Moment of death: ethical concerns.

One of the politically correct themes on which our journalists lavish their rhetorical talents is the blatant and sensational promotion of the alleged virtues and benefits of the donation of human organs for transplantation, after the diagnosis of brain death or cardiac death. In Canada at present, the emphasis is on donation after 'brain death;' irreversible loss of the function of the entire brain.

The Harvard Ad Hoc Committee on Irreversible Coma in 1968, stated that brain death should be regarded as death because, since the patient is in irreversible coma, he or she is, for all practical purposes, if not in reality, dead. This oxymoronic notion has been used ever since as an excuse to justify organ retrieval for transplantation. The truth is that although most persons who are declared brain dead will die within 48 hours of that declaration, some will survive to live a normal life. Some pregnant women have lived 'brain dead' for up to four months and delivered a normal child.

Is 'brain death' actual death?

There is no medical or scientific consensus about the definition or the diagnostic criteria of brain death. These facts were reiterated by a bioethicist at a national conference on organ donation in the U.S. in 2006. (1) No one can tell precisely when a person dies, yet many physicians are willing to take organs from a patient whom they consider "as good as dead." At a different convention in 2006 on organ donation, another bioethicist stated that the criteria for brain death are based on "personal, cultural, social, and political considerations", and yet another expert stated that the public has not accepted brain death as real death. (2)

Donation after 'cardiac death' (DCD)

During the 1990s, another kind of 'death' was described in the U.S. in order to further facilitate the acquisition of organs. It was termed 'cardiac death' or 'cardio-pulmonary death.' This terminology was based on the historical idea that one is dead after the heart stops beating. The problem is, how long after? A typical scenario illustrates the current situation in the U.S. Organ donation after cardiac death is also called Non-Heart-Beating Donation (NHBD).

Someone between the ages of five and fifty-five years, and who is otherwise healthy, but has suffered a severe brain injury, either in a traffic accident, or due to a stroke, is admitted to the intensive care unit of a teaching hospital and placed on a ventilator that is necessary to assist breathing. Soon after admission, the physician in charge makes an arbitrary decision that the patient's prognosis is 'hopeless,' because, in the physician's opinion, the patient either will not survive or will have an unacceptable quality of life. This decision may deprive the patient of the chance of survival, or even recovery, because, especially at this early stage, it is impossible to predict whether a given patient will die or what level of recovery will eventually be attained.

Nonetheless, the physician then proceeds to discuss with the family, the patient's putative 'hopeless' condition and the 'futility' of ventilatory support. If the family or the person with power of attorney for personal care agrees, life support is withdrawn and a 'do not resuscitate' order is written. In some hospitals, potentially dangerous drugs such as Heparin, used to prevent blood clotting that might damage organs, and Regitine, used to dilate blood vessels and help keep the organs well supplied with blood, are administered to the patient. Note here, that even the accidental administration of such drugs to any other patient would be considered a serious reportable mistake.

If the heart is still beating one hour after ventilatory support is withdrawn, the organs are judged to be no longer healthy enough for transplantation and the patient is therefore returned to a hospital bed, eventually to die, without treatment being resumed. If the heart stops beating within an hour, most physicians wait five minutes, then declare that the patient has suffered 'cardiac death' and immediately remove the desired organs from the patient. Some physicians take organs immediately after the heart stops, or wait for only two minutes, despite the fact that, as Dr. Michael DeVita, one of the inventors of DCD, has stated, "the possibility of (brain function) recovery exists for at least 15 minutes."

A further reason for concern is the fact that the interval of two to five minutes before organ retrieval was recommended by the Institute of Medicine (IOM) in 1997, but subsequent studies have not been conducted to provide a statistically valid basis for determining the minimum duration of observation necessary to rule out the possibility of spontaneous resuscitation by the patient. In addition, the National Conference of Organ Donation After Cardiac Death (2006) recommended that appropriate agencies of the Department of Health and Human Services should fund observational studies on the frequency with which a patient spontaneously becomes resuscitated after withdrawal of life-sustaining treatment. The IOM admits that a two-to-five-minute interval between 'loss of heart beat' and 'loss of life' is not relevant to the determination of real death, but will "in a donor with a normal body temperature" produce irreversible brain damage. (3) It should also be noted that, in the U.S., decisions to withdraw ventilation "are being made because of potential quality of life concerns rather than the ability to survive." (4)

There is at present a strong movement to allow DCD in Canada. DCD is legal in the U.S. but not in Canada. Furthermore, in June, 2005, a bill was presented to the federal Parliament of Canada that proposed to allow organ retrieval if the patient had not forbidden it in writing. In February, 2006, a bill before the Provincial Parliament of Ontario proposed to legalize the refusal of a driving licence to anyone who does not declare their intentions in regard to the use to be made of their organs after death.

Conclusion

If organs are removed from a patient too soon after 'brain death' or 'cardiac death' have been declared, there is a definite risk that the patient's death will be caused or hastened by the retrieval process. The precise moment when a given person dies is not known and may never be known with enough precision to allow morally acceptable harvesting of organs. Organ retrieval after the declaration of cardiac death or brain death, as currently practised, is therefore not acceptable.

It is moral, however, for a living person to donate a kidney or a part of the liver. The liver can grow back to replace the tissue that has been removed, but those who donate liver tissue should realize that there is up to a 1% chance that they may not survive after surgery. Certain tissues, such as corneas and bone, can be retrieved from a body many hours after death.

In the light of the current forceful political and media campaign to influence, and even coerce, people into organ donation on the basis of the spurious diagnoses of cardiac death or brain death, it is of paramount importance that the public learn the scientific and moral truth about organ donation and take vigorous action to prevent this practice, so ironically described and understood by many, including those who retrieve the organs, as an act of true compassion in the overriding interest of the public at large.

References:

(1) The National Conference on Organ Donation After Cardiac Death, American Journal of Transplantation, 2006, 6: 281-296. Blackwell: Munksgaard.

(2) Organ Donation After Cardiac Death: Panel Discussion of the Ethical Issues. University of Toronto Joint Centre of Bioethics, Mar. 29, 2006.

(3) Institute of Medicine. "Non-Heart-Beating Organ Transplantation--Medical and Ethical Issues of Procurement." 1997, National Academy Press, Washington.

(4) Nancy Valko, R.N., "Ethical Implications of Non-Heart-Beating Donation." Voices, Michaelmas, 2002, vol. XVII; no.3.

John B. Shea, M.D., FRCP(C)

Dr. John Shea is Catholic Insight's medical/bioethical contributor. He lives in Toronto, Ontario.