Vital Organ Donation

Paul A. Byrne
Reproduced with Permission

Part I

You've probably seen TV commercials, billboards, and magazine articles encouraging you to give the "gift of life" through vital organ donation. It saves lives. It gives meaning to a wasteful, tragic death. But before you fill out an organ donor card, here are a few things to think about.

Vital organs (from the Latin vitae, meaning "life") are those organs like the heart, liver, lungs, and pancreas, which are necessary for life. In order to be suitable for transplantation, they need to be removed from the donor before respiration and circulation cease. Otherwise these organs are not suitable, since damage occurs within a brief time after circulation of blood with oxygen stops. Removing vital organs from a living person prior to cessation of circulation and respiration will cause the donor's death.

Portions of some vital organs can be removed without causing death of the donor, e.g., one of two kidneys, a lobe of a liver, a lobe of a lung. But other vital organs, like the heart, cannot be removed without killing the donor. Both donor and recipient must be fully informed about procedures and risk of death and effect on length of life and health of donor. Organ explantation ought not to cause death or disabling mutilation of the donor.

Since vital organs are not useful for transplantation once the person is truly dead, and taking them before true death causes true death, is it possible to donate vital organs? Organs deteriorate rapidly without oxygen; the heart and liver in 4-5 minutes are so damaged. Thus, there is no way to transplant a heart or whole liver because there is not enough time without circulation to get these organs out. The time without circulation before deterioration of kidneys is about 30 minutes. Thus, it is possible to get kidneys out within this timeframe, but nothing can be done to the donor to initiate or facilitate transplantation prior to true death that might hasten death. Potential donors and potential recipients must be fully and explicitly informed in order to give informed consent or to decline. Kidney function in everyone decreases about 1 percent per year from a maximum at age 20 to about 50 percent of this by age 70. Potential donors and recipients must be fully informed of this.

Pope Benedict XVI taught on November 7, 2008, "Individual vital organs cannot be extracted except ex cadaver" (Pope Benedict used Latin to avoid any question; English: from a dead body). "The principle criteria of respect for the life of the donator must always prevail so that the extraction of organs be performed only in the case of hiss/her true death." (Cf. Compendium of the Catechism of the Catholic Church, n, 476). This teaching is certainly helpful to Catholics but it is also helpful to everyone as organ transplantation is contemplated.

That's where "brain death" comes in.

Before 1968, a person was dead only when breathing and the heart stopped. In the 1950s and '60s when surgeons developed the ability to transplant vital organs, the medical community faced a legal and ethical dilemma: vital organs must be taken from a living body, but removing vital organs will cause death.

In 1968, a committee at Harvard Medical School formulated an alternate definition of death: "brain death." They decided that when certain criteria are fulfilled (for example, no response, coma, and need for a ventilator to support breathing), the patient can be declared "brain dead." Even when the heart is pumping and the lungs are oxygenating blood, vital organs could be removed without legal or ethical consequences.

In 1980, the Uniform Determination of Death Act (UDDA) was approved. According to the UDDA, death may be declared when a person has sustained either "irreversible cessation of circulatory and respiratory functions" or "irreversible cessation of all functions of the entire brain, including the brain stem." Since then all 50 states consider cessation of brain functioning to be death.

Moreover, between 1968 and 1978, more than 30 different sets of criteria for "brain death" were adopted in the United States and elsewhere. Thus, if a hospital has a potential donor, the doctors at the hospital can choose which criteria for determining brain death will best suit its current need.

Part II

Dead or "brain dead?" What's the difference?

If you were to compare a dead body with a "brain dead" body, you would find that the dead body is pale, cold, stiff, and unresponsive. There is no heartbeat, no body functions, no breathing, and no movement. A "brain dead" body is warm and flexible. There is a beating heart, normal color, temperature, and blood pressure. Most functions continue, including digestion, excretion and maintenance of fluid balance with normal urinary output. The body will often respond to surgical incisions. In a long enough period of observation, someone declared "brain dead" will show healing and growth, and will go through puberty if they are a child.

There have been numerous instances of pregnant women with head injuries declared "brain dead," yet with careful medical management they have been able to carry the child to birth. In the longest recorded instance, the child was carried for 107 days.

In other cases, during the excision of vital organs, doctors find they need to use anesthesia and other drugs to control muscle spasms, blood pressure and heart rate changes, and other bodily protective mechanisms common in live patients.

