Delimiting death
Maxine Clarke
Tuesday, 13 October 2009 15:06 UTC
Prompted by the increasing practice of organ transplantation, and thus the need to procure donor organs that are as fresh as possible, many countries have modelled their legal definition of death on a US law passed in 1981 after extensive debate and thoughtful input from a specially appointed president’s commission of experts: “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.”
In practice, unfortunately, physicians know that when they declare that someone on life support is dead, they are usually obeying the spirit, but not the letter, of this law. And many are feeling increasingly uncomfortable about it, as described in a Nature Editorial (461, 570; 2009, free to read online) .
Death is not a phase transition, whereby a person stops being alive and becomes dead in an instant. It is a long process during which systems, networks and cells gradually disintegrate. At some point, the person is no longer there, and can never be made to return. Yet the kind of clear, unambiguous boundary assumed in the 1981 law simply does not exist.
Ideally, the law should be changed to describe more accurately and honestly the way that death is determined in clinical practice. Most doctors have hesitated to say so too loudly, lest they be caricatured in public as greedy harvesters eager to strip living patients of their organs. But on 24 September, physicians, transplant surgeons and bioethicists called for a reconsideration of the rigid definitions of death, and a wider public debate.
According to the Nature Editorial, the time has come for a serious discussion on redrafting laws that currently push doctors towards a form of deceit. Just how incendiary is this theme? Few things are as sensitive as death. The Editorial concludes that concerns about the legal details of declaring death in someone who will never again be the person he or she was, should be weighed against the value of giving a full and healthy life to someone who will die without a transplant.
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Replies
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Death with no limits or delimiting death?
Stephen J Wigmore Scottish Liver Transplant Unit,
Royal Infirmary of Edinburgh,
51 Little France Crescent
Edinburgh EH16 4SA
&
John AC Buckels Birmingham Liver Unit,
Queen Elizabeth Hospital
University Hospitals Birmingham,
Edgbaston,
Birmingham B15 2THThe editorial “Delimiting Death”1 raises the argument that current definitions of brainstem death are unsafe and are principally designed to support the provision of organs for transplantation. Delimiting death is not essential for transplantation but it is essential to protect patients from futile treatment, to enable doctors to counsel relatives of patients with non-survivable brain injury and to permit rationalisation of limited intensive care resources. The concept of death with a beating heart is a difficult one for many to grasp. However, the criteria for diagnosing brainstem death in the USA, UK and other countries are based on sound objective criteria involving a series of neurological challenges and creation of a state which tests the ability of the brain to mount a breathing response in the face of accumulating carbon dioxide (following removal of the patient from the mechanical ventilator). These tests require preconditions and can be complimented by neurovascular imaging to demonstrate absence of blood circulation to the brainstem. In the UK the tests must be performed two times by two experienced doctors and failure of any element of the tests infers that the diagnosis of brainstem death cannot be made. Furthermore, the expansion of donation after cardiac death programmes for kidney, lung and liver transplantation has reduced the ‘pressure’ on doctors to make a diagnosis of brainstem death, since the brain-injured patient can still become an organ donor after cardiac death.
As the editorial suggests, introducing doubt into the public consciousness that diagnosis of death may be uncertain is potentially incendiary and could also have a devastating impact on organ donation and transplantation services. In spite of this the editorial uses emotive language that itself risks introducing confusion by implying that in brainstem death, the state of the patient is altered short of death or may be reversible, confusing this diagnosis with that of coma or persistent vegetative state. What concerns the public most of all is clarity and transparency in diagnosis of death and organ donation. Furthermore, the rights of a donor in life to wish to donate organs after death, is afforded low priority in this article, which focuses on the doctor as the prime determinant of organ donation. People of every country deserve the right to know that the diagnosis of death is robust, regularly reviewed and adequately debated but clear demarcation should be made between this issue and requirements of organ donation and transplantation.Reference
1. Delimiting Death, (Editorial) Nature, 461: 570 http://www.nature.com/nature/journal/v461/n7264/full/461570a.htmlConflict of Interest: Both authors are involved in organ donation and transplantation services in the United Kingdom. Neither author has any financial conflict of interest regarding this subject.
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Brain death advocates do protest too much?
