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Two little-known facts about organ transplant

This post will be fairly brief. I hope to write more another time about last year's report by the President's Council on Bioethics (that would be the previous President's council) concerning the determination of death.

Here I just want to highlight two little-known facts that I've become aware of that are very troubling concerning organ procurement practices.

The first fact concerns procurement from patients declared brain dead. Brain death is ostensibly the irreversible cessation of all functions of the entire brain, including the brain stem. That is its legal purport. It must not be confused with being in a so-called "persistent vegetative state." All patients legally declared brain-dead are unable to breathe on their own, whereas patients diagnosed as PVS are usually able to breathe on their own and have at least, as far as anyone knows, brain-stem function.

However, it apparently has been known for quite some time that (some? most? all?) patients declared brain-dead maintain body temperature, though at a somewhat lower-than-normal level and with help from blankets. (See PCBE report, pp. 40, 56, 60.)

In case the relevant bit of human anatomy class has faded into the misty past, body temperature is maintained by the hypothalamus which is...a part of the brain located just above the brain stem.

I have to admit that I fail to understand how anyone could declare in good faith that all the functions of a patient's brain have ceased if a function of the hypothalamus is obviously on-going. A clue may, unfortunately, be found in a passage about which I shall probably have more to say in the PCBE report:

[E]vidence of continued activity of the pituitary gland, or of similar residual brain tissue function in patients diagnosed with “brain death,” is not decisive in determining whether these patients are living or dead.* The question is not, Has the whole brain died? The question is, Has the human being died? This criticism can be leveled perhaps even more sharply at the commonly employed phrase “whole brain death,” which, if taken literally, implies that every part of the brain must be non-functional for the diagnosis to be made. In reality, and somewhat at odds with the exact wording of the UDDA, “all functions of the entire brain” do not have to be extinguished in order to meet the neurological standard under the current application of the law to medical practice. In Chapter Four, we take up the question, “On what grounds might we judge the persistence of certain functions (e.g., ADH secretion by the pituitary gland) to be less important than other functions (e.g., spontaneous breathing)?” (p. 18) [Emphasis added]

Oh. So they didn't mean it. Although it is the activity of the pituitary gland the report is discussing here (the report states [p. 56] that growth has occurred in at least one child declared brain-dead), presumably the authors of the report would say the same about the action of the hypothalamus--that it isn't as "important" as other functions, such as breathing, and hence that it is fine to declare someone brain dead even if his hypothalamus is still working--though such a declaration would be, er, "somewhat at odds with the exact wording" of the Uniform Determination of Death Act.

The second little-known fact is perhaps even more shocking and concerns the other method of organ procurement. In this method, the patient is not declared brain dead. Rather, a ventilator-dependent patient is taken off the ventilator, and doctors wait until he stops breathing naturally. They wait 2 to 5 minutes after breathing and heartbeat stop and declare him dead. Then he is a candidate for organ procurement, which occurs very quickly thereafter so that organs are not damaged by what is known as "warm ischemia."

Most people assume, if they think about non-heart-beating donation at all, that when someone is declared dead because he isn't breathing and his heart isn't beating, that's it. He isn't resuscitated, even if he could be resuscitated, and so he may be declared dead. Even the PCBE (the experts who tried to find out as much as they could before writing their report) assumes this in discussing non-heart-beating donation:

It is important to note that this hypothetical scenario of resuscitating a patient who has been prepared for a controlled DCD procurement is merely a “thought experiment.” In reality, attempting to revive such a patient would be ruled out ethically because the practice of controlled DCD is premised on the assumption that the individual’s family has decided to allow withdrawal of life-sustaining interventions and would, therefore, want to abstain from any efforts to prevent the patient’s death (perhaps by consenting to a “do not resuscitate” order). For this reason, many have argued that the word “irreversible” in this context should be understood in a weaker sense than that spelled out above: It should be understood to mean “cessation of circulatory and respiratory functions under conditions in which those functions cannot return on their own and will not be restored by medical interventions.” (p. 84)

It is understandable that even this argument might bother some people. The obvious philosophical question that arises is this: Why is someone's loss of breathing and respiration considered irreversible because of what someone else has decided not to do? Should not irreversibility be an actual medical determination, not a combination of a medical determination with an intention on the part of people around?

But that concern almost pales into insignificance when one encounters the following quotation from an article about non-heart-beating donation. (I mentioned this in another thread.)

