals retain clear evidence of integrated brain function at the level of the brain stem and mid-brain, and may have evidence of cortical functioning.

Between 22% and 100% of "brain-dead" persons in different studies have been found to retain free-water homeostasis vasopressin. The brain is the only source of the regulated secretion of vasopressin. Many patients (20% in one study) who fulfil the test for brain death continue to show electrical activity on their electroencephalograms. In at least some cases the activity observed seemed fully compatible with function.

Clinicians have observed that patients who fulfil the tests for brain death frequently respond to surgical incision at the time of organ procurement with a significant rise in both heart and blood pressure. This suggests that integrated neurological function at a supra-spinal level may be present at least in some patients diagnosed as brain-dead. Patients who lack whole brain function still have a heart beat; they can digest food and may even bear children. In short, enough scientific evidence exists to cast doubt on the standard definition of brain death as the irreversible absence of all functions of the brain.

Response to question 2:

Is brain death alone equivalent to actual death? The short answer is NO!

Here it suffices to say that the body contains many organs with many functions. The body is dead only, as Dr. Alan Shewmon asserts, when it has lost its function at the level of the organism as a whole. Now, certain functions are not brain-mediated, for example: absorption of nutrients, elimination and detoxification of cellular wastes, gestation of a fetus (as has happened in eleven women of fifty-two comatose survivors).

Shewmon states: If there is a live human body, there is, ipso facto, a live human person. Unconsciousness, per se, even if irreversible, is ontologically a cognitive disability, and not death. If brain death is not death, what is it?

Unanswered Questions

The anti-entropic point of death (the thermo-dynamic point of no return) is reached when there is supra-critical damage to enough cells of enough types in the body as a whole. What percentage of damaged cells in each organ is enough to declare a patient dead? Which organs interact to provide the integrating mechanism?

By what clinical/technical criteria do we know that central unity is lost? When are these criteria fulfilled? Is there biophysical or biochemical evidence of the consequences of disintegration? Are there any accurate scientifically based tests or measurements available to answer these questions?

The accurate determination of what enough' means in regard to cell death may well prove to be an intractable problem at the practical level. Whether organs are still viable and transplantable at this, as yet, putative anti-entropic point appears moot.

If death is truly present only when the body shows that it has passed the thermo-dynamic point of no return, then one cannot be morally certain that death has occurred in any individual unless we have definitive scientific evidence that this point of no return has been reached. Even if we could precisely estimate when this point is reached, the question would remain whether there is enough time for the retrieval of viable organs. A consideration of what is actually happening in our hospitals with regard to organ donation highlights the urgency of bringing this moral debate to a conclusion as soon as possible.

What happens in hospitals

Most people, including Catholics involved in organ procurement think that the process does not involve killing the donor. Yet there is strong evidence that many are more interested in receiving than in giving organs. One of the reasons that this is so is that the fear of not being dead during the removal of organs, reported by 22% of those undecided towards organ donation, was related to the uncertainty surrounding brain death.

The interest of the medical profession and of the public in the brain-death debate is lessening over time. The University of Pittsburgh has a new protocol which allows critically ill patients or their surrogates to offer organs for donation even though the patients never meet the criteria for brain death. Alan Shewmon states. "...there is a serious issue of informed consent. Most signers of organ donor cards and families authorizing donation have very little understanding of 'brain death' and of what actually happens in operating rooms." Where they read the phrase 'after my death', many imagine a pulseless corpse and might be horrified to learn that it really means "after I become comatose and apnoeic (cannot breathe), but all my other organs are working fine, I will be eviscerated while still pink and warm, with my heart still spontaneously beating and blood circulating."

However, no one is informed that the rationale for equating 'brain death' with death remains controversial and that empirical evidence has been accumulating that casts serious doubt on the mainstream rationale. Thus, information highly relevant for the potential donor's moral decision making is systematically withheld.

Truog has said, "The use of the standard of the prolonged absence of circulation and respiration in defining the cessation of the function of the organism as a whole would ... make it impossible to obtain vital organs in a viable condition for transplantation, since, under current laws, it is generally necessary to be removed from a heart-beating donor."

