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And still more on organ transplant

A recent article in the Wall Street Journal by Dick Teresi says much of what I have been saying for a long time about organ transplant. Here are some relevant quotes. If you didn't know this before, wake up and pay attention now (emphasis added):

The exam for brain death is simple. A doctor splashes ice water in your ears (to look for shivering in the eyes), pokes your eyes with a cotton swab and checks for any gag reflex, among other rudimentary tests. It takes less time than a standard eye exam. Finally, in what's called the apnea test, the ventilator is disconnected to see if you can breathe unassisted. If not, you are brain dead. (Some or all of the above tests are repeated hours later for confirmation.)

Here's the weird part.

If you fail the apnea test, your respirator is reconnected. You will begin to breathe again, your heart pumping blood, keeping the organs fresh. Doctors like to say that, at this point, the "person" has departed the body. You will now be called a BHC, or beating-heart cadaver.

Still, you will have more in common biologically with a living person than with a person whose heart has stopped. Your vital organs will function, you'll maintain your body temperature, and your wounds will continue to heal. You can still get bedsores, have heart attacks and get fever from infections.

"I like my dead people cold, stiff, gray and not breathing," says Dr. Michael A. DeVita of the University of Pittsburgh Medical Center. "The brain dead are warm, pink and breathing."

But BHCs—who don't receive anesthetics during an organ harvest operation—react to the scalpel like inadequately anesthetized live patients, exhibiting high blood pressure and sometimes soaring heart rates.

And now here comes another kicker, a reference to a 1999 article that I had somehow missed until now:

In a 1999 article in the peer-reviewed journal Anesthesiology, Gail A. Van Norman, a professor of anesthesiology at the University of Washington, reported a case in which a 30-year-old patient with severe head trauma began breathing spontaneously after being declared brain dead. The physicians said that, because there was no chance of recovery, he could still be considered dead. The harvest proceeded over the objections of the anesthesiologist, who saw the donor move, and then react to the scalpel with hypertension.

And, indeed, that is exactly what Gail van Norman reports. I have now downloaded the article, available here.

The case to which Teresi alludes is the one van Norman labels "Case 2." She describes it like this:

During an educational course for anesthesiologists, a participant described a case (not independently verified by the author) in which a 30-yr-old patient was admitted to a level 1 trauma center with severe head trauma. A computed tomography scan demonstrated diffuse cerebral damage and blood in the fourth ventricle. The patient was declared brain dead by two physicians, and preparations were made to obtain vital organs for transplantation. Liver transplantation was planned for a level 1 recipient: an otherwise healthy 19-yr-old with hepatic dysfunction of unknown origin.

The on-call anesthesiologist noted that the donor was intubated but
breathing spontaneously with a tidal volume of 800 cm3 and a respiratory
rate of 20 breaths/min. When the anesthesiologist questioned
the diagnosis of brain death, one of the declaring physicians reportedly
stated that because the donor was not going to recover, he/she could
be declared brain dead, and that in any case the liver recipient would
die imminently without transplantation. Vital organ collection proceeded
over the protests of the anesthesiologist, who ohserved donor
movement and hypertension with skin incision that required treatment
with thiopental and a muscle relaxant. The liver recipient died in
another operating room of acute hemorrhage before liver collection
was complete. The liver went untransplanted.

So, if we take this report at face value, this patient was breathing on his own at the time his organs were to be taken. Over the objections of the anesthesiologist, he was directly killed by the harvesting of his organs, the argument given being that he could not recover and therefore could be regarded as dead. Oh, and the recipient really needed the organ, so there. Hint: That wasn't what "whole brain death" was supposed to be. At all. Then, because the devil never plays fair, the recipient died anyway. Murder for nothin'.

Van Norman's other two case studies are scarcely less horrifying. Here is Case 1:

An anesthesiologist questioned his colleagues on the Internet about
whether strict brain death criteria are relevant when the organ donor
is not expected to survive his or her injuries. He reported a case in
which, while caring for a multiple organ donor who had been declared
brain dead after an intracranial hemorrhage, he administered a dose of
neostigmine to treat an episode of tachycardia. The donor began to
breathe spontaneously just as the surgeon announced that the vena
cavae were ligated and the liver had been removed. Upon subsequent
review of the patient’s chart, the anesthesiologist learned that the
donor had gasped at the end of an apnea test, but a neurosurgeon had
certified that brain death criteria had been met.

Now, if I understand this correctly, this was also a case in which the patient was killed by organ removal. He began breathing spontaneously only after (oops! too late!) his liver had been completely removed.

Here is case 3, which is the only one with a better ending:

An anesthesiologist requests that his/her department review the events surrounding a potential organ collection. A young woman receiving intravenous magnesium sulfate for pregnancy-induced hypertension suffered seizures several hours after vaginal delivery. After the seizures, she was unarousable and posturing. She was intubated after intravenous administration of 4 mg pancuronium, and a computed tomography scan showed coning, diffuse edema, and occipital lobe infarcts. A neurologist determined that the patient had suffered a “catastrophic neurologic event.” Intravenous esmolol that was being infused to control blood pressure and heart rate was discontinued, and permission was obtained from the patient’s family for the patient to become a vital organ donor.

On the day of anticipated organ collection, the anesthesiologist
found that the donor had small, reactive pupils, weak corneal reflexes,
and a weak gag reflex. The estnolol infusion was reinstituted. Further
review of the patient’s chart showed the previous administration of
pancuronium, and a serum magnesium level of 5.1 mEq/l, more than
2.5 times normal several hours after the magnesium infusion had been
discontinued. After the anesthesiologist administered edrophonium 10
mg intravenously, the patient coughed, grimaced, and moved all extremities.
Vital organ collection was canceled, and after consultation with a
neurosurgeon, the patient underwent placement of an intracranial
pressure monitor. Intracranial pressure was initially 18 cm H2O and
gradually decreased with therapy to 10 cm H2O. The patient ultimately
regained consciousness and was discharged home. She was alert and
oriented but suffered from significant neurologic deficits.

Three cheers for the alert anesthesiologist. A life spared from the harvesting machine.

Van Norman observes,

Transplantation strains the traditional doctor-patient relationship by presenting a conflict of interest for doctors between the best interest of the potential donor and the needs of a potential recipient.