Artificial support of circulation with cardiopulmonary bypass and reintubation for lung ventilation are required for organ viability in donors. The donation-related procedures can resuscitate (reanimate) organ donors during procurement, which requires pharmacological agents (chlorpromazine and lidocaine) and/or occlusion of coronary and cerebral circulation for suppression...

Translation: The possibility of resuscitating patients declared dead under NHBD protocols is not merely a "thought experiment" but very real. First they take the vent-dependent patient off the ventilator and let him stop breathing which causes his heart to stop. Then they wait whatever number of minutes their hospital's protocol calls for--somewhere between two and five minutes. They declare him dead. Then they start the ventilator back up again to keep the organs fresh during procurement. But because it is so soon after the cessation of breathing and heartbeat, they have a very real worry that they may resuscitate the "dead" patient. So they have to block off circulation to his brain or else dope him up to prevent him from "coming to life again."

I wonder how many people know that about NHBD? I wonder how many people would be rightly creeped out by it if they did? It's very obvious from this that NHBD is by no means an ethical alternative to organ procurement from patients declared brain-dead. Indeed, waiting for the patient to be declared brain-dead is arguably applying a more rigorous standard for death, though one which raises all the questions about diagnosis to which I've been alluding.

It is time for conservative ethicists to reconsider seriously their endorsement of vital organ donation. If there is no ethical way to do it, that should be the end of the discussion. Organ procurement is not an absolute imperative.

Comments (23)

From the Report: "The question is not, Has the whole brain died? The question is, Has the human being died?"

This is actually the modern philosophical answer to "What is a human being?" The answer will necessarily be quite subjective. Imagine the number of people who will possess the authority to give that answer. I'm not sure what you'd call the philosophy, or whether there's a "system" of thought to describe it, or even how it came to pre-eminence, but I think it's the core of the problem. In it you can see the potential for the disemboweling of the Terri Schiavos of the world. I think I've told you before that as long this philosophy reigns - one that sees severely incapacitated people as wannabe dead people - there's not much hope for progress. And it's not a defect restricted to the scientists and ethicists who write these things, but one that pervades the whole society.

Lydia thank you for again 'lifting the veil covering our necrotic culture'. I'm stupefied - killing then resuscitating to harvest organs!

By the pricking of my thumbs . . . .

In the French instance, the "definition" of death had been relaxed by the State and medical establishment specifically to allow for quicker (and, theoretically, increased) harvesting of vital organs. This particular man is alive because they didn't begin to dismantle him soon enough.

It's unclear exactly what the new definition was in the French case. Something about heart massage for 30 minutes. I remember the Val Thomas case. There was another very dramatic one last year in the U.S. with a young man who had been in a motorcycle accident. Some of his relatives got some reflex reactions in the room, and at first it was being attributed to "spinal reflex," which is what some have even tried to do with the pain responses noted during removal, but IIRC he then reached out and grabbed a nurse, and that they couldn't attribute to "spinal reflex."

Bill, I was really bothered by that phrase in the quotation as well, especially given the group it was coming from. These are not generally considered liberal bio-ethicists. This was Bush's generally very cautious PCBE. And to do them credit, they expressly address the attempt to declare PVS patients "dead" (which is biologically ludicrous from every angle) and reject that entirely. But it's pretty evident that when they come to admit that "brain death" diagnoses are being fudged in clinical practice, and when they seek to defend that fudging, they are shifting in a dangerous direction. The whole point of whole brain death was supposed to be that it was a strong, stringent, objective, biological means of determining when someone was biologically dead. It was thus supposed to get us _away_ from the subjectivism of "Oh, but maybe the _person_ is dead even thought the _body_ is alive" or any of that junk. Now, they aren't going that far. But then they should be a lot more disturbed than they are about fudging on whole-brain death.

Lydia, I'm with you on the need to be extremely cautious about organ donation, but when it comes to "brain death," using the hypothalamus and body temperature regulation is not a good criterion. I hope I'm not being pendantic, but the hypothalamus doesn't maintain body temperature absolutely, but relatively. If it is not functioning, then the cells in the body still produce heat through their metabolism, just not as finely tuned as they once did. To use a crude analogy, your kitchen is still rather warm--from use of the stove and oven, the compressor on the refrigerator, even light bulbs--when your thermostat is broken and isn't turning on the furnace.

