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The Nasty Side of Organ Transplanting.

Chapter 1

An Invented Death

Transplant surgeons, just like movie vampires and Frankenstein doctors, like their bodies fresh and not quite dead. They need beating hearts as nearly as possible in perfect health from warm, soft and still reactive bodies to make the transfer of organs worthwhile. Their initial ethical and legal problem in the early days of transplanting was that this process constituted murder, (and may still do so).

Christiaan Barnard performed the world’s first human heart transplant in December 1967 in South Africa. He proved that heart transplanting was feasible but the operation was not a success. The donor, Denise Durval, became an instant celebrity after being hit by a car while leaving a junk food store. Brain tissue leaked from her ear and Denise was, for a brief flicker in eternity, the most famous woman in the world. Her father ensured her fame by allowing surgeons to remove her heart for the world’s first human heart transplant.

Louis Washkansky was a Lithuanian Jew from the town of Slabodka who had been deported to the Crimea when the Russians accused the Jews of being German spies. Louis later moved to South Africa and worked as a grocer then developed a bad heart. When the car knocked down Denise he was desperately living each day at a time and waiting to become the world’s first heart transplant recipient.

He was on the operating table when hovering surgeons next door had opened up Denise and were eagerly awaiting her heart to stop forever. But it wouldn't stop.

Christiaan Barnard was worried the slow process of death would ruin Denise’s strong heart. Her brain was badly damaged and some bodily functions were failing and he thought the heart in particular would suffer damage during this prolonged collapse.

When a person suffers catastrophic brain damage body temperature, blood pressure control, renal and endocrine function, and a variety of other processes progressively malfunction as the body dies. The heart is particularly vulnerable to damage during this process.

When Denise’s heart finally stopped, there was confusion in the operating rooms. Incredibly, Christiaan Barnard thought his brother Marius, also a surgeon, would remove the heart and he, Christiaan, would transplant it. It was resolved that Christiaan would do both, but by the time he removed Denise’s healthy, pink heart it had declined to a morbid greyish-blue. It was put into a dish and taken to the anaesthetised Washkansky in the next room. There was a feeling of pessimism and doubt that this heart could be restarted.

But Barnard recounts that after a few electrical shocks, Denise’s heart beat strongly and pumped lifesaving blood throughout Washkansky’s body, but he died eighteen days later, with extensive bilateral pneumonia.

The autopsy of Louis Washkansky’s body showed that the transplantation of Denise’s heart had been technically perfect and, despite the patient’s death, surgeons around the world rejoiced at the world’s first successful human heart transplant. But there was still that problem of the slow dying process. So the second cardiac transplant, less than two weeks later, used a heart which was still beating right up to the time of its removal from a patient who was expected to die very soon from his subarachnoid haemorrhage.

To avoid the legal and ethical problems which would otherwise have been invited by operating on a dying patient to remove his heart while it was still beating naturally and maintaining his bodily circulation, his physician was persuaded to pronounce - and presumably to certify - him “dead” before the procurement surgery commenced. The grounds upon which he diagnosed death are not clear. There were no “brain death” criteria in use for that purpose anywhere in the World at that time. In an account of the crucial part he thus played in that second heart transplant, the greater success of which sparked worldwide enthusiasm for the procedure and secured its future, the physician pleads political pressure, perhaps still searching for some reason to understand his atypical failure to observe the dictates of conscience at that very difficult time.^[2]

An Invented Death

The Harvard Medical School came to the rescue by setting up an Ad Hoc Committee to Examine the Definition of “brain death"– or, rather, to invent a new definition of death and give it status.

This committee of thirteen neurologists, neurosurgeons, lawyers, philosophers and an anaesthetist decided that death could be proclaimed if a ventilator-dependent patient failed to respond to a series of reflex tests. They were called the Harvard Criteria for the diagnosis of “brain death”. This allowed a brain injured patient with a healthy, beating heart and fully operating renal and endocrine system to be defined as dead, just like a cold corpse. ^[3]

Most western countries adopted a de facto version of the Harvard Criteria of “brain death” during the 1970s and early 1980s. Some commentators say this new concept of death was devised to justify turning off expensive life-support machines used for patients not expected to recover consciousness. However, this new death was to the everlasting pleasure of transplant surgeons, who could now declare patients dead before their hearts stopped, remove their vital organs and no longer worry about a murder rap.

