Organ Hysteria
I think that the hue and cry against non heart beating cadaver donor protocols--what I have called "heart death"-- is misguided. And it reflects a misconception about the concept of "brain death," a popular term for death by neurological criteria--which does not mean that every brain cell is dead, but that the brain and each constituent part has ceased to function as a brain. What is even more ironic, is that some pro life advocates oppose brain death as not really being dead because the patient's heart is still beating.
This statement from a story on this issue in LifeSite is wrong factually:
"The person is not dead yet," said Jerry A. Menikoff, an associate professor of law, ethics and medicine at the University of Kansas. "They are going to be dead, but we should be honest and say that we're starting to remove the organs a few minutes before they meet the legal definition of death."No, irreversible cardio/pulmonary arrest is dead, and in these cases the arrest is irreversible because there will be no CPR. When writing Culture of Death, I inquired of many neurologists as to whether patients would have any awareness after such a time. The answer from pro life and non pro life doctors alike was unanimous: No.
Death by neurological criteria, is the other method of declaring death. In other words, there are two methods of declaring death, with heart death being the tried and true one from time immemorial.
Some of these "heart death" protocols permit organ procurement as short as 2 minutes after cardiac arrest. I think this is too short, not based on the patient having any awareness--which I was again told unanimously was not possible--but based on giving the benefit of the doubt to caution and the lack of tests about whether such reverses are irreversible after such a short time.
I think a few people believe there should be no organ transplants because they don't think it can be done ethically. They don't believe in brain death--which is an arguable position. But they also don't believe in heart death along these protocols. That's fine. But we should not let these well meaning advocates panic us. The real danger, in my view, to ethical organ procurement comes not from heart death donor protocols, or from brain death procurements, but rather from shoddy following of ethical rules and from advocacy among many bioethicists to expand the donor pool to people who are not really dead.
Let's chill out there and keep our priorities straight.
Labels: Organ Donation. Non Heart Beating Cadaver Donor Protocols. Heart Death.
posted by Wesley J. Smith @ 9:51 AM
12 Comments
12 Comments:
I think you may be right here and don't have a strong position either way on NHBD. But I'm a little hesitant about the claim that the cardiac arrest is irreversible because there will be no CPR. I mean, isn't "irreversible" supposed to mean that it _can't_ be restarted, not just that in fact it _won't_ be restarted? Saying it's irreversible because in point of fact we aren't going to do CPR sounds a little uncomfortably like saying that someone is terminally ill because we've decided we are going to stop giving him food and water.
Please understand that I don't mean to say that NHBD is like dehydrating the person to death. I'm just making the analogy to show why some people might be uncomfortable with using a term like 'irreversible' as a designation for what we intend or don't intend to do for the patient.
Is it not at all bothersome, though, if this is true, to think that organs are being procured from someone who, let's say, could be "brought back" and even become fully conscious again later and so forth if he were given CPR?
Perhaps there's just something I'm not getting, though.
Yes, well with CPR and intensive intervention, people have been revived after 15 minutes. But without it, they will not spontaneously revive. If they have refused such interventions--which they have the right to do--then after 5 minutes it is irreversible.
Either that, or we can bring organ transplant medicine to a complete halt, over matters that are not really of major ethical concern.
Thanks, that's a helpful clarification. What you're saying then is that it's really objectively true after five minutes with _no_ CPR or intervention that the condition is irreversible. That is, if we sat around and did nothing for five minutes and _then_ started up the CPR and such, it wouldn't work. So the irreversibility really is objectively true of the patient's condition because we've already in the past (the five minutes since heart stoppage) not given CPR. That does make a difference. It's not like the organs are being taken from a person who right then still could have things done for him that could bring him back completely.
No. I didn't say that after five minutes CPR and other interventions might not be able to bring someone "back." I don't know that. I am saying that there will not be CPR and so the collapse of cardio/pulmonary functioning at that point is indeed, irreversible.
Okay. I apologize for over-extrapolating. So here, I think, must be the significance of the 5 minute: It's that after 5 minutes we can be sure the person won't _spontaneously_ "wake up" if nothing is done, whereas after merely 2 minutes there's a concern that the person might spontaneously come to and hence isn't really physically dead. Is that right?
Yes. Of course, there has been no formal testing about this matter--how could there be--but the 5 minutes seems right since by then, any chance of spontaneous revival after 5 minutes without heartbeat or breathing would be as close to impossible as one can say using that term.
This is evidence that I read too many of the *wrong* books and websites...
Okay. The reason I'm bringing this up has nothing to do with Near Death Experiences (NDEs), but it does explain what happens to the brain when it gets shut down. The doctor I'm quoting from is Dr. Pim van Lommel, whose article was published in THE LANCET. The article is about near-death experiences, *BUT* Section Five explains the effect of cardiac arrest on the brain. It's the easiest explanation of heart death and brain death that I've ever read, and *that* is why I'm quoting it here, to explain why I don't think that heart death is bad criteria for organ donation.