For that matter, there seems to be a big difference between cellular death and bodily death, and the line must be drawn somewhere. Do we cry, "Stop!" because a neuron is still producing anti-diuretic hormone in the hypothalamus? I examine brains from dead people all the time (I'm a pathologist), and I assure you that a significant number of neurons are still alive and well at the time I dropped the brain from an autopsy into formalin.


Chad, I understand what you are bringing up, but apparently I'm not the only one who thinks this sounds like hypothalamic function. Karakatsanis does as well. See my post on his article here:

http://www.whatswrongwiththeworld.net/2008/06/serious_questions_about_brain.html

I have the whole article in PDF and can send it to you if you would like to see it. He mentions hypothalamic function along with pituitary function on p. 399. The strong impression given there is that it isn't even terribly controversial that at least some brain-dead patients have hypothalamic function as well as pituitary function (see above on growth), and that the only remaining controversy is how they are being supplied with blood.

Nor are these the only things that seem to indicate that the cessation of brain function may be impossible to diagnose correctly. There are other things, such as lacrimation (aka crying) and other stress responses in patients during organ procurement, leading to the fairly wide use of anesthesia for procurement in the UK to avoid upsetting medical personnel.

The "individual cells may still be alive" point is one that is often made, but I would point out that even if one is not bothered by that, these seem to be indications of _function_. And specifically, function of brain _structures_ (not just individual cells) in the brain. Think of a "brain-dead" child growing. Wouldn't that freak you out? I think it should.

Now, you can say what you like about that, but whatever else it is, it ain't cessation of all the functions of the entire brain, which is not only what the law requires but is also what some of us have thought we were talking about for the past twenty years and more when we talked about brain death or whole-brain death. In other words, it looks unpleasantly like a bait and switch, and it is bothersome. I recommend not only the Karakatsanis article but also the PCBE discussion of all the things "brain-dead" patients do. In the end the PCBE report admits that the body of the "brain-dead" patient acts as a coordinated organism, which is what (the report admits) people who originally worked out the brain death idea thought would not happen. This ought, in my opinion, to be a lot more problematic than most of the PCBE writers think it is. Instead, they zero in on spontaneous breathing and consciousness and let everything else go to the wall. (That's what I hope to write more about in another post.)

Lydia: "It's unclear exactly what the new definition was in the French case. Something about heart massage for 30 minutes. ..."

The "experimental rules" (and the reasoning behind them) run thusly:
1) 90% (if I remember correctly) of those who are successfully revived after their heart stops beating are revived within 30 minutes;
2) therefore, if, after 30 minutes of affort at resuscitation, the patient has not been revived, then he probably will not be revived;
3) therefore, if, after 30 minutes of affort at resuscitation, the patient has not been revived, then we might as well treat him as though he were known to be "brain dead" -- despite that we are not even checking that metric
4) therefore, since we have decided that we are justified in treating the patient as though he were known to be "brain dead," we are justified in sending his body to the chop-shop.

You might want to read Secondhand Smoke-- they're a bioethics blog-- the guy who writes it covered a very related topic, lately.

http://www.firstthings.com/blogs/secondhandsmoke/2009/10/05/killing-for-organs-2/

Thanks, Ilion, that is clear and helpful.

Foxfier, I follow WJS's posts around so religiously that sometimes I worry people are going to tell me I'm just his echo chamber. He does a wonderful, indispensable job. I had a previous post (you can check all my posts under my name on the sidebar) about some of Wesley's recent coverage. Here, though, I've gone into a report that I don't _recall_ seeing him mention (last year's PCBE report), though I found it from reading the article by Miller (who advocates ditching the dead-donor rule), which I did get through WJS. Also, though I found the article on non-heart-beating donation through Wesley's blog, I don't think he ever highlighted the particular paragraph that I quoted that struck me so forcibly about resuming ventilation after declaring death and then having to block blood-flow to the brain to avoid reviving the patient. That's just shocking. It needs to be more widely discussed.

Hehe, I just hopped back to say "never mind, I just found your post about it while reading back in the archives." Guess I wasn't fast enough!