The fact that the donor’s body, if mechanically ventilated was digesting and absorbing food, urinating, defecating, filtering blood through the kidneys and liver, healing itself when injured, maintaining body temperature (and, perhaps, a foetus in utero) meant nothing. ^[4] He or she was declared “brain dead” and operated upon to remove their heart while still in that condition. This killed the donor, but legally it was okay. What one day was murder was the next day a brilliant surgical technique.

Combined with the relative success of Barnard’s second 1967 heart transplant -into Philip Blaiberg, who lived through eighteen months - this legitimisation of “brain death” provided the impetus for the rush towards mass transplanting. It wasn't until the immunosuppressant, Cyclosporin, was introduced in 1983, that the transplant industry received another such boost.

The “Brain Death” Test

Prime candidates for organ donation are those suffering catastrophic brain trauma, with haemorrhage and swelling caused by car and motorcycle smashes, gunshot or knife wounds to the head or stroke victims. In these instances an artery inside the head is broken and surging blood spills into the skull but with nowhere to go. Pressure builds up in the brain and may even force the brain stem downward. Circulation through the brain slows and its cells run out of oxygen resulting in brain damage and eventual death.

Heart attacks, heart failure, asphyxiation from smoke inhalation or strangulation that reduce or stop oxygen rich blood circulating in the brain, causing global cerebral ischemia, can also make someone an organ donation candidate.

The body reacts to these injuries by shutting down functions and going into a deep coma where breathing may cease resulting in death. Ambulance crews reacting in time will ventilate the patients’ lungs until they reach the hospital.

Patients arriving in this condition alert hospital staff to two possibilities, the first being to aid recovery from injuries and, secondly, that they have a potential candidate for organ harvesting. Hospital staff check the organ donor register and personal belongings for donor registration. Transplant coordinators may even contact next of kin and prepare for tissue matching before the patient is declared “brain dead”.

Depending on the country, hospital staff may spend four hours observing the patient for signs of recovery. If recovery isn't forthcoming, doctors perform the first series of “brain death” tests and, if this is indicated, then a few hours later another, final, series of tests is carried out.

However, there are varied protocols around the world, rarely enshrined in legislation, so doctors devise their own methods to determine “brain death”. For example, the United Kingdom Code of Practice requires two doctors to be involved but doesn’t specify time periods between tests so repeat testing may be a formality.

The Australia New Zealand Intensive Care Society (ANZICS) recommends a series of tests but doctors haven't any obligation to use them. The Society refused to provide their recommended criteria for “brain death” testing demonstrating perhaps their disdain for public education. They later published these, including the controversial apnoea test, on their website. ^[5]

The Test for Death Begins

Relatives are discouraged from observing “brain death” testing in case they're sickened by its physical rigour and the appearance that their loved one is being harmed.

A strong light is shone into the patient’s pupils. They should shrink in size and failure to do so may indicate brain injury. This won’t be done if the eyes are full of blood. The doctor holds the eyelids open and abruptly moves the head from side to side observing if the eyes move normally or remain staring straight ahead. This won’t be done if the patient has a broken neck. The eyeball is touched with a cotton-covered prod and painful pressure is applied to the eye-socket to check for reaction. Failure to react may indicate brain damage. Doctors are warned to avoid damaging the cornea during this testing.

A catheter is pushed down the windpipe to provoke a cough reflex, this being indicative of brain function. A probe is stuck into the mouth to check for gag reflex. The doctor turns the head sideways and pours ice-cold saline into the ear. This should provoke deviation of the eyes. If it does not, this indicates loss of function of another neural pathway in the brain stem.

Painful stimuli are applied to various parts of the body to look for responses involving the cerebral nerve network. Reflex responses which can be explained as purely local are no longer regarded as significant.

Electroencephalography is an essential element in many protocols and displays electrical activity in the brain. A “shower cap” is placed on the patient’s head and presses metal electrodes against the scalp. The absence of recordable electrical activity - “electrocerebral silence” - affords evidence of cessation of function in the more superficial parts of the brain, particularly the cerebral cortex. But it does not exclude continuing activity in the deeper parts of the brain and cannot, of course, distinguish between temporary and permanent absence of function. The test doesn't cause harm to the patient.

Some countries use cerebral angiography where doctors inject radio-opaque contrast medium ("dye") into the bloodstream and X-Rays observe the flow of blood to the brain. A lack of dye movement to the brain indicates lack of circulation and possible “brain death”.

