Monday, July 16, 2007

On "brain death"

KAO is an organization of parents who found out what happens to "brain dead" transplant donors only after they had signed consent for their children's organs to be harvested. Below are some excerpts from their web site.


In 1968 the "Harvard criteria" for determining brain death were published in the Journal of the American Medical Association, under the title of "A Definition of Irreversible Coma." This article was published without substantiating data, either from scientific research or from case studies of individual patients. For this reason, a majority of the presenters at the conference in Rome stated that the "Harvard criteria" were scientifically invalid.

In 2002 the results of a worldwide survey were published in Neurology, concluding that the use of the term "brain death" worldwide is "an accepted fact but there was no global consensus on the diagnostic criteria" and there are still "unresolved issues worldwide."


Philosophical considerations


As he put it: Scrutinizing the existence of the symptoms of death as perceived by common sense, science no longer presupposes the "normal" understanding of life and death. It in fact invalidates normal human perception by declaring human beings dead who are still perceived as living.

The new approach to defining death, the German scholar continued, reflected a different set of priorities:

It was no longer the interest of the dying to avoid being declared dead prematurely, but other people’s interest in declaring a dying person dead as soon as possible.

Two reasons are given for this third party interest:

  • guaranteeing legal immunity for discontinuing life-prolonging measures that would constitute a financial and personal burden for family members and society alike, and

  • collecting vital organs for the purpose of saving the lives of other human beings through transplantation. These two interests are not the patient’s interests, since they aim at eliminating him as a subject of his own interests as soon as possible.

    The arguments against the use of "brain death" as a determination of death are being made, Spaemann noted, "not only by philosophers, and, especially in my country, by leading jurists, but also by medical scientists." He quoted the words of a German anesthesiologist who wrote, "Brain-dead people are not dead, but dying."

    Medical evidence

    Dr. Paul Byrne, a neonatologist from Toledo, Ohio, offered a medical perspective - he testified:

    When organs are removed from a "brain dead" donor, all the vital signs of the "donors" are still present prior to the harvesting of organs, such as: normal body temperature and blood pressure; the heart is beating; vital organs, like the liver and kidneys, are functioning; and the donor is breathing with the help of a ventilator.


    Defending the criteria

    Some participants in the February meeting defended the use of the "brain death" criteria. Dr. Stewart Youngner of Case Western University in Ohio admitted that "brain dead" donors are alive, but argued that this should not prove an impediment to the harvesting of their organs. His reasoning was that there is such poor "quality of life" in the "brain dead" patient that it would be more beneficial to harvest their organs to extend the life of another than to continue the life of the organ donor.

    Dr. Conrado Estol, a neurologist from Buenos Aires, explained the steps that should be followed in determining the "brain death" of a prospective organ donor. Dr. Estol, who is strongly in favor of harvesting human organs to extend the life of other patients, presented a dramatic video of a person diagnosed as "brain dead" who attempted to sit up and cross his arms, although Dr. Estol assured the audience that the donor was a cadaver. This produced an unsettling response among many participants at the conference.


    The apnea test

    In his presentation at the conference, Dr. Cicero Coimbra, a clinical neurologist from the Federal University of Sao Paolo, Brazil denounced the cruelty of the apnea test, in which mechanical respiratory support is withdrawn from the patient for up to 10 minutes, to determine whether he will begin breathing independently. This is part of the procedure before declaring a brain-injured patient "brain dead." Dr. Coimbra explained that this test significantly impairs the possible recovery of a brain-injured patient, and can even cause the death of the patients.

    He argued:

    A large number of brain-injured patients, even in deep coma, can recover to lead a normal daily life; their nervous tissue may be only silent, not irreversibly damaged, as a consequence of a partial reduction of the blood supply to the brain. (This phenomenon, called "ischemic penumbra," was not known when the first neurological criteria for brain death were established 37 years ago.) However, the apnea test (considered the most important step for the diagnosis of "brain death" or brain-stem death) may induce irreversible intra-cranial circulatory collapse or even cardiac arrest, thereby preventing neurological recovery.

    During the apnea test, the patients are prevented from expelling carbon dioxide (CO2), which becomes a poison to the heart as the blood CO2 concentration rises.

    As a consequence of this procedure, the blood pressure drops, and the blood supply to the brain irreversibly ceases, thereby causing rather than diagnosing irreversible brain damage; by reducing the blood pressure, the "test" further reduces the blood supply to the respiratory centers in the brain, thereby preventing the patient from breathing during this procedure. (By breathing, the patient would demonstrate that he is alive.)

    Irreversible cardiac arrest (death), cardiac arrhythmias, myocardial infarction, and other life-threatening detrimental effects may also occur during the apnea test. Therefore, irreversible brain damage may occur during and before the end of the diagnostic procedures for “brain death.”