Canada

In a new departure for North America, the Canadian Medical Association has approved of the argument that "... if you do not forbid in writing the retrieval of your organs, then your consent to their retrieval may be morally presumed ... and that this presumption respects one's autonomous will ... since voluntarism is not providing enough." This presumption is already legalized in Brazil, Belgium and Spain.

In June of 1998, a protocol of organ retrieval using the non-heart-beating donor was proposed in Canada. The recommendations are:

* Get informed consent from the family who have been told that the prognosis is hopeless.

* Withdraw life support.

* Declare death 'as per accepted hospital practice'.

* Retrieve organs without delay.

The above protocol avoids the use of brain death criteria, but the interval between stoppage of heartbeat and 'declaration and retrieval' is not defined, and is left a matter of individual judgment by the emergency department or intensive care unit doctor. Note that not only is death not defined but also brain death criteria for declaration of death are not provided except for what is called 'accepted hospital practice'.

Non-heart beating transplants

Spielman and Verhulst recommended 'non-heart-beating' (NHB) organ procurement.

This means that one may remove the organs when the heart stops beating. They do not state how long after the cessation of the heartbeat the organs should be removed. Ethics committees, they tell us, will sooner or later have to decide what to do when a competent patient desires both death and the opportunity to donate organs. NHB, they seem to imply, will help those committees to 'face both issues together'.

Robert M. Veatch states that it is intellectually important to define clearly our concept of death. He objects to the whole idea of whole-brain death because he objects to drawing a line between the brain stem and the spinal cord. To do so is arbitrary, he says. He then, arbitrarily, draws a line between the mental functions (higher brain functions) and other so-called organic functions. He even states that those in whom this 'coordinated integration' of the two types of function has been lost are 'respiring cadavers ...It is simply unaesthetic to bury someone still breathing."

He thereby inadvertently admits that what should not be buried is indeed a 'person'. He later wondered if, when a patient who has foregone life support and suffers cardiac arrest, organs should not be removed before one is certain that irreversible loss of brain function has occurred.

Patients who will become potential braindead organ donors will suffer multiple adverse events such as shock, hypoxia, infections, multiple transfusions, or surgical procedures. As a result, even before brain death occurs, and also as brain death is occurring, radical biochemical changes occur in the donor which harm the donor's organs. Physicians may be tempted, therefore, to avoid donor organ damage by removing the organs well in advance of the occurrence of brain death.

Brain death abandoned

In recent years the fiction of 'brain death' has largely been abandoned. Evidence of this is found in an article in the June 1, 1999 issue of the Canadian Medical Association Journal. Doctors in Calgary, in an effort to increase the number of organs available for transplant, suggested that, as well as using organs from those who are brain dead, organs should also be harvested from patients who are not yet brain dead, but in whom the heart has stopped beating.

Rome

At the third assembly of the Pontifical Academy for Life in 1997, Mauro Cozzoli, writing about the status of the embryo, stated, "The uncertainty with regard to whether we are dealing with a human individual is not an abstract doubt, regarding a theory, principle, or doctrinal position (dubium iuris). As such, it is a doubt about a fact concerning the life of a human being, his existence here and now (dubium facti). As such, "it creates the same obligations as certainty."

The question as to when, precisely, a person dies, is also a question of fact. A doubt about when a person dies, is also a 'dubium facti', and likewise creates the same obligation as certainty.

"The biologist is the only person competent to say when the bodily life of a human begins or ceases to exist. It is his task to determine with certainty, if possible, when the principle which causes integration of the bodily functions, the principle of unity of the individual, no longer functions. Pope John Paul II has stated that death 'occurs when the spiritual principle which insures the unity of the individual can no longer exercise its functions in and upon the organism, whose elements, left to themselves, disintegrate."

It behooves Catholics who are in a position do so to work with a sense of urgency and diligence to discover, if possible, when that moment occurs when the spirit no longer insures the unity of the individual. For such persons, to quote Pascal, "The first moral obligation is to think clearly."

Dr. Shea is a retired diagnostic radiologist and writes on medical matters for Catholic Insight. His most recent articles are "What's wrong with human cloning," April 2001, and "Canada's stem cell research unacceptable," July/August 2001