Should we Donate Organs? A Contemporary Interaction of Ethics and Science
|Bernard Farrell-Roberts FAITH Magazine July-August 2008|
Bernard Farrell-Roberts argues that government proposals use a profoundly unjustified approach to brain death and the dignity of the human person. This has supported an ethically ambiguous culture in the operating theatre. In such a context organ donorship is of doubtful morality. Mr Farrell-Roberts is Course Director of the BA (Hons) Applied Theology Diaconal Ministry programme at the Maryvale Institute in Birmingham. He is a member of the Brotherhood of the Holy Cross, a small semi-contemplative community of clergy and laity, and of the Joint Bioethics Committee of the Catholic Bishops’ of England, Wales, Scotland and Ireland.
“The key question that must be answered by all of us now is: If we allow ourselves to be organ donors, can we be confident that our organs and tissue will be removed following our deaths and in an ethically acceptable manner?”
The British Government has recently raised the issue of organ donorship, and, if their proposal goes ahead, we will all need to make up our own minds about what we need to do about donating our organs within the next few months. If we decide that organ donation is not an ethical option in current circumstances we would need to “opt out” formally. Doing nothing will not be an option for us.
Organ or tissue donorship represents a wonderful gift of self. In 1991 Pope John Paul II stated that: “With the advent of organ transplantation, which began with blood transfusions, man has found his way to give of himself, of his blood and of his body, so that others may continue to live. (cf. John 13: 1)”. The Catechism of the Catholic Church (CCC) goes on to tell us that: “Organ donation after death is a noble and meritorious act and is to be encouraged as an expression of generous solidarity. (CCC 2296).
Having said this, there are conditions that apply to this “expression of generous solidarity.” The Catechism also tells us that: “It (organ removal) is not morally acceptable if the donor or his proxy has not given explicit consent” (CCC 2296). There is a further condition brought out in the literature which can be expressed as “if the separation of the body and life cannot be verified, or if there is doubt about the separation of the body and life, organ excision is morally prohibited and should not be allowed”.
I would therefore like to explore these two key issues, consent and death. Both must be taken into account very seriously by anyone considering becoming a vital organ donor, or removing themselves from an assumed consent donor registry.
In 2000 Pope John Paul II said:
“Both Catholic and Secular Ethics are in broad agreement as to the essential nature of donor consent, and the acceptability of next-of-kin consent. However, due to the shortage of donor organs there are worrying pressures being exerted for some freedom to take organs from donors without consent”.
His words have proved to be prophetic, as this is the very proposition that we face today in the United Kingdom. Assumed consent would have the effect of making our bodies a commodity for the use of the state and others, and would therefore compromise the dignity of the human person. This would be unacceptable to the Catholic Church.
At the moment for informed consent to be held as valid in the UK it must fulfil five criteria: it must be given voluntarily, without undue influence or coercion; the individual giving consent must be able to process information and understand its implications; sufficient information must be provided for an informed decision to be made; the information must be understood; and the decision must be registered.
The British Government intends to move away from this very acceptable set of criteria, to one that cannot be condoned by Catholics, that of assumed consent, or “Routine Salvaging Law” as it used to be called. This represents a very fundamental shift in the relationship between the individual and the State. The individual loses the right to decide what should happen to his or her body.This right passes over to the State which has then assumed all rights over the body after death. Or is it only after death? If laws permitting euthanasia were to be introduced, or a legal definition of death made law that contradicted the Catholic position and understanding, then organs could be taken even prior to death. It is important that moves to introduce Assumed Consent in the United Kingdom should beresisted.
There appear to be many flaws in the Government’s plans on consent. They do not appear to be backed up by statistics or independent surveys. To the contrary, in 1994 research carried out by Nottingham University and the King’s Fund concluded that the introduction of assumed consent was unlikely to result in a significant increase in donor organs. Other reports concur, and the experience of other European and South American countries also backs this up. In one country, Brazil, the number of available organs actually dropped following its introduction, yet here the government predict a 50\% increase in organ availability.
Few of us have forgotten, nor should we forget, the 1998 scandal that broke involving the unauthorised retention of hundreds of organs taken from children at post mortems in the Alder Hey Hospital, Liverpool. The extreme reactions shown by the children’s parents and relatives surprised many, and delayed the lobby for assumed consent legislation for organ donorship. The psychological trauma experienced by families was obvious, and the long term effects are still being studied. It is quite obvious that if this proposed legislation becomes law these experiences are likely to be repeated again and again.
