Wednesday, January 14, 2009

Bioethicists Save Organ Donation by Tweaking the Definition of Death

Photo of a hosspital bed

Hospital Bed - Image: Flickr/Rodrigo Basaure

By Brandon Keim Wired Science

In response to an emerging moral controversy over whether most vital organs used in transplants are technically taken from living people, the President's Council on Bioethics issued a new report that defines brain death as the cessation of engagement with the world.

The report overturns the current neurological death standard's reliance on an outdated notion of the brain as the body's control center for physiological processes.

The Council's definition of life as a process of engagement, which might sound like so much philosophical mumbo-jumbo, could keep the number of organ transplants from plummeting.

"One is faced with a choice of saying that the notion of brain death doesn't work, and since you're not supposed to take organs from a donor until they're dead, we have to stop doing a lot of transplantation — or you can find a better explanation for why total brain failure constitutes the death of an organism," said Gilbert Meilaender, a Valparaiso University bioethicist and Council member. "We offer a better philosophical explanation."

That the line between life and death could be so blurry is a uniquely modern phenomenon. Until the mid-20th century, it was clear: when a person's heart stopped beating, they were dead. But advances in medical technology allowed people to be sustained on machines that kept their lungs pumping and heart beating, though the necessary brain functions had ceased.

Doctors and bioethicists proposed a new standard: if both high- and low-level brain function stopped in a person, and could never be recovered, they were dead, even though machines preserved an appearance of life. A body in this condition is, in medical parlance, a "ventilated, heart-beating cadaver" — and these cadavers are the primary source of vital organs used in transplantation.

In recent years, however, scientists have shown that brain-dead bodies continue to maintain a stable temperature and eliminate waste. More poignantly, their wounds heal, and children kept on ventilators become sexually mature.

These findings undermine the current neurological death standard, which treats the brain as key to integrating and sustaining basic physical processes. Since these processes continue in the absence of brain function, doctors are confronted with three choices: remove organs from a person still technically alive; loosen the standards of brain death; or revert to the old-fashioned standard of cardiac death.

According to the Council's redefinition, the brain is important not because it controls physiological processes, but because of what these processes represent: engagement with the world.

None of these choices is palatable. Taking organs from a living person is ethically unacceptable. Easing standards — focusing purely on higher brain functions, and designating as dead people who are still able to breathe on their own — would also be, to many people, unethical. And reverting to cardiac death standards would require doctors to wait for hearts to stop beating before removing organs.

Even just a few minutes' interruption of blood flow can cause damage that makes vital organs unusable in another body. Making cardiac cessation the measure of death would would drastically curtail modern organ donation.

"If we're right, and there continues to be a persuasive argument to support the neurological standard, then organ transplanation on the scale we continue to do it is a legitimate thing to do," said Meilaender.

"We try to think of organisms as engaging in a work of self-preservation. To be living is to be engaged in that work. To die is to cease to be engaged," said Meilaender.

Engagement, explains the Council, takes three forms: openness to the world, an ability to act on the world, and the need to do so. These abstract requirements can be met by something as basic as breathing — but they are not met by physiological activities that continue in people who have lost all neurological function.

The Council's report conscientiously navigates murky ethical and scientific terrain said University of Pennsylvania bioethicist Art Caplan. "They reaffirm brain death as an acceptable standard — and I think they succeed."

Caplan stressed that people in minimally conscious and persistent vegetative states — such as Terry Schiavo, whose contested removal from life support catalyzed public opposition to expanding definitions of death — will still qualify as living.

"People are getting nervous that we're pushing the standard of death in order to get organs. The public is afraid that surgeons in search of organs for transplant will bend the definition of death to get them," said Caplan. "This report keeps that bright line in place."

"There are people who want to argue that we should define death in terms of higher brain capacities — that if you lose the capacity for consciousness, we should regard you as dead, though you're breathing without assistance," said Meilaender. "But suppose we have a body like that. I wouldn't bury it. It's lost some human capcities, but it's not ceased to be a living being."

Citation: Controversies in the Determination of Death: A White Paper by the President's Council on Bioethics. Jan. 13, 2009.

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