Indeed. Case 2 illustrates this well, does it not? What is supposed to take care of all of this is the separation between the harvesting team and the patient's doctor while the patient is still regarded as a patient. An independent doctor or set of doctors is supposed to declare death, and only then the harvesting team comes in. Well and good, if the distinction is always observed, but what if, as in case 2, the harvesting team happens to witness incontrovertible evidence that the death-declaring team royally messed up and that the patient is still a patient? See, the problem is that at that point the patient is legally not a patient. He's already been declared dead. He's out of the land of the living. He literally has no rights whatsoever.

Had the doctors in Case 1 and Case 2 reported what they knew, I don't know what would have happened. Perhaps the patients' families would have been able to sue. Perhaps not.

Getting back to Teresi in the WSJ, towards the end he gives us this cynical thought:

It is possible that not being a donor on your license can give you more bargaining power. If you leave instructions with your next of kin, they can perhaps negotiate a better deal. Instead of just the usual icewater-in-the-ears, why not ask for a blood-flow study to make sure your cortex is truly out of commission?

And how about some anesthetic?

Bargaining power? And using that bargaining power to get anesthetics? If you really thought it even remotely plausible that you would find anesthetics useful during the organ procurement process, would you want to be a donor at all? I would hope not. Teresi may be writing tongue-in-cheek, but I suspect he's serious. And that's a scary thought. "Hey, I may not really be dead during organ procurement, but I'll tell my loved ones they can use the bargaining power of my not being an organ donor on my license. They can agree to organ donation, but only after some extra tests, and only with anesthetics for the procurement. Just in case I'm really not dead." What a comforting thought.

Now can we rethink organ donation? From the ground up? In principle? Look, what are we seeing here? What we are seeing here is that one set of people--those deemed hopeless, those who are "good candidates" for being organ donors--are being viewed while they are still alive as sources for the use of another set of people--potential organ recipients. What I would suggest is that there is no way around this. No set of safeguards can change that fact, because it is fundamental to the whole business of vital organ procurement from allegedly dead donors. Vital organ procurement under those circumstances requires that the patient be assessed as a potential candidate while still alive, that a way be found to make him legally dead while maintaining oxygenation of the organs, and that the organs be taken before they are "ruined." From that, all the rest follows. This is all intrinsic to the nature of the process.

Nobody is taking hearts and livers from cadavers that are the way Dr. Michael DeVita prefers dead people to be: "Cold, stiff, gray and not breathing." It isn't happening, because it can't happen that way.

So it is no wonder that the situation we have come to is the ghoulish situation in which we presently find ourselves, as described by Teresi, van Norman, and plenty of others. And it is no wonder that the bioethicists want to take us to the next level and just go ahead and take organs from people who don't even begin to meet the criteria for whole-brain death, people who are breathing on their own but are in a so-called "persistent vegetative state."

The time has come to back up and rethink. Maybe the entire "dead"-donor organ donation industry should just be shut down. Immediately.

Comments (45)

What's to keep a government-run healthcare system from requiring all participants to be organ donors?

I had to renew my driver's license last week. For the first time in the 30+ years I've been driving I chose not to be an organ donor.

One thing I don't understand is why it is prosecutable to yell "fire" in a theater, but free speech to advocate murder. Yelling "fire" in most situations would not cause a dangerous situation. It's simply taken as a given that there is a reliable causal link between yelling "fire" and people stampeding each other to death. Yet when a man who is in a position of authority uses that position to write what is clearly intended to sway others to support cold-blooded murder, that is just "vile, but legal speech."

It's probably a distinction based on the same "logic" that kept the 2nd amendment from being incorporated by the 14th for about 140 years. You know, "we make up stuff and write it in philsopherlawyerspeak and hope no one notices we're just pulling stuff out of our rear ends."

It seems to me that we have no problem with criminalizing violent speech that has a theoretical specific target. For example, if someone says to you, "Lydia, I'm going to f#$%ing kill you," that's "assault" irrespective of whether or not other factors would lead to a credible basis to believe it was more than bluster. Yet when people use speech to argue for the normalization of murder on a wide scale, they are untouchable. That seems to me a sort of class bias; we hold the academic or "intellectual" to a lower standard than we hold a normal guy or even a thug on the street.

Mike T, I'm not sure why this topic is coming up _just here_. Organ transplant is considered normal by pretty much everybody, including, I'm sorry to say, serious conservative moral philosophers. That's what I'm trying to change.

If you're referring to the doctor who said to go ahead with the procurement on the patient breathing on his own, now _that's_ direct conspiracy to murder that particular patient, and I wish the doctor had been locked up. But I'm wondering whether he could have hidden behind some other doctor's previous declaration of death.

Bill White, I think they may eventually try. There may be some kind of tit for tat move first: If you don't agree to be an organ donor you can't be an organ recipient. I would accept that, actually, though I do see it as intended to be coercive and hence to that extent sinister.

I would guess that presumed consent will come before outright coercion. That's the direction that advocacy and laws are going around the world. Wales just instituted presumed consent.

I was just reading an interview-in French-of doctor Paul Byrne, who has been fighting against "brain death" for many years, as well as asserting the link between organ transplant and the definition of brain death.

Here is one of his articles, and the interview I was thinking of (in French).

Lydia says:

Organ transplant is considered normal by pretty much everybody, including, I'm sorry to say, serious conservative moral philosophers.

No one has explained to my satisfaction why organ transplant should not be viewed as cannibalism. Christendom has come to view organ transplants as a blessing! The last time I raised this issue publicly I was accused of being a follower of G. H. Kersten.

Thomas, the best shot I've ever seen of an argument for not analogizing organ transplant to cannibalism was in private e-mail some years ago. My friend argued that the difference is that in organ transplant the organ retains its natural function whereas in cannibalism the flesh is merely consumed by another. That's the best I have to offer you. I still consider the analogy a very telling one and have made it myself. I find that it puts some people off, though, so I didn't make it in this particular entry.

My friend argued that the difference is that in organ transplant the organ retains its natural function whereas in cannibalism the flesh is merely consumed by another.

That seems a fair assessment to me, though I can understand your reasoning as well. What I cannot understand are the "moral philosophers" who are against therapeutic cloning of organs. I remember reading a few years ago on Evangelical Outpost that Bush's bioethics counsel was against even that step as a means of prolonging a life, even though it did not have any pro-life issues such as destruction of a full human body or production of a brain-dead human.

Mike T, I'm not sure why this topic is coming up _just here_.