Quote:
We know that patients with cardiac arrest are unconscious within seconds. But how do we know that the electroencephalogram (EEG) is flat in those patients, and how can we study this? Complete cessation of cerebral circulation is found in cardiac arrest due to ventricular fibrillation (VF) during threshold testing at implantation of internal defibrillators. This complete cerebral ischemic model can be used to study the result of anoxia of the brain.
...Through many studies in both human and animal models, cerebral function has been shown to be severely compromised during cardiac arrest, and electrical activity in both cerebral cortex and the deeper structures of the brain has been shown to be absent after a very short period of time. Monitoring of the electrical activity of the cortex (EEG) has shown that ischemia produces a decrease of power in fast activity and in delta activity and an increase of slow delta I activity, sometimes also an increase in amplitude of theta activity, progressively and ultimately declining to isoelectricity. More often initial slowing and attenuation of the EEG waves is the first sign of cerebral ischemia. The first ischemic changes in the EEG are detected an average of 6.5 seconds after circulatory arrest. With prolongation of the cerebral ischemia, progression to isoelectricity occurs within 10 to 20 (mean 15) seconds from the onset of cardiac arrest.18-21
...Anoxia causes loss of function of our cell systems. However, in anoxia of only some minute’s duration this loss may be transient; in prolonged anoxia cell death occurs, with permanent functional loss. During an embolic event a small clot obstructs the blood flow in a small vessel of the cortex, resulting in anoxia of that part of the brain, with loss of electrical activity. This results in a functional loss of the cortex like hemiplegia or aphasia. When the clot is dissolved or broken down within several minutes the lost cortical function is restored. This is called a transient ischemic attack (TIA). However, when the clot obstructs the cerebral vessel for minutes to hours, it will result in neuronal cell death, with a permanent loss of function of this part of the brain, with persistent hemiplegia or aphasia, and the diagnosis of cerebrovascular accident (CVA) is made. So transient anoxia results in transient loss of function.
In cardiac arrest global anoxia of the brain occurs within seconds. Timely and adequate CPR reverses this functional loss of the brain, because definitive damage of the brain cells, resulting in cell death, has been prevented. Long lasting anoxia, caused by cessation of blood flow to the brain for more than 5-10 minutes, results in irreversible damage and extensive cell death in the brain. This is called brain death, and most patients will ultimately die.
From these studies we know that in our prospective study1 as well as in the other studies2,3 of patients who have been clinically dead (VF on the ECG), total lack of electric activity of the cortex of the brain (flat EEG) must have been the only possibility, but also the abolition of brain-stem activity, such as the loss of the corneal reflex, fixed and dilated pupils, and the loss of the gag reflex, is a clinical finding in those patients.
...Unquote.
I stop there because the conversation moves on to NDEs and that's not at all relevant, but as you can see from the detailed explanation that Dr. von Lommel gives, in a very short period of time after the heart stops beating, the brain stops functioning altogether. CPR doesn't restore normal blood flow to the brain and cannot make the brain work properly - it's only when CPR leads the brain stem to take over the heartbeat again that the heart - on its own - can generate enough blood flow to get the brain up and running.
THEREFORE, one can conclude (I believe correctly) that when the heart stops beating, the brain is unable to function at all, and therefore brain death officially occurs. The cells don't have to be dead for the brain to stop functioning properly - the brain won't generate anything while deprived of necessary bloodflow. The person isn't inside his or her head anymore.
If anybody's interested in the entire article, you can read it here:
http://iands.org/research/vanLommel/vanLommel4.php
Section Five has all the details about what the brain is *not* doing when the heart is not beating. Even if you're not into NDEs it's a good read - if nothing else you learn a little bit more about what happens when we're in the process of dying, and that takes some of the fear out of the mystery.
Most of the cases, no problem.
But they mention that it would allow people with terminal neurological disease to donate organs...meaning of course we'll pull the respirator to stop their heart then take their organs. I have real problems with that one.
Boinky: Thanks for stopping by. Yes, in Culture of Death I also expressed concern that this protocol could become a way for very depressed disabled people who require respirators, to give life "meaning" by becoming an organ donor. I think the issue you raise requires real concern and that perhaps such people should not qualify as donors to prevent such a scenario.
I'm trying to see how such a protocol would work. It seems to me there's a real practical problem, because many people who would require a respirator _would_ become at least for a short time disabled--cognitively or otherwise--during or just before the time that they required a respirator. So if there were a rule against using this for disabled people, it would seem as though that wd. rule it out for anyone on a respirator.
_I_ don't mind that myself, but is it likely that anyone would accept it? Like Boinky (and apparently like a lot of people who object to this protocol) I think there's something unpleasant about the image of taking somebody off a respirator just so you can take his organs. Yet how else could it ever work for respirator patients?
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Let me rephrase that:
T.E. Fine: "The person isn't inside his or her head anymore."
Catholic's reading this discussion should be aware that moral theology on the matter, beginning with the Council of Vienne in 1313, condemns the idea that the person can be located in a part of the body. Perhaps the attempts to determine death on the basis of heart *or* brain are misguided; none of the medical criteria can hope to explain the phenomena that defy medical definitions of death and irreversibility.
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