Paul A. Byrne, M.D.
January 26, 2010
Death starts when life has ended!
By Paul A. Byrne, M.D.

The demarcation between harvesting transplantable organs from truly dead donors and from those "who are not dead but dying" is becoming more and more blurred as the need for transplantable organs continues to rise. Dr. Sanghavi in his column in the New York Times of December 20, 2009, with the title "When Does Death Start" advocates that society embrace a new way of dying. This new way is called "Donation after Cardiac Death" (DCD) and is legally based on the Uniform Determination of Death Act (UDDA) that includes "irreversible cessation of circulatory and respiratory functions." Society's embrace is deemed necessary to increase the supply of transplantable organs. At the same time, society places great moral value on and trust in the procurement of organs exclusively from those who are truly dead. Although saving the lives of others through organ transplantation is, in principle, morally praiseworthy, society has yet to formulate an answer to the question whether the death of dying patients can be hastened for the purpose of maximizing opportunities for the legal harvesting of transplantable organs. To avoid even a public debate on this issue, the transplant community, understanding the hesitation and possibly a principled rejection of hastened death, has invested great efforts in reinterpreting the UDDA. This 1981 Act states that "An individual who has sustained either (1) irreversible cessation of circulatory and respiratory functions or (2) irreversible cessation of all functions of the entire brain, including the brainstem, is dead." The notion of "irreversibility" has been at the heart of the discussion about life and death. True irreversibility is not commensurate with the objective of harvesting transplantable organs. The waiting time prior to commencement of the actual procurement that would be required to ensure that none of the vital functions can spontaneously return, exceeds the maximum period that organs are suitable for transplantation. Therefore, as Dr. Sanghavi pointed out, doctors had to create "a new class of potential donors who are not dead but dying." A patient who is dying is, in fact, living. The "old way" ie, procuring organs from "brain dead" patients, is not sufficient to produce as many organs as desired. Meanwhile the very concept of "brain death" continues to be challenged.

The Harvard Committee in 1968 created the concept of so-called "brain death" and equated this with human death because it believed this to be a necessary step to improve the likelihood of societal acceptance and legalization of heart-beating ("brain death") organ procurement. Ever since, opponents have argued "brain dead" patients may have lost spontaneous respiratory drive and consciousness, but the heart and whole body continue to function, maintaining integrated biological functions indistinguishable from living human beings. Despite these continued objections, the fact remains that the Harvard Committee de facto changed death from a well-defined, singular biological phenomenon into a social construct. Bed-side tests are routinely used to determine "brain death" by clinical criteria only. Ancillary diagnostic tests such blood-flow imaging studies are rarely done. However, at least one autopsy study of brains from subjects determined "brain dead" showed that a significant portion only had minimal structural damage. Some have even argued that a significant number of patients determined "brain dead" can be rescued with proper treatment resulting in hospital discharge with close to normal functional status. In fact, concerns about the scientific and philosophic validity of the concept of "brain death" and even compliance with clinical guidelines to determine "brain death" have been growing.

Dr. Sanghavi correctly pointed out that DCD as an alternative to "brain death" is gaining in popularity within the transplant community. His presentation of the facts, however, deserves some scrutiny. First, depicting the Institute of Medicine as an independent advisory board is an overstatement as, at best, the transplant community was over-represented. Second, the two crucial conditions for DCD support are rarely met in day-by-day procurement practices. Families are frequently put under moral stress to consent to organ donation. Team-huddling practices in which procurement agents seamlessly seem to fit in with the care team are designed to maximize consent. The five minute waiting time is not uniformly adhered to and in fact has been reduced to 75 seconds in some institutions. Further, the name donation after cardiac death suggests that patients "flat-line." The truth is that death has been called by circulatory criteria when the heart muscle is electrically active but out-of-rhythm and that patients before final withdrawal off the ventilator undergo a 10 minutes trial of non-ventilation to predict the likelihood of dying within 60-90 minutes of ventilator withdrawal. Not mentioned in Dr. Sanghavi's article was that the account of Children's Hospital of Philadelphia's experience with DCD also raised serious questions. At least in 2 cases high dosages of narcotics were given from extubation to death, which poses a challenge to notion that no euthanasia is involved in DCD. Boucek's premise that spontaneous restarting of the heart has not been reported in the medical literature beyond 65 seconds is incorrect. Autoresuscitation has been reported after more than 10 minutes.

Dr. Sanghavi's comment that no religious organization or right-to-life group has mounted any opposition to DCD is in part explained by the reliance on the integrity of the medical community both in regard to professional standards and medical practice. Religious scholars placed trust in the medical profession despite the fact that health care has increasingly become a commodity, risking the emergence of profit-driven decision making in a free-market environment.

Dr. Sanghavi suggests that for some moving past a binary concept of life and death implicitly legalizing euthanasia may bring the solution to the DCD dilemma. He is quoting Dr. Robert Truog, a professor of medical ethics at Harvard Medical School, when he says that this is a situation where "all the ethical vectors are lined up," Others who believe that organ procurement is likely to be the proximate cause of death may have to come to the conclusion that this kind of organ procurement violates their moral principles.

It would be morally more appropriate, if not mandatory, for the transplant disciplines to be more transparent about procurement processes. Establishing moral and legal clarity would create room for people to make well-informed decisions about organ donation.

Paul A. Byrne, MD. Toledo, Ohio
Joseph L Verheijde, PhD. Scottsdale, Arizona


© Paul A. Byrne, M.D.

 

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Paul A. Byrne, M.D.

Dr. Paul A. Byrne is a Board Certified Neonatologist and Pediatrician. He is the Founder of the Neonatal Intensive Care Unit at SSM Cardinal Glennon Children's Medical Center in St. Louis, MO. He is Clinical Professor of Pediatrics at University of Toledo, College of Medicine. He is a member of the American Academy of Pediatrics and Fellowship of Catholic Scholars... (more)

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