Is the Need for Organ Transplants Changing the Definition of Death?
More than ever before the definition of death is having ethical, moral, economic implications which can impact the lives of not just a family but also a nation. In the 1960s, medical science was beginning to make great advances in the ability to save lives with medical transplants from the deceased. The problem was that using the standard definition of death at that time, irreversible cessation of the heart, often resulted in the loss of many potential organs from willing donor families.
Rapid ambulance response, emergency medical care, and better understanding of resuscitating patients from catastrophic events was saving the hearts and bodies of many who would otherwise be classically dead but not saving their brain function. Unfortunately the brain is the most sensitive organ to loss of blood supply and oxygen and can be permanently irreversibly damaged and even totally cease function while the rest of the body can be functioning almost normally following medical resuscitation.
Medical advances in the ability to keep patients alive with severe brain injuries was also bringing up the concept that this might be considered unreasonable suffering. In 1976, the Karen Ann Quinlan case received national attention when her family wished that she, a victim of drug abuse with severe permanent brain injury, be disconnected from a ventilator. Ultimately the courts agreed with the family although Ms. Quinlan did not die for some years, her case did establish the concept that less aggressive care is an appropriate option for those with permanent brain injury and that over aggressive treatment could be considered inappropriate.
A growing number of patients were being seen that could have their bodies maintained by medical technology but had no discernible brain function by the late 1960s. Over the next 20 years, the concept of “brain-death” was gradually adopted by most states as equivalent of the classic definition of death. By 1981, a Presidential Commission had come to a consensus that led to the Uniform Determination of Death Act. This served two functions, families were relieved of prolonged suffering seeing their loved ones maintained in hopeless states and also provided a uniform way to determine who would be appropriate to consider as a potential candidate for organ donation. The standard was anyone less than brain dead, that is who had any detectable brain function, would not be an organ donor, however, at the same time it was appropriate if the family chose to do so to remove medical technology that was artificially supporting life.
The increasing population and availability of advanced health care nationwide has significantly increased the need for more donor organs. At the same time public education about traffic safety, raised vehicle safety standards, and emergency medical improvements have dramatically decreased the amount of available organ donors who are brain dead. There continue to be thousands of patients nationwide who have severe brain dysfunction but are not brain dead. Lately there has been a movement to allow these patients to be organ donors by removing life support than quickly declaring them dead as soon as the heart stops. Many experts believe that this could be life saving for many who now die waiting for transplants. The millions if not billions of dollars spent maintaining these severely brain injured patients, their taking up of critically needed special care or intensive care beds in financially strapped hospitals (these patients costs are usually not paid by insurances companies in full), and the rapidly increasing need for organ donors is putting great pressure on this concept to move forward.
Many traditional Christian religious leaders have accepted the concept of brain death and the removal of aggressive life support in the face of inevitable death. The official Catholic view has been that these are “medical decisions” but not without some descent. On the other hand, Orthodox Jews and Muslims among others, have been reluctant to accept the brain death concept. Lately there has been renewed controversy raised in the Catholic Church when Pope Benedict XVI called this week for there “not to be the slightest hint of arbitrariness in the determination of death” and asked that there be a consensus among experts in light of the latest scientific advancements. Some interpreted his message to be questioning the concept of brain death but he later clarified as not the intent of his message. Even the esteemed New England Journal of Medicine has gotten into the controversy recently when it questioned whether some patients who are declared brain dead are really brain dead. The article by Drs. Troug and Miller stated that it in effect you cannot get a live organ from a dead body and stated that it is now ethical to move beyond the concept of the “dead donor rule” and allow donations from patients that are not brain dead.
One of man’s greatest problems has always been that our technological advances are always ahead of our ethical and moral advances. Our ability to keep bodies going with expensive technology has created the ability to save other lives with transplants but in so doing gives us more power than ever to determine when “death” occurs. Doctors and technology are not faultless, it is impossible to predict with absolute certainty who will recover some function and who will not for people in conditions where there is some brain function especially if that condition has been short lived. This is one of the reasons the original definitions were so stringently made for brain death which has a very high certainty. On the other hand, the power that families have to rightfully decide that they do not want aggressive life support for a loved one is inherent to our society.
We must remain mindful that there are tremendous external pressures on these decisions. Hospitals are always short of intensive care unit beds and also lose money on these chronic patients. Families understand that medical bills for these patients can add up to hundreds of thousands of dollars for chronic care of the brain damaged. The transplant industry has desperate clients and is a lucrative medical enterprise for those hospitals that participate in it. In fact, even indigent medical donors get some of their medical expenses paid for by transplant programs.
Allowing families to have their loved ones who are not brain dead but reasonably determined by several experts to have severe brain injury after a prolonged period of observation to be organ donors if they “die” following removal of life support is not unreasonable. The most important issue is to educate the public and the families fully of what is reasonably certain and of what is reasonably not certain. We also, as a society, have to come to grips with the concept that there are finite resources available to each of us as individuals. Life has a beginning and an end. Medical science can examine heartbeats and brainwaves but it cannot define what living means. There may appropriately be different answers to the question “What is Living?” based upon our differing religious, cultural, and family backgrounds. Extreme care must be taken not to cloud these beliefs with the exigencies of financial or societal pressures. Finally, legislators need to be mindful in writing laws addressing this issue that allow families and their physicians to be the principal deciders of what should or should not be done.
Tony Barclay is a retired physician and graduate of Harvard Medical School.
