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An extract

Organ Donation: The Inconvenient Truth

By Dr. John B. Shea, MD, FRCP(C)

(From Catholic Insight Magazine, September 2007)

Ever since organ donation after a declaration of “cardiac death” was first practised in the Ottawa Hospital in June 2006, Canadians have been subjected to an incessant drumbeat of rhetorical manipulation in the media in favour of organ donation. The following commentary is offered in order to inform the public about the truth in regard to both the moral principles and scientific facts pertaining to both the donation and harvesting of human organs for transplantation purposes. Many physicians have serious and well-considered concerns about the morality of human organ transplantation and about the fact that the general public has not been properly informed about what really happens when organs are retrieved.…

In his message on the World Day of the Sick, February 4, 2003, Pope John Paul II said, “It is never licit to kill one human being in order to save another.” The Catechism of the Catholic Church states (paragraph 2296): “It is morally inadmissible directly to bring about the disabling mutilation or death of a human being, even in order to delay the death of other persons. ⁽³⁾

Methods of organ retrieval

“Many physicians have serious and well-considered concerns about the morality of human organ transplantation.”

Today, organs are retrieved under four different sets of circumstances.

• * From a living donor; for example, a single kidney or part of a liver. This presents no moral problem, provided there is properly informed consent and there is no major risk to the life or health of the donor
• * From a person who is declared dead using the older criteria of loss of respiration and cardiac function along with rigor mortis. Tissues such as bone marrow, corneas, heart valves and skin may be removed. This procedure is morally acceptable
• * After the patient has been declared “brain dead”
• * After the patient has been declared to have suffered “cardiac death.” The moral status of both “brain death” and “cardiac death” is questionable

Theory and practice

…The concept that whole brain death (irreversible loss of function of the cerebrum, cerebellum and brain stem) means the loss of integrated organic unity in a human being has been subjected to a powerful critique by neurologist Alan Shewmon. ⁽⁶⁾ Some physicians question whether we can be sure the entire brain is really dead in patients declared dead in the U.S. by “whole brain,” or in the U.K. by “brain stem,” criteria.⁽⁷⁾ Neurological criteria are not sufficient for declaration of death when an intact cardio-respiratory system is functioning. These criteria test for the absence of some specific brain reflexes. Functions of the brain that are not considered are temperature control, blood pressure, cardiac rate and salt and water balance. When a patient is declared brain dead, these functions are not only still present, but also frequently active.

There is no consensus on diagnostic criteria for brain death. They are the subject of intense international debate. Various sets of neurological criteria for the diagnosis of brain death are used. A person could be diagnosed as brain dead if one set is used and not be diagnosed as brain dead if another is used.^(8),(9), ⁽¹⁰⁾,⁽¹¹⁾

A diagnosis of death by neurological criteria is theory, not scientific fact. Also, irreversibility of neurological function is a prognosis, not a medically observable fact. There is also evidence of poor compliance with accepted guidelines of brain death. ⁽¹²⁾

Utilitarian rationale

Brain death can be used for purely utilitarian purposes. In 2005, Dr. Robert Spaemann, a former philosopher at the University of Munich, told the Pontifical Academy of Sciences that the brain death approach to defining death reflects a new set of priorities. It was no longer the interest of the dying to avoid being declared “dead” prematurely, but the community’s interest in declaring a dying person dead as soon as possible.

“There is no consensus on diagnostic criteria for brain death.”

Two reasons are given: 1) guaranteeing legal immunity for discontinuing life-prolonging measures that would constitute a financial and personal burden for family members and society alike, and 2) collecting vital organs for the purpose of saving the lives of other human beings by transplantation.⁽¹³⁾

The goal is to move to a society where people see organ donation as a social responsibility and where donating organs would be accepted as a normal part of dying. In cases where a person chose to withhold recording a specific choice about donating his or her organs, the surviving family members would agree to donation.⁽¹⁴⁾…