David Albert Jones
Professor of Bioethics
St Mary’s University College
Twickenham TW1 4SXStephen Wigmore and John Buckles complain that “a clear demarcation should be made between [diagnosis of death] and requirements of organ donation and transplantation” and yet also complain that “introducing doubt into the… diagnosis of death… could also have a devastating impact on organ donation”. It seems therefore that their interest in the diagnosis of death is not wholely independent of the practice of organ transplantation.
Neither is it true to say that the identification of brainstem death with death “is essential to protect patients from futile treatment, to enable doctors to counsel relatives of patients with non-survivable brain injury and to permit rationalisation of limited intensive care resources”. For these purposes it is enough to know that brainstem criteria give a reliable prognosis of death.
However for organ transplantation certain prognosis of death is not enough, is it?
Even though brainstem criteria for death retain support among clinicians, they have been subject to sustained criticism among philosophers, both in the United Kingdom and in the United States. Sceptics of brain-death/brainstem-death include both conservative thinkers such as GEM Anscombe and liberal thinkers such as Peter Singer. A survey of the bioethical literature would quickly show the extent of this disquiet, even among philosophers who strongly support organ donation. The possibility that there might be fundamental problems in the rationale for “beating heart cadavers” is not a comfortable thought, but uncomfortable thoughts can still be true.
For myself I find a more worrying development is the extension of transplantation to donation after cardiac death. For whereas the beating heart cadaver seems to be alive (but is argued to be dead) the DCD donor seems to be dead but if the brainstem is alive then there may well be a possibility of recovery of heartbeat, and this may even occur spontaneously.
I would also suggest, purely as a matter of public perception, that the argument that the diagnosis of death is nothing to do with organ transplantation is more likely to be convincing if the argument is made by people who are less visibly advocates of the benefits of transplant medicine.
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Michael Potts, Ph.D.
Professor of Philosophy
Methodist University
5400 Ramsey Street
Fayetteville, North Carolina USAThe editorial in Nature (“Delimiting Death”)1 refers to the serious problems with the “whole brain death” criterion defended by the 1981 U. S. President’s Commission Report. The editorial specifically discusses continued brain function in patients declared “brain dead.” This implies that “all functions of the entire brain, including the brain stem” have not ceased, and therefore the entire brain is not dead. Yet the editorial claims that physicians “are usually obeying the spirit…of the law” when they pronounce patients with continuing brain function dead. The justification for this view is that death “is not a phase transition whereby a person stops being alive and becomes dead in an instant. It is a long process during which systems, networks and cells gradually disintegrate.”
However, the editorial also affirms that “[a]t some point, the person is no longer there, and can never be made to return” (italics mine). Now the editorial cannot have it both ways: it cannot both affirm death to be a process and then claim that at some point the person is gone. Dying is a process, but not death itself. One is either a person at time t or not a person at time t; there is no state in-between. The possibility that “brain dead” individuals may be alive underlines the morally problematic nature of physicians’ declaring a patient “brain dead” and removing the patient’s vital organs for transplant. Killing “brain dead” donors for their organs, no matter how physiologically impaired they may be, places physicians in the role of killing patients, violating their fundamental duty of nonmaleficence. The fact that such killing is done to save others does not magically change killing a human person into a noble moral act. Nor does the consent of the donor’s family and the donor’s prior altruism make an unethical act ethical.
