The National Catholic Review
Some pro-life groups are questioning the criteria for organ transplants. Pope John Paul II would have disagreed.
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Few medical procedures have proven to be as effective in saving lives as organ transplantation. Patients on the verge of death from organ failure often live a decade or longer after receiving a transplant. The Catholic Church, and the late Pope John Paul II in particular, have been enthusiastic proponents of this extraordinary medical procedure. According to the Catechism of the Catholic Church, “organ donation after death is a noble and meritorious act and is to be encouraged as an expression of generous solidarity” (No. 2296). Yet despite the church’s longstanding support for organ donation, some Catholic pro-life groups challenge practices essential to it.

The latest challenge pertains to so-called brain-death criteria, which are used to declare death in over 90 percent of all cases of organ donation in the United States. In a front-page article in L’Osservatore Romano (9/2/08), Lucetta Scaraffia, a professor of history at La Sapienza University in Rome and a frequent contributor to the Vatican newspaper, argued that the Catholic Church must revisit the question of brain death because it rests on an understanding of human life that is contrary to Catholic teaching. While Federico Lombardi, S.J., director of the Vatican press office, quickly stated that Scaraffia spoke for herself and not for the magisterium, her article shows there is disagreement within the church on the question of organ donation.

Earlier this year, Paul Byrne, M.D., a former president of the Catholic Medical Association and a long-time opponent of brain-death criteria, published a letter on the Web site Renew America arguing that God’s law and the natural law preclude “the transplantation of unpaired vital organs, an act which causes the death of the ‘donor’ and violates the fifth commandment of the divine Decalogue, ‘Thou shalt not kill’ (Dt. 5:17).” The letter was signed by over 400 individuals, including at least three Catholic bishops and many pro-life program directors.

‘A Genuine Act of Love’

In 1985 and 1989 the Pontifical Academy of Science studied the question of brain death and concluded that neurological criteria are the most appropriate criteria for determining the death of a human being. In the academy’s view, one really should not speak of “brain death”—as if only the brain had died—but rather of the death of the human being, which may be determined neurologically.

In 2000 Pope John Paul II expressed support for organ donation and the use of neurological criteria. He wrote: “The criterion adopted in more recent times for ascertaining the fact of death, namely the complete and irreversible cessation of all brain activity, if rigorously applied, does not seem to conflict with the essential elements of a sound anthropology.” He concluded that “a health worker professionally responsible for ascertaining death can use these criteria….” Moreover, he strongly reasserted his support for organ donation, calling it a “genuine act of love” and noting that he had earlier called it a “way of nurturing a genuine culture of life.”

To be fair, the Pontifical Academy of Science has no moral teaching authority, and a papal allocution is not the same as a papal encyclical or conciliar teaching. Still, it is ironic that many of the same people who continue to question brain-death criteria after John Paul II’s allocution argue that the same pope’s allocution on artificial nutrition and hydration for patients in a permanent vegetative state has decisively settled that matter.

For many people, concerns about brain death arise from a simple misunderstanding of the facts. I have spent years studying how the general public and health professionals understand death and organ donation. People in focus groups and surveys often confuse brain death with P.V.S. Yet P.V.S. patients breathe spontaneously and have sleep-wake cycles. Brain-dead bodies depend upon artificial ventilation; without it there would be no respiration and no heartbeat. Moreover, many think it is possible to recover from brain death, just as patients sometimes recover from deep coma. Yet there is no documented case of a patient recovering from brain death, despite some popular reports of misdiagnosed brain death. An organ that has been deprived of oxygen sufficiently long will die, and it is medically impossible to change dead brain cells to living brain cells. Finally, about half of Americans do not know that brain death criteria are used legally in all 50 states to pronounce patients dead. They are also used in nearly all Catholic hospitals in the United States.

Three Objections

While these factual misunderstandings are common among the general public, they are not the source of the concerns expressed by Catholic pro-life groups. Their objections to brain-death criteria tend to be more philosophical. In a recent article in The National Catholic Bioethics Quarterly, I have tried to address some of these concerns. Here I will summarize three key points.

Human development. Lucetta Scaraffia and others have voiced concern that if we decide a human being is dead because he or she lacks a functioning brain, then we will deny that embryos are human until they form a brain. However, we are developmental creatures: in our earliest days of development in the uterus, we do not depend upon a brain to live. Yet as we grow, we come to depend upon a functioning brain; and when it dies, we die. To argue that support for brain death criteria calls into question the status of early human life is to misunderstand basic human biology.