It's a good starting point for a broader discussion of whether or not free speech should include speech which a reasonable person would consider as having the purpose of broadening the societal norms so as to normalize a legitimately felonious act. I was also thinking about that recent infanticide post when I wrote that comment.

If you're referring to the doctor who said to go ahead with the procurement on the patient breathing on his own, now _that's_ direct conspiracy to murder that particular patient, and I wish the doctor had been locked up. But I'm wondering whether he could have hidden behind some other doctor's previous declaration of death.

Acting in good faith on bad information is hardly sufficient to form a mens rea without at least showing severe negligence that could have lead to the discovery of it being bad information. I have no problem with the courts stringing the first doctor up from the nearest tree for murder. The second doctor, I could see many plausible scenarios in which he or she doesn't have sufficient information to be found to have formed criminal intent to harm the patient.

Acting in good faith on bad information is hardly sufficient to form a mens rea without at least showing severe negligence that could have lead to the discovery of it being bad information. I have no problem with the courts stringing the first doctor up from the nearest tree for murder. The second doctor, I could see many plausible scenarios in which he or she doesn't have sufficient information to be found to have formed criminal intent to harm the patient.

No, if anything, it's the other way around. Let's assume that the doctor who declared death found the patient at that time failing the apnea test, unable to breathe on his own, and satisfying other criteria for whole-brain death. It was then the _second_ doctor who could see for himself that the patient was at that time breathing on his own. He was alerted to this by the anesthesiologist, who continued to object to the removal of the liver. The second doctor did _not_ reason that the patient's whole brain function really had ceased. Rather, he argued from the legally *completely false* premise that a patient who "could not recover" could be declared dead and also that the recipient needed the organ. These are completely contrary to the actual state of law. Being in an irrecoverable state does _not_ legally constitute whole-brain death, and the ability to breathe on one's own is supposed to be completely incompatible with the diagnosis of whole-brain death. It was the second doctor who, confronted with a breathing patient--that is to say, a patient manifestly not dead under whole-brain death criteria--who ordered the liver to be taken from that patient over the anesthesiologist's objections. He is thus directly responsible for the murder of the patient.

I'm not sure what you are talking about, Mike T., concerning "therapeutic cloning of organs." Could you be talking about IPSC's? I know of no pro-life bioethicists who are opposed to the use of IPSC's to grow new organs from the patient's own cells.

The term "therapeutic cloning" is in my experience _always_ used for actual cloning a la Dolly, which is indeed cloning of an embryo. If done with a human being, it is human cloning. The distinction between human "therapeutic cloning" and human "reproductive cloning" is in fact specious, because once the embryo has come into existence, reproduction has taken place. Some states have legalized what they called "therapeutic cloning" which meant, horribly enough, that it was legal to clone and kill embryos but was _illegal_ actually to treat the embryo as a human being and attempt to gestate it.

There is no such thing, as far as I know, as "therapeutic cloning of organs." Now, IPSC's hold out the hope of "growing" organs from a patient's own cells, but that is not cloning. It does not involve somatic nuclear transfer or anything of the kind. The cells are coaxed back to a less differentiated state and then re-differentiated into a new type of cell. Recent advances even hold out the hope of moving more or less directly from one differentiated cell type to another.

I'm not sure what you are talking about, Mike T., concerning "therapeutic cloning of organs." Could you be talking about IPSC's? I know of no pro-life bioethicists who are opposed to the use of IPSC's to grow new organs from the patient's own cells.

It's been a while since I've read any discussions of bioethics. Actually about 8 years now, and I remember Evangelical Outpost seeming to make arguments in favor of Leon Kass viz a viz a view that any form of artificially making new human parts was intrinsically wrong and that natural life ought to not be extended. Simply that if you are say, 70, and could live another 20 years by growing a new heart, it was somehow not a good thing to make a new heart regardless of the methods.

Needless to say, I stopped paying attention to "bioethics" mainly because of two factors:

a) If you need to be told why playing God with sentient life is almost intrinsically wrong (I am not entirely sure where, say, Australopithecus would fall into that) then you are almost beyond reason.
b) I put many bioethics arguments close to the extremist political views of the 20th century that resulted in mass atrocities. I stopped reading when I realized many of the non-Christian "bioethicists" being talked about would likely have been executed at the Nuremberg Trials if they had their way.

Thanks for your post.

I agree with the main point the article is making. And I totally agree with all the points you're making. Most importantly, I, too, would love to rethink organ donation "[f]rom the ground up," as you say.

All that said, I did want to say a few things about the article:

1. This is more of a nitpick than anything substantial. It's fine and good that the article hones in on brain death. But I just wish Dick Teresi had said a bit more about the cardiovascular and respiratory criteria for death since that's the other half of the picture and criteria for death. According to the Uniform Determination of Death Act: "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 brain stem, is dead. A determination of death must be made in accordance with accepted medical standards." Teresi does say a bit about why he doesn't do so, but still I wish he had said a bit more because it seems to me to paint a bit of a lopsided picture.

2. Maybe Teresi didn't have the length to detail everything in the article, and maybe he elaborates in his book, but it seems to me he glosses over the various criteria for brain death, which again could unfortunately help foster some misunderstandings about criteria for brain death, I think.

For starters, I wouldn't say the exam for brain death is "simple."

Prior to neurological tests for brain death, one has to meet other preconditions. One has to find the cause of the coma, figure out whether the coma is truly irreversible, perform lab tests, run neuroimaging tests (e.g. cerebral perfusion CT scan), and resolve any possible confounding factors like other medical conditions (e.g. locked-in syndrome). To put it another way, one can't begin to perform neurological tests without first looking at the patient's temperature (e.g. absence of hypothermia), blood pressure (e.g. hypotension), acid-base and electrolytes problems, metabolic state, absence of drugs which could induce coma (e.g. poisons, neuromuscular blocks), etc. Each of these could require further investigations.

After satisfying the above, one can move onto a neurological exam which, as the author noted in his article, includes tests for coma, brain-stem reflexes, and the apnea test. But each of these is, in my opinion, much more involved than just "A doctor splashes ice water in your ears (to look for shivering in the eyes), pokes your eyes with a cotton swab and checks for any gag reflex, among other rudimentary tests. It takes less time than a standard eye exam."

A minor error is when the article notes the "doctor splashes ice water in your ears (to look for shivering in the eyes)." Absent is an alternative like warm water is also used in the caloric reflex test.