Radioactive tracers are injected into the bloodstream during the Radioisotope Study. These radioisotopes emit radiation and their presence is detected by devices like Geiger Counters that respond to radioactivity. The flow of blood to the brain is indicated by the movement of radioisotopes inside the skull.

Some further comments on cerebral angiography and radioisotope studies may be found in Appendix One.

Many methods (30>) of diagnosing “brain death” are used around the world, none being universally accepted as sufficiently stringent or reliable for the purpose of certifying death on neurological grounds. There are, in fact, so many variants that they obviously do not all define the same clinical syndrome. “Brain death", as clinically diagnosed, is clearly not a true entity. That being so, the highly relevant conceptual arguments about any novel form of diagnosing death on such grounds do not arise for consideration.

The Apnoea Test

The Doctor Disconnects the Breathing Machine

The Apnoea Test is the final test for patients not responding sufficiently to previous tests. The doctor turns off their ventilator, which has maintained their breathing, and leaves it disconnected for up to ten minutes.

Oxygen is pumped down the trachea to minimize oxygen deprivation while the ventilator is no longer inflating and deflating the lungs. During the disconnection, the carbon dioxide tension in the bloodstream rises - because it is not being “blown off” by the unventilated lungs - and will trigger spontaneous breathing efforts if the respiratory centre in the brain stem is still sufficiently responsive (alive). If not, and the patient fails to begin breathing when the CO₂ tension has reached the prescribed level, the penultimate “brain death” requirement is satisfied. The ventilator is then reconnected and mechanical breathing resumed until such time as the test is repeated.

Every effort is made to ensure that, during this test, the patient does not become crucially short of oxygen - which would risk damage to wanted organs - despite the fact that a very low level of oxygen in the bloodstream (anoxaemia) is a more powerful drive stimulus to the brain stem respiratory centre than high CO₂ levels. Patients who have not shown breathing efforts when subjected to the latter may yet exhibit breathing efforts - “agonal gasps” - if the ventilator is left disconnected so that anoxaemia develops.

Apnoea testing is the Achilles heel of all “brain death” protocols - too dangerous to use on a patient who is still, by common consent, alive at this stage. And, even so, not stringent enough to diagnose irreversible loss of the capacity to breathe spontaneously.

Second “brain death” Test

A second series of “brain death” tests is undertaken prior to harvesting. In Japan the second doctor waits six hours, in Spain twelve hours with adults and twenty-four hours with children. Australians wait two hours. Two doctors have to certify death in the United Kingdom but they’re not required to undertake two series of tests sequentially. In many cases the second doctor is simply an observer, watching the other doctor perform the tests.

A patient failing to respond to the second test is certified “brain dead”. The patient loses legal entity status, has no human rights and is called the “heart-beating cadaver”. The ventilator is re-started and the body, though legally dead, is kept alive on life support until surgeons have been assembled and transplant hopefuls brought to the hospital. This may take hours or days. ^[6] All treatment to heal the injured brain will cease and doctors will increase fluid drip and blood pressure, and inject anti-psychotic medications like chlorpromazine to maintain the organs at the expense of the “dead” brain. The patient may be transferred to a hospital better equipped to remove organs though authorities deny this happens.

Various Types of “brain death"

Most European countries and some American states recognise the “whole brain death” criterion that requires “irreversible cessation of all functions of the entire brain, including the brainstem” as defining “brain death”.

The United Kingdom, most Commonwealth countries and some American states, particularly Minnesota, have adopted the lesser “brain stem death” criterion. The brain stem is situated between the major part of the brain - the big cerebral hemispheres and the mid-brain - and the top of the spinal cord. It controls some of the automatic physical functions such as breathing and regulation of blood pressure. The concept of “brain stem death” means that part (or even most) of the brain may be alive but if the brain stem is irreversibly damaged then this is considered equivalent to “brain death” which is equivalent to being legally dead which is equivalent to being really dead, or so the logic goes.

Many medical specialists working in thetransplant field acknowledge privately the absurdity of the “brain death” concept though few state this publicly. One exception is United Kingdom Critical Care Consultant, Tom E Woodcock, who suggests the medical colleges stop equating “brain death” with the death of the patient and start administering anaesthetic to these vital organ donors. ^[7] 

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