"The scenario is familiar: tragic accident, young victim, distraught family. Follow-up media coverage reports approvingly of the donation of the brain-dead victim's organs. The family expresses relief that some good has arisen from what could have been merely a senseless tragedy.
Most would find little controversy in donating the organs of a brain-dead patient. However, a small but growing number of experts are protesting what they deem too hasty a rush to procure transplantable organs - so hasty that so-called 'brain-dead' patients are in fact alive when they are put to the knife.
'Brain death is not for diagnosing somebody who is dead. It's for creating a fiction for the determination of death, in order to get organs,' says Dr. Paul Byrne, a Toledo, Ohio physician who has studied the subject of brain death for 20 years.
But Dr. Christopher DeGiorgio, professor of neurology and neurological surgery at the University of Southern California, feels that using the diagnosis of brain death to procure organs for transplant is positive and morally acceptable. 'When the organs of a brain-dead individual are transplanted, they can save the life of seven or eight people,' he points out. 'You've got two kidneys, one heart, valve, lung, liver, corneas, all sorts of things that can benefit living people.'
The Uniform Determination of Death Act (UDDA), adopted by most states, defines brain death as the 'irreversible cessation of all functions of the entire brain, including the brain stem.' The act states that patients are legally dead when they fulfill either the traditional criteria for death - cessation of breathing and heartbeat - or when they are brain-dead. Due to the use of artificial life support, many patients are now pronounced brain-dead before their heart and lungs stop. Although these individuals are legally dead, they may be kept on artificial life support in order to preserve their organs for transplant.
'To refer to someone who is on a ventilator, whose heart is beating, and [who has] blood pressure and other findings that we identify with being alive, as a cadaver, is simply not the truth,' maintains Byrne, a board-certified pediatrician and neonatologist. The term 'coma,' even 'irreversible coma,' describes 'someone who's alive, not someone who's dead,' he says.
Dr. DeGiorgio appears to agree with Byrne on this point. 'From a purely metaphysical point of view,' he says, 'one can still argue that as long as the heart is beating, you have a human being. Again, [the definition of brain death] is a medical-legal definition, it is an artificial definition, because it is a criteria for death, but it doesn't mean that a variety of the individual organs aren't functioning.' The word 'brain-dead' is a misnomer. Technically the person is not dead, but legally he is, and in the medical community he's dead, even though he is a body with organs. What we're saying is that we have decided as a society that these individuals are no longer alive, and that we're defining death as either death of the heart or vascular system, or irreversible cessation of function of the brain. What we're talking about is a mechanism to allow us to withdraw life support.'
Dr. DeGiorgio, a Catholic, cites Pope Pius XII's 1957 address to the International Congress of Anesthesiologists, which alluded to a distinction between the life of an organism and the life of its cells. DeGiorgio interprets this as saying that 'it was up to physicians to determine criteria for death. There was this idea that once the person had stopped functioning as an integrated organism, even though he may have a collection of organs that may be functioning independently, that person may be considered dead. The pope, from the late 1950s, recognized that indeed it was up to physicians to provide criteria for death in cases where the heart or the kidneys may still be functioning, but the brain is not functioning.'
Byrne points out that Pius XII's statement cited by DeGiorgio reads in full: 'But considerations of a general nature allow us to believe that human life continues for as long as its vital functions - distinguished from the simple life of organs - manifest themselves spontaneously or even with the help of artificial processes.' According to Byrne, this quote, in which the Pope specifically refers to comatose patients, has been widely misquoted with the word "unless" replacing the phrase "or even," which reverses its meaning.
'There is some modest debate among theologians about if there really is something called brain death,' DeGiorgio admits. 'But the Catholic church recognizes the validity of brain death guidelines.' (He is unable to cite an additional Vatican source for this statement.)
This 'modest debate' extends beyond theologians to physicians and bioethicists. The objection most frequently raised is that current criteria for determining brain death cannot adequately assess the presence or absence of irreversible coma. In a book entitled 'Life, Life Support, and Death' (published by the American Life League), nine physician co-authors -including Paul Byrne- argue that, 'Brain-related criteria are flawed not only in scientific theory but also in application. In order to fulfill the current 'brain death' criteria, the entire brain stem must not be functioning. In fact and in practice, however, often only some brain stem reflexes...are evaluated... Although there are other functions of the brain stem, including maintaining a normal body temperature, producing hormones via the hypothalamic-pituitary axis, neurogenic control of heart rate and maintenance of normal blood pressure, either these brain functions are not considered at all or they are said to be inapplicable or insignificant for determining death.'