The deadly apnea test

Every set of criteria for “brain death” includes an apnea test, considered the most important step in the diagnosis of brain death. The ventilator is discontinued. “Apnea” is the absence of breathing. The only purpose of this test is to determine if the patient is unable to breathe on his or her own, in order to declare “brain death.” It aggravates the patient’s condition and is commonly done without the knowledge or consent of family members. The ventilator is turned off for up to 10 minutes, carbon dioxide increases in the blood and the blood pressure may drop, indicating that cardiac arrest has occurred. The test significantly impairs the possibility of recovery and can lead to the death of the patient through a heart attack or irreversible brain damage. Dr. Yoshio Watenabe, a cardiologist from Natoya, Japan, stated that if patients were not subjected to the apnea test, they could have a 60 per cent chance of recovery to normal life if treated with timely therapeutic hypothermia (cooling). Note the similarity to cardiac death, later described. ⁽¹⁷⁾

“The (apnea) test significantly impairs the possibility of recovery and can lead to the death of the patient through a heart attack or irreversible brain damage.”

Some form of anesthesia is needed to prevent the donor from moving during removal of the organs. The donor’s blood pressure may rise during surgical removal. Similar changes take place during ordinary surgical procedures only if the depth of anesthesia is inadequate. Body movement and a rise in blood pressure are due to the skin incision and surgical procedure if the donor is not anesthetized. Is it not reasonable to consider that the donor may feel pain? In some cases, drugs to paralyze muscle contraction are given to prevent the donor from moving during removal of the organs.…

Organ harvesting after ‘cardiac death’

In 1993, a new way for categorizing patients as “dead” was conceived. According to a protocol developed at the University of Pittsburgh, a patient could be declared dead, even though not “brain dead,” if he or she was declared to have suffered “irreversible loss of circulatory and respiratory function.” The Institute of Medicine found that in so-called “controlled non-heartbeating donation,” a typical patient would be five to 55 years old, would have suffered a severe head injury, would not be brain dead, would not be a drug user or HIV-positive and would be free from cancer or sepsis. This patient would frequently be unconscious as a result of a car crash.

Typically, the patient would be in an emergency department, in coma, and on a ventilator. If the physician decided that treatment was futile, he asked the relatives’ permission to withdraw ventilation and then for their permission to remove organs, if the patient’s heart had stopped beating. Ventilation was then withdrawn. If the heart stopped beating within an hour, the surgeon waited two to five minutes before taking out the organs. If the heart had not stopped beating within an hour, the patient would be returned to a hospital bed to die without any further treatment. Note that the patient’s physician has a conflict of interest. The longer he waits, the less suitable the organs are for transplant due to damage from lack of oxygenation. The sooner the doctor declares treatment futile, the less chance the patient has of spontaneous recovery.⁽¹⁸⁾

… it is now widely known that a patient whose heart has stopped beating for 15 minutes after a heart attack can recover if he is treated by cooling the body to 33C, cardio-pulmonary bypass, cardioplegia (stopping the heart beat chemically) and a slow increase in oxygenation for 24 hours. Up to 80 per cent of these patients can be discharged from hospital, 55 per cent having a good neurological outcome. Clearly, the assumption made by physicians that a patient is dead five minutes after the heart has stopped beating is incorrect. ⁽²⁴⁾

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References: (From original article)

1. Address of the Holy Father, John Paul II, to the 18th International Congress of the Transplantation Society. August 29, 2000.

2. Dr. Alan Shewmon and Elizabeth Seitz Shewmon. “The Semiotics of Death and Its Medical Implications,” Brain Death and Disorders of Consciousness. Edited by Machado and Shewmon. Kluwer Academic/Plenum publishers, New York, 2004, pp. 105-6.

3. Carol Glatz. “Vatican resuscitates issue of whether brain death means total death.” Vatican Letter, Catholic New Service. Sept. 15, 2006, backgrounder xxxi.

4. Capron, A.M. “Brain Death – Well Settled, Yet Still Unresolved.” New England Journal of Medicine. April 19, 2001, vol. 344 (16).