    Dr. Coimbra concluded by saying that the apnea test should be considered unethical and declared illegal as an inhumane medical procedure. If family members were informed of the brutality and risk of the procedure, he stated, most of them would deny permission. He pointed out that when a heart attack patient is admitted to the emergency room he is never subjected to a stress test in order to verify that he is suffering from heart failure. Instead the patient is given special care and protection from further stress to the heart.

    In contrast when a brain-injured patient is subjected to the apnea test, further stress is placed on the organ that has already been injured, and additional damage can endanger the patient’s life. Dr. Yoshio Watanabe a cardiologist from Nagoya, Japan, concurred, saying that if patients were not subjected to the apnea test, they could have a 60 percent chance of recovery to normal life if treated with timely therapeutic hypothermia.

    The question of a brain-injured patient's possible recovery also concerned Dr. David Hill, a British anesthetist and lecturer at Cambridge. He observed: "It should be emphasized first that it was widely admitted, that some functions, or at least some activity, in the brain may still persist; and second that the only purpose served by declaring a patient to be dead rather than dying, is to obtain viable organs for transplantation." The use of these criteria, he concluded, "could in no way be interpreted as a benefit to the dying patient, but only (contrary to Hippocratic principles) a potential benefit to the recipient of that patient’s organs."

    "The deception"

    Dr. Hill recalled that the earliest attempts at transplanting vital organs often failed because the organs, taken from cadavers, did not recover from the period of ischemia following the donor's death. The adoption of brain-death criteria solved that problem, he reported, "by allowing the removal of vital organs before life support was turned off - without the legal consequences that might otherwise have attended the practice."

    While it is remarkable that the public has accepted these new criteria, Dr. Hill remarked, he attributed that acceptance in large part to the favorable publicity for organ transplants, and in part to public ignorance about the procedures. "It is not generally realized," he said, "that life support is not withdrawn before organs are taken; nor that some form of anaesthesia is needed to control the donor whilst the operation is performed." As knowledge of the procedure increases, he observed, it is not surprising that - as reported in a 2004 British study - "the refusal rate by relatives for organ removal has risen from 30 percent in 1992 to 44 percent." Dr. Hill also suggested that when relatives see with their own eyes the evidence that a potential organ donor is still alive, they harbor enough doubts so that they are not ready to consent to the organ removal.

    In the United Kingdom, Dr. Hill reported, there is mounting pressure for individuals to sign, and always carry with them, donor cards authorizing doctors to use their vital organs. Today only about 19 percent of the country's people have registered as organ donors, but vehicle-registration forms, driver's-license applications, and other public documents provide "tick boxes" allowing citizens to give this advance directive; even children are encouraged to sign. All such documents specify that organs may be harvested only "after my death," but there is no definition of what constitutes "death."

    Again, Dr. Hill remarked, the acceptance of transplants hangs on the public's lack of understanding about the procedure. And yet, he pointed out, "For any other procedure, informed consent is required, but for this most final of operations no explanation nor counter-signature is required, nor is the opportunity given to discuss the question of anaesthesia."


    The Signs of Death


    Many in the medical and scientific community maintain that brain-related criteria for death are sufficient to generate moral certitude of death itself. Ongoing medical and scientific evidence contradicts this assumption. Neurological criteria alone are not sufficient to generate moral certitude of death itself, and are absolutely incapable of generating physical certainty that death has occurred.

    It is now patently evident that there is no single socalled neurological criterion commonly held by the international scientific community to determine certain death. Rather, many different sets of neurological criteria are used without global consensus.

    Neurological criteria are not sufficient for declaration of death when an intact cardio-respiratory system is functioning. These neurological criteria test for the absence of some specific brain reflexes. Functions of the brain not considered are temperature control, blood pressure, cardiac rate and salt and water balance. When a patient on a ventilation machine is declared "brain dead," these functions not only are present but also are frequently active.

    The apnea test - the removal of respiratory support - is mandated as a part of the neurological diagnosis and it is paradoxically applied to ensure irreversibility. This significantly impairs outcome, or even causes death, in patients with severe brain injury.

    There is overwhelming medical and scientific evidence that the complete and irreversible cessation of all brain activity (in the cerebrum, cerebellum and brain stem) is not proof of death. The complete cessation of brain activity cannot be adequately assessed. Irreversibility is a prognosis, not a medically observable fact. We now successfully treat many patients who in the recent past were considered hopeless.


    L. said...


    I have a donor card -- if I am ever brain-dead, I want my organs harvested while my body is still alive, and doled out to people who need them. If one of my children were ever brain-dead, I would not hesitate to sign their organs over, too.

    But the apnea test sounds outmoded, in this day and age of brain scans.

    Christina Dunigan said...

    But I still wouldn't want you killed, nor your children killed, on my behalf.