It is possible, by continuing to ventilate a brain-dead patient, to test the diagnosis of death. If cardio-pulmonary death - that is, death in the classical sense - has occurred, in a short time the patient's heartbeat will slow and become irregular, despite continued ventilation. Eventually, no amount of artificial life support will be able to sustain the heartbeat. By the time this occurs, however, lack of oxygen likely will have damaged the vital organs. The deceased patient will no longer be a source of viable organs. Therefore, there is little interest in confirming death in this manner.
There may be a further reason why such confirmatory tests are not done - namely, that most 'brain-dead' patients are not truly dead. According to DeGiorgio, 'You can keep somebody on life support for a few days or a few weeks at the longest, but generally people do not survive past two weeks who are truly brain-dead.' Yet Byrne cites cases of brain-dead individuals who have survived for long periods of time, even years.
A casual search of pro-life resources soon reveals ten such cases, the most gruesome being that of a 'brain-dead' patient who put his arm around the assisting nurse as he was about to have his heart removed for transplant (Journal of California Nurses for Ethical Standards, September 1996).
Further evidence is provided by Dr. Alan Shewmon in his article 'Recovery from 'Brain Death': A Neurologist's Apologia' published in the Linacre Quarterly. Dr. Shewmon cites a collection of over 30 cases of protracted survival of brain-dead patients, ranging from one week to nine months, with half of these patients surviving over eight weeks. There are other documented accounts of patients who have been diagnosed as brain-dead, and who have later recovered consciousness. Such cases, though, are rare.
As further evidence, Byrne and his colleagues maintain it is impossible to transplant vital organs from a corpse. 'The present state of the art for these vital organs is such that they have to come from someone who is alive,' says Byrne. 'It takes about an hour of operating to get the heart out, during which time the heart has to be living, and many other organs and systems of the body are also functioning, while they take the heart out. Likewise, to get a liver out, it takes perhaps three hours of operating. Without circulation, the heart becomes not able to be used for transplant in about three or four minutes. The liver becomes not useful for transplant in about three or four minutes. Not useful for transplant means that the tissue of the heart or the tissue of the liver becomes destroyed so it's no longer what it was before.'
If such reports of prolonged survival are relatively few, it could be because the diagnosis of brain death becomes a self-fulfilling prophecy. As Dr. Byrne notes wryly, 'No one ever recovers if their heart is cut out.'
As a solution, Dr. Byrne and his colleagues advocate a return to the traditional cardio-pulmonary standard for determining death, with the additional caveat that, 'No one shall be determined or declared dead unless and until there is destruction of at least the three basic unifying systems of the body, namely, the circulatory and respiratory systems, and the entire brain.' Although the application of this standard 'would preclude transplantation of unimpaired vital organs,' they believe that 'it is the only acceptable standard to ensure that living human beings are not treated with the scientifically inaccurate and morally repugnant haste that leads to a premature grave.'
The ultimate issue, Byrne says, is the progressive devaluation of human life. He believes that the acceptance of brain death was a major step in the acceptance of abortion. Because of the 1968 Harvard Criteria defining irreversible coma as 'brain death,' he says, 'the medical community accepted that absence of brain function was sufficient to call someone less than human. That was part of preparing them for the acceptance of abortion. If you have certain human beings in intensive care units, and you can call them something less than human, so that you can get organs, why can't you have other human beings that are out of sight in the uterus, and call them less than human so that we can kill them also, or use them for our own purposes?'
Dr. Byrne's concerns about the 'slippery slope' are borne out in an article by Robert Truog, Associate Professor of Anaesthesia at Harvard Medical School. Entitled 'Is It Time to Abandon Brain Death?' (Hastings Center Report, January-February 1997), Truog's article draws conclusions similar to those of Byrne and his colleagues. The concept of 'brain death,' Truog writes, is 'incoherent in theory and confused in practice.' He too recommends a return to the traditional definition of death, based on the cessation of respiration and circulation rather than neurological criteria.
However, the difficulty of obtaining organs for transplant troubles Truog. One way to solve this problem, he writes, 'would be to abandon the requirement for the death of the donor prior to organ procurement and, instead, focus upon alternative and perhaps more fundamental ethical criteria to constrain the procurement of organs, such as the principles of consent and nonmaleficence.' In other words, with the prior consent of the donor or surrogate, vital organs would be removed from living donors.
Truog notes approvingly that this approach would open the door to removing organs from patients in a persistent vegetative state and anencephalic newborns. Both these groups are currently barred from being considered potential organ donors. 'The most difficult challenge for this proposal,' Dr. Truog says, 'would be to gain acceptance to the view that killing may sometimes be a justifiable necessity for procuring transplantable organs.'"
Sources:
Article by Monica Seeley, in: San Diego News Notes, 1997.
www.sdnewsnotes.com
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