90% of what Mr. Smith covers is depressing, shocking and in need of being shared-- several times his animal nuts articles have scooped the professional lists my mom subscribes to. (beef ranchers)

When Roman Catholics of a particular persuasion bring up this topic for discussion it is always something to wonder at how many respondents have ever observed the patient in ICU whose heart still pitter-patters as physicians/nurses/etc. (someone who understands physiologically what is going on), OR, has ever been the patient relative (someone who personal grief issues at a loved one called away so soon), OR, is familiar with the work of the nursing assistant in the 'rehab' longterm care facility turning the patient every two hours and performing personal care watching the body and facial features of a non-responding human being contract slowly with living death, OR, perhaps has ever had someone they care about on a transplant list (with an interest in receiving a living organ replacement mindful at the sacrifice of another), OR, even might be someone invested invested in organ procurement, OR others that are involved in group discussion and/or choosing this topic with an eye to making a political statement.

It is fascinating to consider how one might reconcile consideration of all these scenarios and still retain a single attitude in defining which nerve ending anoxia to consider the obligatory definition of death.

Would the person arguing for these 'legal' 'definitions' really respond to this issue given the scenario of a devout Catholic and physician licensed in family medicine in a small communition, whose beloved only child has minimal CNS function two weeks post-emergent surgical procedures to cover a gaping cranial wound sustained in a head-on collision? Say, this young person was over in Iraq and hit by shrapnel? What would the pros and cons in taking a stand one way or the other? Why, or why not?

Ms. Lane-
if I understand your question correctly, you're asking: "what emotionally difficult problems might make someone change their mind about the morality of this action?"

I can only respond that when folks go for emotion and the person making a rational argument, as their primary argument, then they generally don't think they can get anywhere with reason.

First, Cathy, I am not a Roman Catholic. Second, I'm not sure where you are going with this, but my answer is that yes, there needs to be a consistent position concerning a) the fact that it is essential to maintain the dead-donor rule, b) how determination of death ought to be made, and c) the importance of keeping high standards for being sure that donors really are biologically dead. If a consistent and principled position on these matters means that organ donation for vital organs must come to an end, so be it. The mere fact that there are many different people involved with many different patients in these areas does not mean that a consistent position is somehow impossible.

Whatever your point might be, we don't decide whether people are really dead or not by means of considering the "pros and cons of taking a stand one way or another"--that is, I take it, by utilitarian considerations. Biological death needs to be an objective matter, determined beyond reasonable doubt by rational means, or we are behaving unethically in taking organs. As for "minimal CNS function," the UDDA _supposedly_ meant "no brain functions." If we are now going to be told that that isn't what it really means, then we are being subject to a bait and switch and need to object loudly and clearly.

Lydia: "Thanks, Ilion, that is clear and helpful."

Well, it's true that that particular page (which just duplicates this article from The Independent) doesn't explain the "experimental rules" which the French establishment had set up not too long before this incident occurred -- which incident, by the way, wasn't reported to the public until several months later. However, some of the other articles (in UK papers) at the time did explain the rule change; I'm sorry I didn't find one of those.


Lydia (to C.Lane RPh): "Whatever your point might be, we don't decide whether people are really dead or not by means of considering the "pros and cons of taking a stand one way or another"--that is, I take it, by utilitarian considerations. Biological death needs to be an objective matter, determined beyond reasonable doubt by rational means, or we are behaving unethically in taking organs."

Just so: if we don't *know* that these people are dead, then we commit (or allow to be committed) grave moral error -- sin, in a word -- in chopping them up for parts.

Think about it: two hundred years ago, many people had a great fear of being buried alive; and the fear wasn't entirely unreasonable. Today -- if only people knew what was going on -- people ought to have a fear of being killed by the so-called doctors who have taken over medicine.

It is my own opinion that it would be quite reasonable for all of us to put it in writing that we do not consent to be donors and to make sure that our loved ones all know this in case we should be incapacitated.

My point? Unless we consider all scenarios above, we cannot contemplate making a decision based on a single definition i.e. neural death, physiological organ failure death, death below or above a brainstem function while maintained on phenylephrine, massive sepsis death, practical death where a major chunk of the cranium is removed and brains spilling-out deatth, spirit-left-the-body death, life-giving death, etc.. Many people imagine death as a living being's body slowly weakening, simply and slowly stopping breathing with heart rate following, or an acute and massive myocardial ischemia event (blockage of blood flow), but patients revived on respirators in ICU often are 'artificially' retaining some semblance of being 'alive'.

Dopamine and other sympathomimetics may be useful in maintaining blood and other nutrient flow through a living organ to keep its mechanical functions performing until harvest for transplant transport, but there is a certain window of anoxia after which tissue is unusable. When the body functions at a level below the brainstem for maintaining respiratory status without evidence of a single thought process, then time is of the essence for transplantation.

