December 6, 2021

Are brain dead patients really dead?

Dead donor rule under threat

Doornails and
dodos are certainly dead, either because they were never alive or
because they stopped breathing in the 17th century. But determining
exactly when the rest of us shuffle off this mortal coil is not so
easy, especially for doctors who want organs of certifiably dead people. An article in the Boston Globe highlights a
little-known dispute in the profession about whether most donors are alive or not when their organs are removed. The universally
accepted “dead donor rule” forbids the removal of
essential organs from living donors. This reassures potential donors
and the public that transplant surgeons are not just high-tech ghouls.
People are normally deemed to be dead when their brain ceases to
function. This is the state of
so-called “brain death”. But, says a medical ethicist at
Harvard Medical School, Dr Robert Truog, this definition crumbles
upon closer examination. “It’s completely ethical to
remove organs from patients we diagnose as brain dead,” he
says. “It’s just ethical for reasons other than that we
think they’re dead, because I don’t think they are.”

Truog’s critique of what it means to be dead is supported by other
physicians. "Brain death is not true death,” says Dr Paul Byrne, who has been an outspoken critic of the brain death criteria for many
years. “Brain death is a fiction concocted to get organs. After
true death very few, if any, organs are suitable for transplantation.
True death is the body without life, when disintegration sets in. It
is more than just non-functioning, which brain death revolves
around.”

And University of
Wisconsin medical ethicist Dr Norman Fost points out that the brain, or
parts of it, may still be functioning in “brain dead” people. For
instance, many have a functioning hypothalmus, which regulates blood
pressure and
appetite. “We have been taking organs out of those patients by
the thousands,” he says. “And they are not brain dead.”

Other doctors,
however, assert not only that that brain death is an adequate
criteria, but that there is nothing to talk about. A leading
authority on the topic, Dr Eelco Wijdicks, of the Mayo Clinic, told
the Globe that the concept is widely accepted by neurosurgeons and
neurologist. “There is no controversy about brain death,”
he says.

The older criteria
for determining death was cardiac death, or when the heart stopped
beating. This fell out of favour after brain death became widely
accepted, because organs from people whose hearts had stopped beating
were not as viable. However, with the growing shortage of organs,
donation after cardiac death is being revisited. Patients with no
apparent chance of recovery
are removed from ventilators; their hearts eventually stops; and within
two minutes their organs are being removed. But Fost finds this
criterion just as unsatisfactory. He and other critics point out that
countless people have been resuscitated after their hearts stopped
for two minutes.

What is really
under threat is the dead donor rule itself. Truog and Fost and other
ethicists are by no means opposed to organ donation. Indeed, they want to expand the
potential pool of donors to include people who are manifestly not
dead, but will never become conventionally alive: people in a
permanent vegetative state, people who consent to having their organs
removed when they lose consciousness, anencephalic children, and so
on. “Reconsidering the Dead Donor Rule: Is it Important that
Organ Donors Be Dead?” was the unsettling headline over one of Dr
Fost’s articles. Stay tuned for future developments as the
organ donor shortage becomes more acute. ~ Boston Globe, Mar 9;
Zenit, Mar 2