The editorial finally suggests that the information about brain death be carefully disseminated, so that the general public does not gain full information about the current debate, lest the current organ shortage be worsened. Such withholding of the truth from people who are considering donating their organs is unethical; if organ donation from the brain dead involves killing patients, such a practice should be abandoned, and no utilitarian justification is sufficient to justify it.1. Delimiting death. Nature 461, 570 (1 October 2009), doi:10.1038/461570a
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Delimiting death for procuring transplantable organs: embracing utilitarian homicide in medical practice
Joseph L. Verheijde, PhD, MBA
Associate Professor of Biomedical Ethics
College of Medicine, Mayo Clinic
Department of Physical Medicine and Rehabilitation,
Mayo Clinic Arizona, Phoenix, Arizona, 85254, United States of AmericaMohamed Y. Rady, MD, PhD
Professor of Medicine
College of Medicine, Mayo Clinic
Consultant
Department of Critical Care Medicine
Mayo Clinic Hospital,
Mayo Clinic Arizona, Phoenix, Arizona, 85254, United States of AmericaThe editorial “Delimiting death” (1) highlights the difficulties in defining death that originate from equating severe, even neurologically unsalvageable brain injury with human death. The editorial states that “[Physicians] know that when they declare a death – according to strict clinical criteria, the principles of which are outlined in the original report of the president’s commission – that the person is to all intents and purposes dead.” This statement is challenged by the histopathological observations made in at least one study showing that even with strict adherence to clinical guidelines, more than 60% of heart-beating donors have no or minimal structural disruption of the brain stem on autopsy (2). Several studies have also shown inconsistencies in the way the standards for brain death determination are being applied (3, 4). As the editorial points out, various commentators have presented clinical observations in patients declared brain dead that invalidate the very concept of brain death. These findings include the presence of auditory or somato-sensory evoked potentials, maintenance of electric cerebral activity on electroencephalogram (EEG) , uptake of lipophilic radiopharmaceuticals by viable cerebral cells, presence of integrated hypothalamic-endocrine functions, and maintenance of stable hemodynamic state (5). Surgery and the procurement of organs without the administration of general anesthesia or opioidergic agents for pain control in persons declared “brain dead” result in nociceptive hemodynamic responses and limb-withdrawal movements that often require suppression by administration of neuromuscular-blocking agents (6). Extreme sensation of pain during surgery for organ procurement cannot be totally excluded (7). Routine EEG is never monitored during surgical procurement in heart-beating donors and these donors can obviously never describe their experiences. In recent EEG recordings of dying persons, sharp increases in brain electric activities were demonstrated lasting up to 3 minutes after complete circulatory arrest (8). Such persons could be donors and have their organs surgically procured in non-heart-beating protocols (or donation after cardiac death) without general anesthesia (9), which highlights the issue of donor sufferance. The editorial comment that these activities have “nothing to do with a person being alive in any meaningful way” is unsubstantiated, even false. Not only would that raise the question of how and by whose standards the term “meaningful” is to be defined, it also ignores the fact that some people determined brain dead have returned to normal function in life (as reported by the news media) (10, 11). In conclusion, for physicians to know that patients declared brain dead are to all intents and purposes dead is a premise, as Miller recently postulated, for which we have no plausible and coherent account (12).
1. Delimiting death. Nature. 2009;461:570.
2. Wijdicks E, Pfeifer E. Neuropathology of brain death in the modern transplant era. Neurology. 2008;70:1234-1237.
3. Greer DM, Varelas PN, Haque S, Wijdicks EFM. Variability of brain death determination guidelines in leading US neurologic institutions. Neurology. 2008;70:284-289.
4. Mathur M, Petersen L, Stadtler M, et al. Variability in Pediatric Brain Death Determination and Documentation in Southern California. Pediatrics. 2008;121:988-993.
5. Karakatsanis KG. Brain death: should it be reconsidered? Spinal Cord. 2008;46:396-401.
6. Young PJ, Matta BF. Anaesthesia for organ donation in the brainstem dead – why bother? Anaesthesia. 2000;55:105-106.
7. Fitzgerald RD, Hieber C, Schweitzer E, Luo A, Oczenski W, Lackner FX. Intraoperative catecholamine release in brain-dead organ donors is not suppressed by administration of fentanyl. Eur J Anaesthesiol. 2003;20:952-956.
8. Chawla LS, Akst S, Junker C, Jacobs B, Seneff MG. Surges of Electroencephalogram Activity at the Time of Death: A Case Series. J Palliat Med. 2009;ahead of print online DOI: 10.1089=jpm.2009.0159.
9. Boucek MM, Mashburn C, Dunn SM, et al. Pediatric Heart Transplantation after Declaration of Cardiocirculatory Death. N Engl J Med. 2008;359:709-714.
10. White H. Woman Diagnosed as “Brain Dead” Walks and Talks after Awakening. LifeSiteNews.com. Friday February 15, 2008 http://www.lifesite.net/ldn/2008/feb/08021508.html.
11. Morales N. ‘Dead’ man recovering after ATV accident. Doctors said he was dead, and a transplant team was ready to take his organs — until a young man came back to life. Dateline NBC News. http://www.msnbc.msn.com/id/23768436/.
12. Miller FG. Death and organ donation: back to the future. J Med Ethics. 2009;35:616-620. -
Maxine – is difficult the topic. In my country is very difficult this problem due the people are very suspicious in regard to donate organs for transplants. In general behind this there are vested interests.
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