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Posts Tagged ‘organ transplants’

Forgive the crude title, but this is the question I was discussing with a group of healthcare professionals recently. The specific topic was ‘brain death’, which is a phrase so widely used today that it hardly ever gets questioned. If someone’s brain is ‘dead’ then surely the person is dead as well? If the human brain has ceased to function then surely the human being has ceased to be alive? Not necessarily.

Much of the controversy is about organ transplantation. If you are going to take someone’s heart and give it to another person, you have to be sure that they are dead before you remove the heart, otherwise the act of removing the heart will be the very cause of their death. At least, that’s what most ethicists would say. The surgeon wants to know that he or she is taking a heart from a corpse and not killing a person. For many years, it has been assumed that if someone is certified ‘brain dead’ then they are definitely dead, and the transplant can go ahead. But this is being questioned more and more.

E. Christian Brugger, Senior Fellow of Ethics at the Culture of Life Foundation, gives some background:

For purposes of organ removal, there are two commonly accepted sets of criteria for determining that death has occurred: the “cardio-respiratory” standard and the “neurological” standard (sometime referred to as the “whole brain death” criterion). The Uniform Determination of Death Act formulated in 1981 by the President’s Commission and widely adopted throughout the U.S. defines the first as the “irreversible cessation of circulatory and respiratory functions”, and the second as “the irreversible cessation of all functions of the entire brain, including the brain stem.” Although each criterion focuses upon a limited set of critical functions, the state of death of the entire human organism is thought to be able to be inferred by focusing on any one of them.

In his 2000 address, John Paul II says that when “rigorously applied” the neurological criterion “does not seem to conflict with the essential elements of a sound anthropology.” He goes on to say “therefore a health-worker professionally responsible for ascertaining death can use these criteria [i.e., cardio-respiratory and neurological] in each individual case as the basis for arriving at that degree of assurance in ethical judgment which moral teaching describes as ‘moral certainty'” (No. 5).

In other words, the pope states that the neurological criterion seems to be a reliable basis for arriving at moral certitude that a person has died, which is required before harvesting vital organs can be legitimate.

But new questions have come up in the last few years.

Research has emerged in the past decade, especially by D. Alan Shewmon, professor of pediatric neurology at UCLA Medical Center and Consultant for the Pontifical Academy of Sciences, challenging the reliability of the widely accepted neurological standard.

Recall the pope says that death consists in the “disintegration of that unity and integrated whole that is the personal self” (no. 4), and that we can identify biological signs that follow upon the disintegration. It seems to follow that an apparent absence of certain biological signs of somatic (bodily) disintegration can raise reasonable doubts as to whether death has occurred.

Shewmon’s research demonstrates conclusively that the bodies of some who are rightly diagnosed as suffering whole brain death express integrative bodily unity to a fairly high degree.

Brain dead bodies cannot breathe on their own since the involuntary breathing response is mediated by the brain stem, which has suffered complete destruction. So the bodies need to be sustained on a mechanical ventilator, which supports the body’s inspiration and expiration functions (breathing in and out). But with ventilator support, the bodies of brain dead patients have been shown to undergo respiration at the cellular level (involving the exchange of O2 and C02); assimilate nutrients (involving the coordinated activity of the digestive and circulatory systems); fight infection and foreign bodies (involving the coordinated interaction of the immune system, lymphatic system, bone marrow and microvasculature); maintain homeostasis (involving a countless number of chemicals, enzymes and macromolecules); eliminate, detoxify and recycle cell waste throughout the body; maintain body temperature; grow proportionately; heal wounds (i.e., the immunological defense of self against non-self); exhibit cardiovascular and hormonal stress responses to noxious stimuli such as incisions; gestate a fetus (including the gaining of weight, redistribution of blood flow favoring the uterus, and immunologic tolerance toward the fetus); and even undergo puberty.

The data is indisputable. Yet there is considerable disagreement on how to interpret the data with respect to the question of human death. Some scholars such as James M. DuBois, writing in the 2009 “Catholic Health Care Ethics” manual published by the National Catholic Bioethics Center, refer to this long list of functions of brain dead bodies as “residual biological activities” no more expressive of life than the twitching of a lizard’s amputated tail. Others, including scientists and several philosophers and theologians who, with me, accept magisterial teaching, are less comfortable setting them aside as possible signs of true somatic integration.

Although Shewmon’s evidence certainly does not establish that brain dead bodies are the bodies of living (albeit highly disabled) persons, in my judgment, and in that of other competent scholars and scientists, it raises a reasonable doubt that excludes “moral certitude” that ventilator-sustained brain dead bodies are corpses.

It’s not an argument to say that a brain dead person is necessarily still alive – it simply suggests that there are serious doubts and questions about the meaning of brain death. And as long as such questions remain, we shouldn’t pretend that we have absolute confidence that a brain dead person is definitely dead. And if that’s the case, then there are implications for how we continue to care for such persons, and whether or not we transplant their organs.

If you want to follow this up, see this article on the Signs of Life conference on brain death in 2009; Pope Benedict’s 2008 address to a conference about organ transplantation; a Linacre Centre paper that touches on brain death, and another about the definition of death; and the NHS page about brain death, which includes the following uncritical remarks:

Brain death occurs when a person in an intensive care unit no longer has any activity in their brain stem, even though a ventilator is keeping their heart beating and oxygen circulating through their blood.

Once a brain stem death has occurred, the person is confirmed dead.

Unfortunately, there is no chance of a person recovering once their brain stem has died. This is because all of the core functions of the body have stopped working and can never be restarted. Although a ventilator can keep the heart beating, the person is effectively dead.

If permission has been given, organs can be removed for transplant and ventilation is withdrawn. Once ventilation is withdrawn, the heart stops beating within a few minutes.

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