A bigger problem is the phrase "other rudimentary tests" hides a lot or at least leaves a lot out which should instead be spelled out if you ask me. I'd like to go into this but it'd be a bit too time-consuming for me. Instead please check out a review article in a standard medical journal like the New England Journal of Medicine or the Journal of the American Medical Association on how to clinically diagnose brain death and see what specific steps a physician needs to take in order to run through these tests. (However, please feel free to ignore their liberal bioethics.)

Teresi's statement that it "takes less time than a standard eye exam" is slightly misleading. For one thing, it depends what age we're talking about. If I recall, for neonates and pediatric patients one is required to do two evaluations 24-48 hours apart, while for adult patients this isn't the case. Or even if we assume it's true, it could just as well be due to the skill of the physicians (as I recall there has to be at least two physicians) than something akin to negligence.

By the way, I'm not suggesting there aren't problems with these tests. Rather I'm merely responding to Teresi's seemingly breezy descriptions, which I believe could lend themselves to misimpressions about how the tests are performed.

3. On the other hand, I'd think a practical problem with these neurological tests is, well, ideally a neurologist or neurosurgeon would be best suited to perform neurological tests, but it could be many hospitals don't have neurologists or neurosurgeons on hand and have to rely on other physicians.

4. I think a real area of contention is the fact that the human body can and will sometimes elicit signs of life or at least brain activity even if one's brain has "died." Say an arm or both arms are suddenly raised after brain-death was established. Or the head turns from one side to the other. Or parts of the face twitch. Or the plantar reflex aka Babinski's sign is observed.

Of course, this sort of thing happens in animals. Like I've been able to make truly dead frogs twitch their leg muscles as if they were alive and kicking. Galvani knew about this centuries ago.

But if it happens in a human being, obviously we have to take extra care to ensure the individual has truly died.

5. An unfortunate error I spotted in the article is the following: "But BHCs—who don't receive anesthetics during an organ harvest operation—react to the scalpel like inadequately anesthetized live patients, exhibiting high blood pressure and sometimes soaring heart rates." I don't doubt this sometimes happens. Poor and bad medical practice exists. There are, obviously, unscrupulous doctors too. However, if and when anethesia is not used in "organ harvest operation[s]," it would be considered a huge (and I think horrifying) aberration to the rule. The rule is anesthesia is always used in organ harvest operations. This includes medication, oxygenation, pain relief, etc. If, say, a truly brain-dead patient's arm moves as if in pain due to a surgical incision, then pain medication would be immediately administered as if the patient were alive.

Rocking, I'm frustrated to say that I just lost a very long comment in response to yours. Rats. I will try slowly to recreate it in chunks.

First, were the most rigorous standards really standardized, we would not have cases like the three, especially 1 and 2, that van Norman describes. Nor like the case of Zach Dunlop:


In Zach's case, a PET scan was performed. The doctors were not negligent. The tests they did simply weren't good enough. I remember some doctors at the time said that some other perfusion scans should have been performed as well. But that simply illustrates the fact that the most rigorous possible tests are not in fact standard practice. In fact, I gather that testing for whole-brain death varies a good deal from one hospital and one doctor to another.

On ahesthetics: My impression is that they were _not_ standard practice in the UK until recently. Hence, it was from the UK that we got some of the data on patient response to organ procurement. I am quite unconvinced of claims that these responses are just "chicken-without-a-head" reflexes. Teresi and plenty of others better qualified than Teresi have expressly stated that these responses are just like the responses of insufficiently anesthetized live patients.

Why should ahesthetics be needed? Why should they be standard practice in the U.S.? Something is very wrong here. They are partly used so as not to distress the procurement team! Because it looks like they're taking organs from a live person without anesthetics. The standardization of anesthetics simply isn't comforting. If these were truly dead patients, it should not be necessary.

I totally agree with you about the disturbing nature of non-heart-beating donation and will later post a link to a post of mine on that subject. I have quite a few. Off to lunch now.

Rocking, I think perhaps you were alluding to the Pittsburgh Protocol in your first paragraph. I agree with you that there is a lot of interesting and very disturbing stuff that arises out of that. You may find interesting the second half of this post of mine in which I discuss that.


Does Catholic Church has a position on organ transplants?

This from Touchstone on Malcolm Muggeridge:

After the South African Christian Barnard performed the world’s first heart transplant surgery in December 1967, Muggeridge asked him (on a BBC television program with the risible title, “Dr. Barnard Faces His Critics”) whether such experimental surgery was first performed in South Africa because facilities there so outpaced the rest of the medical world, or because the vile doctrine of apartheid had so devalued human life that it had conditioned Dr. Barnard and people like him to regard human beings as spare parts for medical experimentation. It was a shrewd question, albeit it caused consternation all around. Dr. Barnard’s soi disant “critics” on the BBC panel immediately distanced themselves from Muggeridge’s question, urging Barnard not to dignify it with an answer—which he didn’t.

This episode marked the beginning of Muggeridge’s emergence as a relentless opponent of medical hubris: in abortion, euthanasia, genetic engineering, etc. Two decades before the existence of a worldwide black market in human organs was admitted to, Muggeridge had not only predicted its emergence but had also detailed the economies of its operation and just how it would work


Gian, I believe the magisterium has declared vital organ transplant to be morally licit. If someone knows that I am _wrong_ on this, please let me know. That is my strong impression. Query: If that has in fact been declared by the magisterium, can they revise it? Or would that be to call infallibility into question?

Because in my opinion, they should definitely rethink. If there can be a "development of doctrine" on the death penalty, this is a much better candidate for such a development!


To my knowledge, vital organ transplant is not considered morally illicit. The Catechism (2296) states that organ donation after death is a noble thing, with some caveats: consent of the donor and the family, not incurring disproportionate cost and risk to the patient... It further states in that particular place that it is NEVER morally justified to shorten another person's life or to mutilate them for another party's well-being (understood in a context other than self defense, just war, etc...).
Also to my knowledge, if this is written black and white in the Catechism, then there can be no "development of doctrine", in so far as this is a euphemism for changing your mind. And in fact, there is no need. The Catechism is very clear that the life and physical integrity of a potential donor is never to be endangered for a potential recipient, which is the problem here, right?