5. Pope John Paul II. Letter to the Pontifical Academy of Sciences. Feb. 3, 2005.

6. D. Alan Shewmon. “Recovery from Brain Death. A Neurologist’s Apologia.” Linacre Quarterly, Feb. 1997, 30 – 96.

7. Donald W. Evans, retired physician, Queen’s College, Cambridge. Journal of Medical Ethics. April 11, 2007.

8. Wijdicks, E.F. Neurology. 2002, Jan. 8; 58(1): 20-25.

9. Haupt, W.F., Rudolf J. “European brain death codes: a comparison of national guidelines.” J. Neurol. 1999, June; 246(6): 432-7.

10. Evans, D.W. and Potts, M. Brain death. BMJ, 2002; 325:598.

11. David W. Evans. Open letter to Prof. E. F. M. Wijdics. Dec. 11, 2001, www bmj.com.

12. Wang M.Y. et al. Neurosurgery. 2002, Sept; 51(3): 751-5.

13. Institute of Medicine, National Academy of Sciences, Report Brief, Organ Donation - Opportunities for Action, Committee on Increasing Role of Organ Donation. May, 2006.

14. D. Truog et al. Recommendations for End-of-Life Care in the Intensive Care Unit. The Ethics Committee of the Society of Critical Care. Crit. Care Med. 2001, vol. 29, no. 12, pp. 2332-2334.

15. Paul A. Byrne et al. “Brain Death is Not Death!” Source: Essay – Meeting of the Political Academy of Sciences, in early February, Paul Byrne to the Compassionate Health Care Network. March 29, 2005, via e-mail.

16. See reference 6.

17. Ari R. Joffe, critical care physician, Stollery Children’s Hospital, University of Alberta, e-letter to J.R. Cuo et al. Time dependent validity in the diagnosis of brain death using transcranial Doppler. J. Neurol Neurosurg Psychiatry. 2006; 77: 646-649.

18. Institute of Medicine. “Non-Heart-Beating Organ Transplantation – Medical and Ethical Issues of Procurement.” 1997, National Academy Press, Washington, D.C.

19. Adhiyaman V., Sundaram R. The Lazarus phenomenon. J. R. Coll. Physicians Edinb. 2002, 32: 9-13.

20. American Heart Association. Management of Cardiac Arrest. Circulation. 2005; 112:IV 58-IV66.

21. Institute of Medicine Committee on Non-Heart-Beating Transplantation. The scientific and ethical basis for practice and protocols, executive summary. Washington, (D.C.): National Academy Press, 2000.

22. Magliocca, J. F. et al. Extracorporeal support for organ donation after cardiac death effectively expands the donor pool. J Trauma. 2005; 58:1095-1201.

23. Younger, J.G. et al. Extracorporeal resuscitation of cardiac arrest. Acad Emerg Med. 1999: 6: 700-7.

24. Weisfeldt, M.L., Becker L. “Resuscitation After Cardiac Arrest” A 3 – phase Time-Sensitive Model. JAMA. Dec. 18, 2002, vol. 288, no. 23, pp. 3035-8.

25. Catherine McVearry Kelso, MD. et al. Palliative Care Consultation in the Process of Organ Donation after Cardiac Death. Journal of Palliative Medicine, vol. 10, no. 11, 2007.

26. Prof. Mauro Cozzoli, The Human Embryo: Ethical and Normative Aspects. The Identity and Status of the Human Embryo. Proceedings of the Third Assembly of the Pontifical Academy for Life, Vatican City. Feb. 14-16, 1997, p. 271, Libreria Editrice Vaticana, 00120. Citta Dei of Vaticano.

27. Steven Long, Regarding the Nature of the Object of the Moral Act According to St. Thomas Aquinas. The Thomistic Institute, 2001, maritain.nd.edu/jiuc/ti01/long.htm.

28. See reference 15.

©Copyright 1997-2006 Catholic Insight

Updated: Mar 5th, 2008 - 17:28:36

(Extract from “Organ donation: The inconvenient truth” by Dr. John B. Shea, MD, FRCP(C). Viewed Dec 18, 2010 at: http://catholicinsight.com/online/bioethics/article_747.shtml )