Consider a congenital birth defect wherein a baby is born without a brain. The baby might be born alive and able to breathe on its own for a few minutes, but quickly dies afterward. Potentially, this newborn might be harvested.

If one is to belabor the point of whether one is completely dead before organ harvest with a narrowly defined death as interference with God's plans, then the possibility of transplants will be limited to dead hair transplants. or giving up a kidney. The opposite argument may very well equally and vigorously extended for validation, that man has no business in exhausting every avenue to keep a person alive, even by artificial means. Nor should in vitro fertilization be sanctified, and don't stop the argument, then that premature babies should be administered every lifesaving option that the highest level of care would provide.

As for the reasonableness, just point the recent brouhaha about physicians who though they might have vested interests if a mind thinks that way, would be able to advise a person about the meaning of life and death, in discussing advanced directives and some might think that the US Government is promoting 'death panels'. It would be of interest to see some statistics about individuals addressing their donor status and what to do if incapacitated.

Consider a congenital birth defect wherein a baby is born without a brain. The baby might be born alive and able to breathe on its own for a few minutes, but quickly dies afterward. Potentially, this newborn might be harvested.

a) Some "anencephalic" infants live for days. I know of one that lived for months.

b) They are not born without a brain but only without most or all of the upper portion of the brain. That's _why_ they breathe, etc.

c) It is an abomination to suggest harvesting live infants, and the very suggestion disgusts me and should disgust anyone who isn't a monster. You can draw the implication for yourself, since you evidently think harvesting these live infants is no problem.


When the body functions at a level below the brainstem for maintaining respiratory status

Maybe I'm misunderstanding, but, um, you're an RPh and you appear here to be saying that it is possible for the body to breathe on its own without even a minimally functional brainstem. To put it mildly, a new one on me, and universally contradicted by every article, including technical ones, I have ever read on this subject.

Yes, Lydia, you misunderstood. Sometimes I hear conversations about human life and death issues discussed in terms of a single defining instant, as if there is a switch or technical end. These debates are carried on by very intelligent people with backgrounds in law, history, or philosophy, without nursing or biology background knowledge. When, in reality, often death is the end in a process.

I recall the first death I witnessed at nursing homes when I worked as an nursing aide. Mr. Thomas had bone metastases from a cancerous prostate and over the months patiently avoided movement as much as possible while pain pressed forward relentlessly. I had cranked the head of his bed up so that he could eat, and as was helping him, he raised up on two hands, and looked over to the sunrise, murmuring at its beauty, then relaxed back into the mattress, and I somehow knew he'd given his last breathing efforts. I don't recall if I called the nurse first, but I did attempt to hold his bony emaciated hand, and ask that his passage go easily.

A body may be able to function with a certain degree of brainstem injury, but not on its own i.e. would not be able to maintain respiratory status, and therefore would require artificial respiration to maintain life. Take away the respirator, and death ensues. A person with a brainstem injury above the level required to maintain balance of carbon dioxide and oxygenation may not require artificial respiration, yet, with the 'lights on and no one home' so to speak. Are we to use this as a single definition of being alive vs. not alive?

My point was not to argue levels of brainstem injury, but to point out that there is not one single definition of death, practically. However, as a lay person, it may be perfectly fine for you to wait until the physician prounces the patient dead. Working in the pharmacy to supply the phenyephrine (and, knowing that extensive contact with these type of drugs makes the tissue no longer viable) and other vasopressor drips to maintain cardiac function while the organ procurement organization arrives, leads me to believe that there is no such thing as an exact point to 'reach' before one can be declared dead before harvesting organs.

I brought up the point of the anencephalopathic birth for one main reason; the repugnance factor. While lower functions may be performed, with absence of cerebral cortex, there never was a level of 'human consciousness' if that is some consolation. However, if we are to go by a single definition by someone of death, then organ donation might be restricted to a few cases of death by the guillotine.

Notice, nowhere have I suggested we kill people who prove no longer useful to society.

Cathy, your last paragraph implicates that you see PVS people, whose cerebral cortex isn't viable but their brainstem is, therefore they need not ventilator, as "not human beings" and candidates for organ harvesting.

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There are really a lot of issues when it comes to organ transplantation, organ donation and other related stuff. Most patients received organ donations from other patients who are brain dead and there is actually an issue when their organs are being removed and being donated. I guess, it's all up to the family to decide.

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