Also, I think I take exception to the idea that there was a real change of the attitude on the death penalty--JPII's teachings on this in EV were non-binding, as far as I know, though certainly well advised, as he was expressing an opinion that in most western countries today, the cases where death penalty fell within the conditions given by the RCC were rare. I don't see how such a teaching could in any way be binding. Or even indicative of a change in attitude. But maybe you were thinking of another instance?

The Catechism is very clear that the life and physical integrity of a potential donor is never to be endangered for a potential recipient, which is the problem here, right?

Welll. Sort of. Two things. First of all, what if the entire vital organ donation from dead donors industry (for want of a better word) needs to be shut down flat? What if it turns out that there is, contrary to what the authors of the Catechism probably believed, just no good way to get those organs from donors that are un-de-ni-ably dead? Now, isn't that a bit radical compared to what they said? What it's going to come to is something like, "Well, if you could really get these organs from people who are cold, grey, and not breathing, then that would be okay, but you can't. And as it turns out that there are serious questions both about brain death diagnosis and about diagnosing death from cessation of heartbeat and then _reconnecting_ the person to a ventilator which might actually revive him without blockages or drugs, there just is no ethical way to obtain these organs. So in principle it could have been 'noble', but we've learned a lot since then about how it actually works, and it just should stop for ethical reasons."

Now, I can see that you might sort of wangle out of that so that you could say that the Catechism wasn't really wrong, but I think it's stretching it a bit. It would be like saying, "The death penalty is morally licit in principle, but in practice it's always wrong." Huh?

Second, I would say outright that I think that what has happened should make us rethink the intrinsic nature of taking organs from dead people. Why, as Thomas asks above, is it _not_ analogous to cannibalism in a serious ethical sense? Should not the ethical mayhem that has been wrought by vital organ donation make us wonder whether the basis of it actually is intrinsically exploitative, using others as a means and not as an end? In which case, well, the Catechism was wrong, and there's no way out of that.

For the first thing, ok-maybe organ transplant from dead donors is nigh impossible to achieve in any moral manner today (it would certainly seem so), but it may well become possible in the future, and so the precept still stands.

For the second, I agree that it is an interesting issue (but, being Catholic, I will trust the Church on it). If you accept that dead organ donation (supposing it were done in a sound, moral manner) is analogous to cannibalism, what about living organ donation? Donating bone marrow? Blood?

By "living organ donation", I mean voluntarily donating a kidney or such, not ripping vital body parts from "brain-dead" people.

The living donation issue is very interesting. It seems to me that it is very likely not an ethical problem insofar as the material is renewable: Blood and bone marrow being obvious examples here. The next step up would be extremely minimal donation of organ material--a liver lobe, which apparently does not harm function in any way. (I don't _believe_ those grow back, but if so, they would fall into the previous category.)

When we get to donating a whole kidney, I think we've entered an ethical grey area, because it really is a serious medical operation and does leave the donor without a backup. The second kidney was, to speak in Christian terms, clearly intended by God to be there in case you lose one kidney to disease or injury. Is it therefore ethical to allow one person to alter permanently that natural backup system and make his body permanently more vulnerable and in more danger of death?

I think we see the issue with this perhaps more clearly when we see what is happening in third-world countries, where impoverished people are actually directly selling a kidney to rich recipients. Serious business, and quite obviously exploitative.

So I'm quite ambivalent about live donation of a single kidney and have not fully made up my mind on the morals thereof. Should it be regarded as a form of mutilation, perhaps? A case can be made for that conclusion.

And here's an interesting question: Why do we allow donation of a single kidney but not of a single cornea? Presumably because that would leave the donor blind in one eye. But people do survive and cope just fine being blind in one eye. It would be a bigger change in day-to-day life but would probably make a smaller difference to life expectancy than donating a single kidney.

The other thing, of course, is that in practical terms it's highly unlikely that we would be able just to have live donations of a single kidney to a family member and _not_ donations from dead (or we-hope-dead) donors. It just isn't going to happen that the line is going to fall there.

Now, it isn't going to happen that the whole industry is going to shut down, either. But it seems to me even more implausible, if possible, that only donations from living family members or friends, for just kidneys, would be permitted while other donations, even other kidney donations, were not.

First, I completely agree that, even if organ transplant is not intrinsically immoral, it would probably be a good idea to impose some (or very many) practical limitations, as the evils may well overrun the good in this particular case.

Second, to know why the cannibalism analogy does or does not apply, I think we need to figure out

1) if cannibalism is intrinsically wrong (which natural law, as well as quite a few Biblical sources, suggests)
2) why it would be so.

I think we can agree on 1, so let us skip to 2. This is what I can make out:

A) Cannibalism often involves killing someone. This is clearly intrinsically evil, as it is when someone is killed to harvest their organs.
B) Cannibalism involves mutilating someone, usually irreversibly. Now we sometimes need to "mutilate" people to save their lives, by amputating a gangrened body part, for example. So cutting out body parts without killing is not intrinsically evil. And the purpose of donating a kidney is generous (thinking donation, not organ trading, selling, etc.)
C) Cannibalism involves seeing people as food, thus on the same plane as animals and vegetables. This is a complete denial of the specific dignity of humans. I do not see how you can transpose this to willing organ donation.

For the cornea: first, you will not save anyone's life by donating a cornea. So the circumstances do not justify it, even if it was medically feasible. Second, there is probably a form of scandal involved in gouging out one of your eyes for all to see, whereas a kidney, blood, or bone marrow are a much more discrete donation.

I am stepping out on a limb here, so I hope this is not so much hogwash.

I think cannibalism is wrong even when it doesn't involve killing someone--for example, eating people's bodies after they are dead from natural causes. I don't know that mutilation would fit as a description if we are talking about dead people. I would definitely focus on the analogy to your letter C. Organ harvesting, even if the person was willing while alive (cannibalism isn't made right if the person says, "Eat me after I die"), involves seeing other people's bodies as _sources_ for others' use. The very term "harvesting" implies this quite clearly--indeed, it's an analogy to vegetables. Think of the constant talk of an "organ shortage," as though human bodies were a resource.

When you read organ donation advocacy sites, they constantly talk about the number of "usable organs that are buried each year." What? They are talking about one of the corporal works of mercy! Burying the dead! But from their perspective, what's happening there (oh, so sad) is that a "resource" is being lost because those body parts of those dead people are not being _used_. The funny thing is that they use this rhetoric completely unself-consciously. They expect it to be highly persuasive, in fact, not to be angering or disgusting.

