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.
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.