The unity of the human being. According to some Catholic pro-life advocates, the brain death criteria accepted by the larger medical community rest on a “dualistic” view of the human being that assumes the human soul is radically distinct from the human body. They argue that if the soul is the life principle of the body and if an artificially maintained brain-dead body shows some signs of life, like a beating heart, then the soul must be present. Like many members of the Catholic medical community, I do not dispute the Catholic understanding of life and death; we take seriously the fact that the soul and its proper functions are intimately bound with the body. Yet a mature human body that is functionally decapitated is no longer a living human being.

Ken Iserson, M.D., a professor of emergency medicine at the University of Arizona, cites the Talmud when describing brain death: “The death throes of a decapitated man are not signs of life any more than is the twitching of a lizard’s amputated tail.” If one rejects the notion that a decapitated body is a dead body, then one is left with a conclusion repugnant to common sense and good metaphysics: a severed head and a decapitated body would both have to be considered living human beings if separately maintained alive (a view held by at least one opponent of brain death criteria). In fact, to be wholly consistent, one would need to hold that each is independently the same living human being that existed prior to the decapitation—a view that flatly contradicts the unity required to be human.

Strange case reports. Following brain death, most bodies spontaneously lose circulation within days, even when they are artificially ventilated and provided with aggressive critical care. But there have been exceptional case reports of prolonged “survival” of the ventilated body. These are not misdiagnoses. In some cases, the entire brain liquefies and extremities begin to turn black. Despite continued circulation, there is no room for speculation that such bodies are any more conscious than a corpse that has been buried, and the likelihood of recovery is the same. Professor Scaraffia has noted that there have also been cases of pregnant women who were pronounced brain dead; yet with artificial ventilation and aggressive support their bodies sustained pregnancies until viability. But the fact that many parts of the body may survive and function for a time is wholly compatible with death of the human being. This is precisely what makes organ transplantation possible. The human heart may beat outside of the human body in a bucket of ice, and may even be transplanted and made to function again inside another human being. That the placenta and womb may survive and function in a body maintained artificially is similarly amazing, but it does not indicate that the womb belongs to a living human being. Importantly, none of these cases present “new data” that became available only after John Paul II’s allocution, and thus they do not merit a re-examination of church teaching. They are well known, even if strange and rare, phenomena.

Human Bodies, Not Objects

In the end, I think these philosophical disputes about brain death are actually motivated by a much deeper, more fundamental opposition to organ donation. This is illustrated by the resistance pro-life groups have offered to other kinds of organ donation, including donation after cardiac death. This opposition ultimately is driven by two deeper concerns that often go unarticulated.

First, organ donation risks treating human beings or their deceased bodies as “objects.” In John Paul II’s 2000 allocution on organ donation and brain death, he stated that “any procedure which tends to commercialize human organs or to consider them as items of exchange or trade must be considered morally unacceptable, because to use the body as an ‘object’ is to violate the dignity of the human person.” He also noted that organ donation requires the informed consent of the patient or the patient’s family. Yet the continual shortage of organs leads some policymakers to consider payments for organs and even organ procurement without expressed consent. Overly hasty pronouncements of brain death—which are rare but have received considerable attention in recent years—also reinforce suspicions that a concern for organ donation is trumping care for patients.

The ethical question at hand is how we should deal with the risk of treating persons as objects or commodities. It is worth recalling that Hans Jonas, one of the more famous opponents of brain-death criteria, also expressed deep reservations about medical research in general, which has yielded numerous treatments, vaccines and cures. Jonas feared that such research tends by its very nature to treat human subjects as “objects” or things. But the Catholic Church does not view medical research as intrinsically wrong for that reason; rather, it suggests how research may be conducted respectfully. It is the same with organ donation.

A second obstacle to organ donation within some Catholic circles rests on a misunderstanding of the so-called precautionary principle. This principle has been used in Catholic social teaching and basically urges caution in the face of uncertainty regarding grave risks of harm (for example, the possible harm from genetic modification). Paul Byrne, M.D., and colleagues seem to seek an absolute certainty that death has occurred, one marked by the destruction of all major organ systems. This is why Dr. Byrne opposes not only brain death, but also deceased-organ donation; by the time he would consider a body dead, no organs would be healthy enough to transplant. Yet this desire for absolute certainty conflicts with what Pope John Paul II wrote on the subject. He stated that “a health worker professionally responsible for ascertaining death can use these [neurological] criteria in each individual case as the basis for arriving at that degree of assurance in ethical judgment which moral teaching describes as ‘moral certainty.’” He added that this “moral certainty is considered the necessary and sufficient basis for an ethically correct course of action.”