Human bodies should not be seen as a resource, any more than human bodies should be seen as food. That is contrary to the dignity of man.

I don't quite see where scandal would come in as far as donating a cornea, if it isn't _wrong_. Scandal is supposed to involve leading others to sin. It might be upsetting, of course. I would be inclined to agree that giving up a cornea while one is alive _is_ wrong, but my reason for bringing it up was as an intuition pump that perhaps harming one's body's integrity in such a serious way as giving a kidney while one is alive is also wrong. As I said, though, I am a fence-sitter on that.

I doubt that I am wrong about this, but I believe the technology that assists now in keeping a donor alive for organ transplantation originally was developed to keep the patient going during recovery from a crisis.

Over time it was discovered that the technology could keep the patient going long after recovery from the crisis was probable. This created the problem with pulling the plug. When and why to do it?

The death of a loved one changed from something to accept to something to decide. An unnatural, heartrending moral and personal dilemma for the living, like having to shoot the horse but now with the beloved 30 year-old spouse or the child.

Enter the techno-solution to the techno-problem. Pull the plug in a controlled, utilitarian way. All has been done to make beloved's death meaningful, now make it useful. Conscience at rest.

Technology drives the modern definition of personhood because it creates seemingly non-persons and provides opportunities for the use of a body to benefit those whose body it is not. Whatever you want to do with a body, it is OK by any utilitarian calculus if it is not a person, and by law as long as it is in a clinical setting and clinical experts are there to counsel, encourage, and affirm it is the correct choice.

Technology produces and defines on its own terms what are non-person bodies for real persons to have to decide the fate of. The more the body in question belongs to/is a non-person, and the more the pressure of utilitarian clinical expertise bears down upon one answer, the easier and more utilitarian the solution becomes for what to do with it, right or wrong.

Thanks, Lydia. I just wanted to say you gave me a great response, and again I entirely agree with what you're saying. I hope more people will consider your points.

With all due respect to people in the UK, I'd only add I think the UK is probably, bioethically speaking, further along the moral spiral downwards than we are. Although places like California (where I'm from) might be giving them a run for their money.

You're certainly right about their being further along the moral spiral down than we are. I suppose though, to be fair, that doing organ procurement without anesthetic might not even be an example of that. It's logical to try to do it without anesthetic, I shd. think. Allegedly, the patient is dead, so...

Good post. There are a number of physicians, philosophers, and theologians who now oppose brain death criteria and organ transplants from "brain dead" donors. Some of these scholars have also pointed out the problems with so-called "donation after cardiac death." Supposedly in "whole brain death," the entire brain is dead, but the body temperature has to be a certain level before organs are removed, and body temperature is a pituitary-hypothalamic function--the pituitary may be an endocrine gland, but the hypothalamus is part of the brain. Even if the whole brain were dead, as long as circulation continues, even with ventilator support, the body functions as an organic whole, circulating, respiring to nourish cells and tissues with oxygen, and in one case the body of a brain dead victim underwent sexual maturation at puberty. The so-called "brain dead" are alive, and given that Christians cannot separate the living human organism from the human person, they are human persons as well. Thus, removing organs is the proximate cause of the death of a human person, and is therefore manslaughter.

A bit more about donation after cardiac death: Donation after cardiac death was, I suspect, originally thought of to avoid the sense of the macabre associated with brain dead donors. That was one reason. Another was probably to avoid waiting. Donation after cardiac death allows, I would guess, organs to be taken sooner from ventilator-dependent patients who are undeniably not brain-dead. All that is necessary is to turn off the ventilator, wait for breathing and heatbeat to stop, declare death, and then wait a couple of minutes.

What I did _not_ know at first was that at that point the ventilator is restarted and that the patient may well revive if blood vessels are not blocked or drugs are not administered. I was already very uneasy about donation after cardiac death because of the extremely short time period involved and the way that it kept getting shorter and shorter (75 seconds, in the case of some babies I blogged about). But this was incredible. It made it absolutely clear that it was an open possibility that the patients were alive after having been declared dead. The danger of reviving the patient in the Pittsburgh Protocol is unfortunately not widely known. President Bush's bioethics counsel wrote an entire document on organ donation in which they expressly said that reviving the patient was a purely hypothetical possibility in the case of donation after cardiac death.

Sorry for the delayed reply...

Lydia, we agree that considering other people's bodies as resources, as is all too easy in organ donation (but also blood donation) is wrong, and I do think that this is was makes it comparable to cannibalism.

However, in the hypothetical case that
1) people are not pressured into donation
2) said donation does not endanger the donor's health (and ok, kidney donation would probably be borderline for the reasons you stated)
3) no one's life is put above another's (ie, everything possible is done to save a dying donor's life, even if it renders his organs unusable)
4) donation is seen as a generous gift, and not in any way an obligation
then this is in accordance with human dignity: there is no debasing of the body, as the organs are used in the purpose for which they were made (and not eaten), and it is given by free will.
What would you think, for example, of giving your body to science? I would find that worse.

As I said above, though, this might not be possible in practice.

Point taken about scandal: definitely the wrong choice of words.

What would you think, for example, of giving your body to science?

I wouldn't do it. Nuh-uh. I hope that my loved ones can bury me, if possible and not crushingly expensive, when I die. Cremation isn't intrinsically wrong, but it's become all too common. It's a shame that burial is so incredibly expensive.

On organ donation, I'm inclined to think that it may not be possible to avoid, in some objective sense, treating the dead person as a resource.

Here I would make an analogy to in vitro fertilization. When those opposed to it in principle say that it involves treating the child as a product to create the child outside the womb in the lab, pro-life parents of well-loved IVF children can respond that that _could_ be the case, but that _if_ they don't think of the child as a product (for example, not making "extra" embryos, not implanting more than one at a time, not having them diagnosed and discarded if imperfect, loving the resulting child no matter what, etc.), then it does not involve treating the child as a product. As I understand the argument, the point of in-principle opponents is that "treating the child as a product" is an objective fact of the process and that, while such ethical limitations are not at all bad things, they cannot remove this objectification of the child. It is a feature of the case even with the best possible parental attitudes and restrictions.

Something similar, I much fear, may be true of taking vital organs from dead donors.