    I think there needs to be a serious informed consent process, both for donors and for people going on a transplant list. The current check box says the organs will be taken after the donor has died, which is a serious lack of informed consent since it's the harvetsting of the organs that kills the patient. People need to know that this is what they are consenting to. You are evidence that this will not deter people who still think it's a good thing.

    And people who would be put on a transplant list who would have qualms about that need to be informed so that they can opt out.

    L. said...

    I honestly thought it was common knowlege, that organs are harvested while the body is still alive -- this is the way it's always been done, since the very first transplants. It's nothing new.

    Christina Dunigan said...

    I'm not sure what I thought. I didn't really give it any thought, because the premise was that they take them after you were dead. I guess I figured that they had you on a heart/lung machine until they had the organs collected, or something like that.

    I started having my first qualms when I encountered Wolf Wolfensberger's file of clippings about people who recovered while doctors were trying to get their families to consent to organ donation.

    I can't ask for anybody to be killed for me, even if they were going to die soon. One of the Christian charaties is to comfort the dying, so my job would be to sit beside the person and hold his hand and let him know that he wasn't alone, even if letting him die a natural death meant that I'd be following him soon. Even if he didn't appear at all conscious to us, I'd have to assume that his spirit was around somewhere still and that he'd have some awareness that somebody was there with him to comfort him.

    L. said...

    It is thoroughly consistent that you of all people request never to have an organ transplant harvested from a still-living donor.

    But if I'm ever in that condition and my spirit is around somewhere, I would be comforted by the thought that my corneas, liver, kidneys, etc. were going to help many others.

    Organ donation is illegal in Japan for exactly this reason -- because they don't accept brain death as death. I know parents who took their brain-dead 8 1/2 year old son off life support (a friend of my son's, who very suddenly developed encephalitis), and they were unable to donate his organs. I always figured if that happened to one of my kids, I could ask to move them to one of the U.S. bases to have their organs harvested, because hundreds of kids in Japan die waiting for transplants every year.

    Christina Dunigan said...

    I can understand that and applaud the willingness to lay down one's life for another.

    I just think this is a huge gray area and people need more awareness so that they're going in with their eyes open, fully aware of what the process means for both the donor and the recepient.

    And just think of how much the demand for organs would go down if there was more of an informed consent regarding the moral gray areas for recipients! A lot of people are like me, I would think, and would bow out if they knew that 39% of "brain dead" people move, and how their blood pressure and pulse go up when they're cut into.

    It might even be that those who opt out, given this information, would reduce the demand to where the supply is more readily able to meet it!

    Anonymous said...

    Wow, thanks for posting this...I had no idea...may have to rethink my organ donation that I ticked off on my drivers license. I have no problem having my body parts donated after I've died...please don't take them from me if I have a chance of pulling thru though! There's got to be a better way of figuring out when someone has really died and there is no return and when the body has gone into a sort of stasis mode to promote healing...I think I'm with you on this one Christina. I wouldn't want someone's organ if I knew they hadn't died until I took it from them...

    Christina Dunigan said...

    So it looks like Sam and I are having no net impact on the proportion, since I've bowed out on both ends and it looks like Sam will as well.

    I think that probably the net impact would be balance. The people with qualms would have qualms both ways -- they'd not want to be recipients or donors. And the people with no qualms would likewise remain willing to donate and remain willing to be recipients.

    I'd like to see more research going into alternative treatments. There are new and exciting cardiac possibilities that had originally been developed as stopgap measures for people awaiting heart transplants, that it turns out allow the heart to heal so it can function again. That seems to me a much better way to go than trying to get organs from donors without informed consent. Or indeed any consent at all, which is what a default presumption of consent entails.

    L. said...

    I am leery of proposals to get organs from donors without informed consent -- I do not believe that any individual should be compelled to surrender use of his/her body without consent, or consent of next-of-kin if unable to consent (which is consistent with my favoring legal abortion).

    Obviously, I would make any consent decision about my children based on the best medical information available at the time, and that's always changing. When I read about babies like this --

    -- I think that if several doctors told me my child was irreversibly brain-damaged and unable to live if disconnected from life support, allowing his/her organs to be harvested would be an easy decision for me to make.

    Christina Dunigan said...

    Let me turn that into a link for you: LINK

    I'm not sure what is your point on the link though. Did little Jackson die for want of a transplant organ? I only saw a page about surgery, and didn't see a ready link to anything that gave background.

    L. said...

    I forget his story now -- that was just a link to a random "liver baby," who didn't make it. I was following his parents' blog for a while.

    Anonymous said...

    i have my grandfather declared as brain dead, but breathing on his own without the ventilator, how can v b sure that he is brain dead? is there any treatment 4 this?

    Christina Dunigan said...

    sim, the brain is a mysterious thing. We're constantly learning how much we don't know.

    If you want potential help for your grandpa, see if any of the links here help.

    In the mean time, assume he can hear you, simply because we really don't know. People presumed "brain dead" have surprised doctors and families by having been aware all that time.