Determining death in the context of organ donation is challenging and will likely remain controversial for the simple reason that death must be determined quickly lest all transplantable organs die with the human being. Nevertheless, the decision to reject organ donation in the name of precaution is not without cost. Patients in need of an organ transplant will die years earlier than necessary, and families who often find organ donation consoling will be bereft of the opportunity to find some meaning in their loss. We may not do evil that good may come of it, but neither should we bury our talents out of fear.

James M. DuBois is the Hubert Mäder Professor and department chair of health care ethics at Saint Louis University.

Comments

Jody Gibson | 5/4/2012 - 1:28pm
I think the issue here is that first you must understand how brain death is determined; these are very basic answers above. Brain death testing, as determined by the American Academy of Neurology, consists of a clinical exam and an apnea test, followed by one of several confirmatory tests available. The clinical exam checks for brain reflexes of the majority of the 12 cranial nerves. This includes testing for a cough, gag, eye movement to stimuli and also to touch, withdrawing to pain, etc.

The apnea test determines if the patient is overbreathing the ventilator at all. And yes, if there's even one breath in the 8-10 minute duration of the test, that patient is determined to not be brain dead.

To me, the best confirmatory test is a CBF, or cerebral brain flow test, which indicates the flow of blood to the brain. When the brain herniates, it swells and then collapses onto the brain stem, and blood flow ceases. On a CBF, the lack of flow to the brain appears as a black hole, or what is known as "hollow skull phenomena." A brain that is not "dead" will appear white due to flow. It's a powerful tool when communicating what brain death is and that the person is no longer clinically alive, but the organs are solely being maintained by machines.

The reason potential donors are kept on machines is that the donation process can take up to 24 hours or longer, depending on the number of organs that are able to be procured (not "harvested" - families HATE that word). Organ condition also can be improved during this time in some cases so more organs end up being transplantable (lungs in particular). Time is also needed so organ offers can be sent to the appropriate transplant centers, and arrangements can be made for transplant surgeons to come and retrieve the organ for their recipient. It is a time-consuming process. Trauma patients who die at the scene or who are actively dying won't be organ donors due to the time needed for this process to take place. The donor has to be stable, and it's quite a job to keep that patient stable.

I would direct those of you who wonder about brain death to http://www.neurology.org/content/74/23/1911.abstract, which discusses the accuracy of brain death testing WHEN DONE APPROPRIATELY. I have witnessed more than one physician performing these tests incorrectly, such as only checking for a few of the cranial nerves, or doing a 2-minute apnea test. When done according to AAN guidelines, there is NO evidence of a person "coming back to life" from brain death. This is another reason why donation is helpful - because the organ procurement organization on the case is going to redo any test if needed to confirm brain death if the physician didn't do something correctly. OPOs deal with it every day; physicians deal with it 2% of the time...

Again, cardiac death is really circulatory death, so the heart stops once circulation ceases. I'm not sure why people insist on the beating heart meaning someone is "still alive" because we've all seen how a heart can quit and be restarted. I've also seen a heart beat when stimulated outside of the body, like that lizard's tail - it's used to doing a job and the muscle will continue to contract if poked. That doesn't mean the person is still alive, does it?

To put your minds at ease, let me tell you how extremely difficult it is to be a donor. Less than 2% of the hospital population is even referred to organ procurement agencies, and only .5% may qualify as donors. In the entire United States in 2011, there were only 6,799 donors and as of this writing there are 114,200+ people waiting for a life-saving transplant, 3/4s of whom need a kidney. (www.organdonor.gov) 

It is extremely rare to be a brain dead donor, and even more rare in many areas to be a DCD donor, as many physicians don't have the time to go sit in the OR waiting for someone to die when they have "living patients to take care of," as I've heard some say. I just hope people who do not support organ donation never have a child or family member who needs one, because with 18 people dying off the list every day and another name being added every 14 minutes, the chances of survival are slim, and with the health problems Americans face today, they are going to get even worse.