Dr. R. Albert Mohler has also discussed this issue on his March 15 episode of The Briefing: http://www.albertmohler.com/2012/03/15/the-briefing-03-15-12/


Fair points, and thank you for taking the time to clarify your arguments.

However, there are, I think, lines to be drawn. First, in IVF, you are creating an entire living person. In other words, the "product", the "resource", is not only organic material, but also the soul that only our Creator can endow us with. Treating a child as a resource is not the only issue here.
Second, I am not sure I agree with the idea that a dead organ donor, or living blood/bone marrow/... donor, when all the previously cited conditions are verified, is a "resource is an objective sense". They gave part of themselves of their own free and informed will. When someone, say, a family member, gives you money for your birthday, are they a resource in an objective sense?

Also, if you consider that the analogy between organ donation and cannibalism holds because in both cases, people are considered as resources, then how is blood donation not cannibalism? The previous argument was that it was renewable. (I may just be confused).

I think the blood/marrow donations are probably legitimate because they really are more like a gift than like cannibalism. That is to say, the person is alive, is not mutilating himself, and is right at this moment giving you something more like money, as you say, something that his own body will replace and that it will not harm him to give. (Rather like a woman donating her breast milk to someone else.)

When you look at a live person and think of that person as dying and about using his body after he is dead for some other purpose (other than as his own living body), then I think this involves intrinsically thinking of him as a resource, even if he consents ahead of time. Hence the analogy to cannibalism.

Probably part of the objectification arises because "giving" organs after you are dead is more like leaving something to another person in one's will. Ought bodily organs, or for that matter one's whole body, to be the kind of things we can leave in our wills? I'm having doubts.

As someone who's actually received a kidney, I thought I'd weigh in here. First, I have nothing to add to the discussion of cadaver kidneys. I've heard too many first-hand stories of people recovering from being "brain dead" to consider the practice to be ethical.

However, to compare living donation to cannibalism is absurd. You've completely overlooked the most basic aspect of cannibalism: whatever is taken is consumed. A transplanted kidney is not consumed, it just performs its intended function in a new body. My brother donated his kidney to me 25 years ago, and if he hadn't, I'd have died about 20 years ago. Dialysis is not a healthy long-term way to live. My brother weighed the chances that he'd have trouble with his remaining kidney versus whether he'd like me to continue living, and made the choice to give a gift of his own body to save my life. A brave and noble act, that many of you have likened to cannibalism.

It seems like some people are more interested in trying to find fault everywhere they look, and overlook the obvious sacrifices and good being done by people actually taking action, and not just taking part in hypothetical discussions.

It's good to keep in mind the distinction between reasons that have to do with what is common, or likely, or will be likely if a practice becomes common, and reasons that have to do with the act in principle. So, for example, the problem of thinking about (living) organs (and people) as a resource-for-others is something that will always be a danger given the practice of organ transplanting, but it is not clear that this attitude attaches to the practice of using dead bodies in principle. Or, at least it is possible to ask whether the attitude necessarily bound up in willing your body for "use" after your real, verified death is a use that harbors the same evil sense that making a use in "donation" of an organ while living is.

Part of the point is that we have an obligation to respect the body of a person, even a dead body of a person, as something set apart from "use", set apart from "a thing to be taken advantage of". However, I think that we can see that the reasons for setting apart the body of a living person, and for setting apart the body of dead person, are not _exactly_ the same reasons. At least, that's the way it seems to me. The reason for a living person is that viewed correctly the body of the living person IS THE LIVING PERSON, in his physical dimension, not merely something belonging to him. And persons are not to be used, they are not to be loved-for-the-sake-of something else, they are to be loved in their right. But the body of a dead person we respect on account of its _having_been the body of a living person, its former being. Now that the person is dead, the body is really a collection of closely fitting together tissues which are no longer integrated and no longer coherent as part of some real whole. Therefore, the respect we owe it is not on account of its current state, but of its former state - and on account of its future state resurrected and glorified. As such, the kind of respect we give it will be different in significant ways.

Let me give an hypothetical example of that: many of us have read science fiction stories of colony ships that are expected to take several generations to get to the next stars, wherein the ship constitutes effectively a closed ecology that is self-maintaining. Part of that self-maintaining is, of course, that air, water, and soil are re-used through a planned recycle program using all waste products. Organic waste is sent through a plant with bacterial breakdown, worms, acids, etc. One typical arrangement has dead people go through a funeral, and a symbolic "burial", then being sent off to the organic processing plant, after which it will eventually become completely re-conditioned as soil and the like.

The reason I bring this up is to make a point about the intentions. We all know that the body will decompose in the ground. In old times it happened a good deal faster, without embalming. There is nothing wrong with making use of the soil after bodies have decomposed: once the remains are no longer physiologically "a human corpse", it is unrealistic that we treat those decomposition products with any special respect - they are just chemicals at that point. So, for the above colony ship practice, would we accept their method as simply a (necessary) speeding up of the natural process after treating the dead body with respect, or would we blame them for "making use" of the body in the recycle process? My thought is the former: they are not treating the body as a resource while the body is visibly a human body, and they are allowing it to suffer the same fate that all other dead things face in decomposition, just accelerated. And it doesn't seem somehow disrespectful of the body's future state resurrected and glorified to merely speed up the process of decomposition that they all undergo anyway. However God can manage to "put it all back together again" (miraculously, with many a nod to the sorts of miracle in the multiplication of the loaves and fishes, I am sure), the process won't be bothered one bit by the acceleration used.

Having a body part be used (after real, verifiable death) for some purpose that is consistent with real death, and is also consistent with it formerly_having_been a human body would not seem to be inherently a way of being disrespectful of the body. I think that the principle for cadavers is not to use the body in any way that repudiates the notion that it was the body of a person, and it will be so again, but that in its current state it can indeed be used. The question then is how to express the limitations that belong to that kind of use that is consistent with having_been_a human body?

For example, using the cadaver (after a funeral and sending-off ceremony) that has been preserved in formaldehyde for dissection by medical students doesn't seem to be inherently disrespectful. That sort of use doesn't seem to presenting the body as if it wouldn't have mattered whether this used to be a person's body or not. But cannibalism, using it for food, DOES seem to violate that: it is treating the body as if it had been the body of an animal.

Is there a way to make the concept more definitive than simply "no use that is inconsistent with its having_been human body and future_destiny to be so again?"