Hospitals allow "brain-dead" patients to occupy a bed; insurance companies cover expenses as they do for other living patients. If the patients' organs are suitable for donation, any transfer of the patient to another hospital is covered by insurance. If they are used for teaching purposes or vital organ donation, they (the "brain-dead" patients) receive life support procedures, antibiotics and other drugs, or anything else necessary to maintain their organs in a healthy state. Insurance also covers this.

Interestingly, in cases of suspected homicide, attorneys hesitate to file charges until the patient is truly dead, even if the patient has been declared "brain dead." But in the meantime, if someone else would act to "finish the job," this "new aggressor" could possibly be held or prosecuted for murder, since the patient is alive, but legally "brain dead." Other discussion with legal experts suggest that since the victim is legally dead, the case for murder by the second assailant would not be tenable since the victim is already legally dead. However, the second assailant could be liable for intent to mutilate the "corpse," which in some jurisdictions is the property of the victim's family.

Legally "brain dead" patients are considered corpses or cadavers, and are called such by organ retrieval networks. The corpses can be used for teaching, for trying out new procedures, and for vital organ harvesting. Yet these same "corpses" are carrying preborn children to successful delivery. Certainly this is extraordinary behavior by a "cadaver"!

It appears that "dead" is not the same as "brain dead." So if "brain dead" persons aren't dead, what are they?

More moral dilemmas created by the existing flawed neurological criteria for death

Sometimes a potential organ donor does not meet the criteria for "brain death," but has sustained certain injuries or has an illness suggesting that death will occur soon. Such cases brought about the development of "Non-heart-beating (so-called) donation" (NHBD) and more recently labeled Donation by Cardiac Death (DCD) in which treatments considered extraordinary means, such as mechanical ventilation, are discontinued and certain drugs are used to lower the blood pressure and cause the patient to be pulseless. As soon as the patient is pulseless (not necessarily without heartbeat), death is declared, and after 5, 2 or 1.75 minutes, which varies in different institutions, the body could still be resuscitated to restore cardiac and respiratory activity. This cannot be accomplished in the remains of someone who is truly dead.

It seems clear that in certain cases we are playing games with human lives for utilitarian gain. So glaring is the reality of this issue that there are those who now argue that doctors should not be burdened with determination of death criteria, since the good of organ donation outweighs the harm (killing) done to the donor. Scary, isn't it?

Government involvement

The federal government is deeply involved in transplant programs for reasons that are unclear. A federal mandate issued in 1998 states that physicians, nurses, pastors, and other health care workers may not speak to a family of a potential organ donor without first obtaining approval from the regional organ procurement organization (OPO). If there is the possibility of vital organs available for transplant, a trained "designated requester" visits with the family first, even if the family adamantly opposes organ donation. If someone at the hospital speaks to the family first, the hospital risks losing its accreditation and/or federal funding.

Why the "designated requester"? Studies show that these people have greater success obtaining permission for organ donation. They're trained to sell the concept, using emotionally-laden phrases such as "gift of life," "your loved one's heart will live on in someone else," and other similar platitudes, all empty of any true meaning.

Where does the money go?

The donation and transplant industry costs billions of dollars a year, according to several sources (e.g., a 1996 series by Forbes magazine.) But it's difficult to obtain financial data. One thing is clear: donor families do not receive any monetary benefit from their "gift of life."

Something to think about

Based on what you've just read, take a moment to ponder the following: Why can health insurance cover intensive care costs on "brain dead" patients? Why do "brain dead" patients often receive intravenous fluids, antibiotics, ventilator care, and other life support measures? Why is it wrong to tell families their "brain-dead" loved one is dead? Why do "brain-dead" organ donors often receive anesthesia and other drugs to stop natural physical responses when they're undergoing vital organ harvesting? How can "brain dead" patients have normal body functions, including vital signs, if they are truly dead?How can a "brain-dead" pregnant mother deliver a normal, healthy infant? Why does a ventilator work on a "brain-dead" person, but not on a cadaver? Why is it wrong to carry out burial or cremation of a "brain-dead" person? Are "brain-dead" persons really dead? Are they alive?

But it is not up to us to decide who does not have the right to live . . . and who must die!

Dr. Paul Byrne has been a practicing physician for 54 years. He is Board Certified in pediatrics and neonatology, and a Clinical Professor of Pediatrics at the University of Toledo, College of Medicine. He has written numerous articles on life issues in medical and law journals, as well as lay literature on topics including abortion, "brain death," organ transplantation and imposed death.