On a final note, organ donation can be very healing for families - not always immediately, but often over time. Their loved one is going to live on through others, and keep other families from experiencing that loss of a loved one before his or her time. Google "Ray of Hope" or Chris Henry's story of donation, and see what it's done for the families left behind. I hope more and more people will realize the donation is so much better than letting organs rot in a casket in the ground...
Pedro Guevara-Mann | 4/21/2009 - 4:00pm
I have interviewed Dr. Byrne and I believe he makes a valid point: If the body requires a ventilator to stay "alive." Then it is dead. Here is the logic: will someone who's brain stops functioning, ie. brain death, eventually die? Yes, because without the brain function, the other organs won't function either. As soon as the heart stops beating, the person dies. The question here is not about Catholics opposing organ donation. We oppose the essential killing of someone who's heart is beating, in order to harvest the organ while it is still viable. But, if the brain has stopped functioning, the heart will eventually stop beating. Why not wait? If the heart (and lungs) are viable up to 5 minutes after they stop working, why can't doctors, expecting real death, get everything ready, disconnect the ventilator. If the person is really dead, then the heart will stop beating. As soon as it does, remove the organ for transplantation. To me, that is the only way to interpret Church teaching on organ donation: it is encouraged, but only after the person is dead. This is what Dr. Byrne says: There is no such thing as brain death. If the person has died, the heart will eventually stop beating. Only then, can we truly remove the organ.
William May | 2/27/2009 - 8:50am
Dr. DuBois' article does not take into account the The President’s Council on Bioethics December 2008 White Paper "Controversies in the Determination of Death." In its conclusion, the White Paper affirms “Among members of the President’s Council on Bioethics, the prevailing opinion is that the current neurological for declaring death, grounded in a careful diagnosis of total brain failure, is biologically and philosophically defensible” (p. 89). Two critical questions were considered: “First, are patients in the condition of total brain failure [the Council proposes this term rather than “brain dead”] actually dead? And, second, can we answer the first question with sufficient certainty to ground a course of action that treats the body in that condition as the mortal remains of a human being? Most members of the Council have concluded that both questions can and should be answered in the affirmative” (p, 90). Obviously, some Council members did not reach that conclusion. Among them was Alfonso Gomez-Lobo, a Catholic professor of philosophy at Georgetown University. Moreover, “Many members of the Council judge that affirmative answers to these questions must be supported by arguments better than and different from the arguments advanced in the past [these arguments are those already summarized as providing the rationale for the earlier consensus on brain death criteria. The Council, at its hearings in November 2007, heard D. Alan Shewmon’s detailed critique of those arguments and as a result formulated a new argument, which now follows in the words of the Council]. “Another argument can be advanced to support the declaration of death following a diagnosis of total brain failure….According to this argument, the patient with total brain failure is no longer able to carry out the fundamental work of a living organism. Such a patient has lost, and lost irreversibly, a fundamental openness to the surrounding environment as well as the capacity and drive to act on this environment on his or her own behalf.” This argument was persuasive to most Council members (p. 90). “However, another view of the neurological standard was voiced within the Council. According to this view, there can be no certainty about the vital status of patients with total brain failure. Therefore, only traditional signs—irreversible cessation of heart and lung function—should be used to declare a patient dead” (p. 91). Hence the President’s Council was divided on the issue, with a majority in favor of the neurological criterion freshly formulated and a minority not convinced. I thus think DuBois's position may not he as firm as he thnks, given the new rationale used by the President's Council, its rejection of "brain death" for "total brain failure," and the fact that the Council was divided with some not convinced even by new arguments.
Thomas Mone | 2/20/2009 - 2:22pm
I appreciate Dr DuBois's recognition that objections to the determination of death relied upon by the organ donation and transplant communities (and ultimately by all of us)often is tied to misgivings about organ donation and by extension, the use of deceased human tissues for any purpose. For those who harbor some concerns about the methodology of the determination of death in organ donation, I would strongly recommend they read the December 2008 publication by the President's Council on Bioethics "Controversies in the Determination of Death" http://www.bioethics.gov/reports/death/index.html which is a superb review of the topic and the history of concern...that concludes that the standard methodologies utilized are appropriate and respectful of the "humanity" that we ultimately share.
Joseph L. verheijde, PhD | 2/8/2009 - 6:30pm