Just a small note about the "development of doctrine" and the Catechism: First, the Catechism is NOT supposed to stand as the final arbiter of dogmatic statements, it is a teaching tool. As a teaching tool, it includes some statements of what has already been stated dogmatically and irreformably, but nothing that is in the Catechism is irreformable by reason of being in the Catechism. And much that is in the Catechism is reformable.

There has indeed been a change of attitude about the death penalty, but "change of attitude" does not constitute a development of doctrine. I would suggest that the attempt by JPII and a number of bishops to push this new attitude about the DP is an attempt to push a development of doctrine to recognize a new principle in addition to the old ones, but I think that push has failed of its goal, and it is NOT a development of doctrine in any useful sense. Notably, the bishops have failed to provide any successful explanation of a rationale for the new angle that is consistent with the clear and definite 4000 year teaching of Judeo-Christian standards. Given that, the change of attitude is, at this current stage, a novel theory looking for a principle to attach it to the tree of Christian doctrine. Until it locates such a principle, it is no more than an attitude.

The teaching of the Catechism on organ transplants does seem to be an area that allows for exactly the sort of development of doctrine that Lydia outlines: First it was declared that IF you can protect the integrity of living persons, THEN organ donation is OK. AFTER which it is discovered that you can't protect the integrity of living persons. The second discovery does not upset the truth of the If / THEN construction of the initial teaching, it further qualifies the field of discussion.

Although, it does appear that the use of ligaments from a cadaver which can be taken well after certain total death, pose no problems of the sort above as with organ transplanting. The problems of the industry as a whole remain.

I pretty much agree with everything Tony just said, except perhaps to add that one would have to be very careful about the use of the body for scientific purposes (but I guess that is self-evident).

And thank you for clarifying that point about the catechism. My original comment was definitely unclear.

Actually, Greg, I didn't at all ignore the point about not consuming but using organs. I brought it up in discussion above.

And the objections I have chiefly raised to live donation of a single kidney in this thread have had to do with the disruption of the backup system for the donor. Moreover, I've said again and again, that I am ambivalent about live donation of a single kidney and that it might be morally legitimate.

Tony, on accelerating the breakdown process of bodies: In the Dune novels dead bodies are immediately "rendered" for the water contained in them, because it's a desert planet. I think if you read the novels (not that I'm suggesting you run out and do so) you'll see that there really _is_ something macabre and disturbing about this acceleration (for use) of the recycling process.

There might be a way to accelerate things while maintaining the symbolic respect for the bodies. If you reverently buried the bodies on your ship and knew that they would turn into soil in a year rather than ten or whatever that might be different. But going right out and recycling the body does have some issues.

(In California someone is recommending right now that dead human bodies be immediately dissolved by powerful chemicals and poured into the sewer system. This is supposed to be more environmentally friendly even than incinerating them. I think people should have a problem with that.)

Tony and Jane, here's something I just want to throw out there, with all respect (seriously). It will probably not be convincing, but I think it's worth thinking about:

Consider two issues in our present culture--IVF and contraception. On both of them, my impression is that Catholic moral theorists often argue something like as follows: "Look at the way that things have gone in society with the use of these technologies. Look at promiscuity and the use of force by governments such as China to make people use contraception and the Obama administration to make Catholics pay for it. Look at the wreck of divorce and fornication. For IVF, look at the pre-implantation diagnosis and the development of the designer baby mindset. Consider carefully the possibility that these social consequences are merely the outworking and poisonous outflow of the _logic_ of these technologies and actions. Maybe what we're doing is using the human reproductive 'machine' contrary to the way that God intended it to be used. Maybe we're tampering with and even breaking something. If so, it would make sense, we should expect, terrible social consequences. Therefore, the fact that we do apparently have terrible social consequences should make us go back and reconsider these things in themselves and ask ourselves whether they are intrinsically wrong in the way that the Catholic Church has taught that they are."

Now, is that a knock-down argument? No, it isn't. It's possible that someone would listen seriously, go back and rethink, and still conclude that neither contraception nor IVF is _intrinsically_ wrong, that it is merely their misuse that has occasioned all these social ills. Or the person might decide that one of them is intrinsically wrong and the other isn't, or that both are intrinsically wrong. After all, lots of things (like the automobile or the Internet) have had some pretty bad social consequences without being intrinsically evil to use. Is that the _only_ argument Catholic moral theorists make against those technologies? No, it isn't. They also make further arguments about the things in themselves. However, is it a legitimate argument make a shot at? It seems to me that it is. I could even give you a probabilistic recasting of it.

Look at vital organ donation from dead (or "dead") donors. Look at what it is in practice. Look, too, at the continual pushes for worse and worse things in this area. (In Belgium they've begun coordinating it with assisted suicide.) Then ask whether this is a clue, much as these other things are said to be a clue, to the thing in itself. Perhaps we're tampering with something we shouldn't be tampering with.

There is a way in which the analogy may not work right: if the Church is right about IVF, then the inherent evil in it is part and parcel with the evils that are attendant on it but not intrinsic to it: contributing directly to an inherent evil will set you up morally and psychologically for going along with rider evils that could be otherwise avoided. But if IVF is not inherently evil, then there is no core evil that is urging and pushing you to take on the "lesser" fishy evils that run alongside since you have "already swallowed the main bait." If that latter condition were true, then a person might reasonably say it is just our job to be alert and on the lookout for the dangers but permit something morally neutral.

As a practical matter, I don't know which argument is an easier sell: (a) the practice is imprudent because it leads to things which are definitely evil, so let's not even start down that road and just ban the whole industry; or (b) let's ban the stuff that is (for the moment) still not being practiced openly and defended openly; and after that let's ban the stuff that is openly being done which is clearly evil, and then we should ban the current stuff that is doubtful and morally troublesome, and then let's erect a huge brick wall to restrict the industry to the tiny smidgeon of its current self that we are OK with. Both options seem so far from possible that it seems foolish to give it much effort.

Although, with the latter we can at least erect legal and cultural barriers to the stuff that is still considered edgy. And we should be doing that. We should not be making it easy to fall into "accidental" mistakes of taking organs from a live person.

Right, the argument is that there is probably an inherent evil that is driving the attendant evils. It's perhaps not always easy, especially in an accepting social milieu, to see the intrinsic evil immediately, so one's attention has to be drawn to it indirectly--to reconsider the possibility that it _is_ an intrinsic evil. That's my intent w.r.t. "dead" organ donation.

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