A Response to Brain Death and Organ Donation” by James Dubois Despite a general consensus that transplanting organs saves lives, legitimate concerns and objections to the current criteria for the determination of human death underlying the practice of organ procurement exist. In fact, opposition to the determination of death has strengthened over the past decade and has expanded to not only include “some pro-life groups,” but also secular scholars from fields like bioethics and law. Dubois correctly quotes the Catholic Catechism as saying that organ donation after death is noble and meritorious. Few people would object to that position. The critical words, however, are “after death.” Legally, in compliance with the dead-donor-rule, death must have been determined prior to organ procurement. The criteria by which this is done are at the core of the debate in both heart-beating (i.e., brain dead) and non-heart beating (death determined by circulatory criteria) organ harvesting. For many years, the very concept of brain death as well as the scientific validity of the so-called neurologic criteria for the determination of death has been called into question. Opposing arguments have not been made on the basis of ignorance or a simple misunderstanding of the facts, as Dubois postulates. This kind of accusation has been pervasive and is commonly but incorrectly used by proponents of the current practice of organ procurement. An unsubstantiated claim to opponents’ ignorance or misunderstanding contributes nothing to a constructive academic debate. Regardless, opposing arguments made are based on scientific or empirical data. In fact, the President’s Council on Bioethics in its recently published white paper “Controversies in the Determination of Death” (http://www.bioethics.gov/reports/death/determination_of_death_report.pdf ) acknowledged the inadequacy of scientific, clinical, and pathophysiologic evidence underlying the concept of brain death. In order to continue the use of brain death, the President’s Council proposed to switch to a philosophical rationale for the justification of the concept of brain death. There has been no public discourse on the acceptability of such rationale thus far and it is likely that the subject matter will be vigorously debated in the near future. With this acknowledgement of inadequate or absent scientific validation of the concept of brain death, Dubois’s argument that opponents simply are misunderstanding the concept of brain death is factually incorrect, if not arrogant. But that is not the only incorrectness in Dubois’ argument. Dubois is selective in quoting religious leaders and sections of the Catholic Catechism. Pope Benedict XVI, for instance, stated that vital organs can be extracted “ex cadavere,” if and only if, the donor’s death can be certified beyond a doubt. Section 2296 of the Catholic Catechism states that it is “not morally admissible to bring about the disabling mutilation or death of a human being even in order to delay the death of other persons.” The moral admissibility of the current procurement practice is exactly at the core of the debate and the main premise of Scaraffia’s argument. If donors are not dead in compliance with the law as well as the Catholic teachings, then the procurement of transplantable organs de facto constitutes the proximate cause of death, and as such, a violation of the dead-donor-rule as well as the Fifth Commandment. Furthermore, Dubois provides no evidence for his claim that no patient has ever recovered from brain death. He claims that those incidences published in popular reports only represent examples of misdiagnoses. Although Dubois offers no data to substantiate that claim, even when he would have been correct, it is an explicit admission that errors are being made. His explicit admission of misdiagnosis of brain death in persons from whom organs are subsequently being harvested is also clear evidence that salvageable persons ma
DONALD RAMPOLLA | 2/1/2009 - 12:29am
What I find missing in this article is any direct reference to Jesus words (John 15) “A man can have no greater love than to lay down his life for his friends” So far as I can determine, everyone who hears the story of the four WWII army chaplains aboard the USAT Dorchester who gave away their lifevests is moved by their courage and selflessness, and no one has ever suggested that their action might have been a sin. My drivers license identifies me as an organ donor. I know that If I’m seriously injured in an accident there’s the possibility of a medical professional deciding incorrectly that I have no chance of survival, and that my organs may be removed prematurely. I’m perfectly comfortable with this prospect, knowing that my premature death may save one or more other lives. In a way it’s no different from the situation of the four chaplains. I’m sure not worried that should this happen, when I see God face to face I’ll get tossed out because of my decision to be an organ donor. Concerning the risk that the decision to harvest my organs may be driven by greed, life is full of risks, so I accept this risk just as I accepted the risks of being a volunteer firefighter. I’m now 76, and there’s only a slim probability of any of my organs being considered useful . However I made the decision to be an organ donor at a much younger age when the probability was much larger. So needless to say, I find nothing of merit in any of the arguments against organ donation. But I have a huge problem with the opponents of organ donation essentially portraying God as a heartless judge who would consider organ donation a sin. Surely God is greater. Please give God a break.