The Catholic Church is clearly opposed to the Government’s proposals, the Catechism telling us that: “It (organ removal) is not morally acceptable if the donor or his proxy has not given explicit consent” (CCC 2296).
The Holy See accepts “brain stem death” as being a valid definition of death. The accepted medical definition being “irreversible cessation of all cerebral activity”. However, it is possible to have “brain death” as defined here, whilst human cells themselves still are alive, and organs continue to function. So how can we know if death has occurred?
The United Kingdom has clearly defined guidelines for the diagnosis of death, designed to ensure that death has indeed occurred. However, the recommended procedures are only as good as the definition of death that they apply, and these definitions often vary considerably from country to country. Peculiar contradictions exist in national laws with regard to organ transplants. In Japan, for example, if a patient has expressed a written wish to be an organ donor then organs can be taken on medical diagnosis of brain death. However, if no such consent is given then a “brain dead” patient is considered still to be alive!
If ethics is allowed to be controlled by the laws of any individual state there is a danger of returning to legal positivism, where the laws of a single state are allowed to contradict universal human rights, allowing residents of that state “legally” to carry out actions that are totally unacceptable to the international community and the Catholic Church.
Medical science is always developing, and what was accepted as true in the past can be disproved in the present. How can society be sure that the medical profession is correct in their diagnosis of brain death? Governments rely on the medical profession to advise them when formulating national law, but what happens when the medical profession is wrong? Numerous documentaries regularly show us examples of exceptions to accepted medical understanding.
Yet when talking about the cutting out of organs, or the removal of a limb, there is no margin for error, life simply must not exist in the donor. Pope John Paul II referred to this problem area, stating that “It is obvious that vital organs can only be donated after death”. Then, in Evangelium Vitae, he went on to further develop this theme, declaring:
“Nor can we remain silent in the face of other more furtive, but no less serious and real, forms of euthanasia. These could occur when, in order to increase the availability of organs for transplants, organs are removed without respecting objective and adequate criteria which verify the death of the donor.”
Pope John Paul II later highlighted the difficulties posed by the need to know that the donor is dead prior to tissue removal. He stated that:
“It is helpful to recall that the death of the person is a single event, consisting in the total disintegration of that unitary and integrated whole that is the personal self. It results from the separation of the life-principle (or soul) from the corporal reality of the person. The death of the person, understood in this primary sense, is an event which no scientific technique or empirical method can
Lack of Clarity and Integrity Concerning Brain Death
It is clear that the Catholic Church not only desires that an acceptable definition of death be officially applied, but also wants there to be confidence that medical individuals involved in the removal of any organs should actually apply such a definition.
The late Dr Phillip Keep, former consultant anaesthetist at the Norfolk and Norwich Hospital, risked his career by publicly saying that:
“Almost everyone will say they have felt uneasy about it. Nurses get really, really upset. You stick the knife in and the pulse and blood pressure shoot up. If you don’t give anything at all, the patient will start moving and wriggling around and it’s impossible to do the operation. The surgeon always asked us to paralyse the patient.” ... “I don’t carry a donor card at the moment because
I know what happens.”
Is it possible to know that death has occurred in cases where organ donorship may be applicable? Dr David Jones, Professor of Bioethics at St Mary’s College, London, has pointed out that he does not accept that brain death can be assumed for any cadaver with a beating-heart, and challenges the ethical acceptability of the use of any such cadaver for donor purposes. This view is becoming widely held.
It is worth taking a few moments to reflect on a few of the views currently being expressed by medical researchers.
Dr David W. Evans, cardiologist, formerly of the Papworth Hospital in Cambridgeshire, is one of a number of medical professionals who doubt that all organ donors diagnosed “brain dead” are actually brain dead at all. He explained that: “The reason why the heart goes on beating in patients pronounced ‘brain dead’ is, usually, that their brain stems are not really and truly dead but still providing the ‘sympathetic tone’ necessary for the support of the blood pressure.” He is convinced that “brain death” is an invention of those promoting organ transplantation, stating in a letter to the BMJ that their: ” explicit recognition that “brain death is a recent invention for transplant purposes is most welcome and should do much to expose the fallacies and fudgings associated with this supposednew form of death, which have been hidden from public and professional view for far too long.”
Professor Deng of Columbia University carried out research in 1999 into the results of heart transplants in Germany. His research concluded that only those with a high risk of death actually benefited from heart transplants, more than 80\% of donor hearts going to patients who were likely to live for longer without a transplant.
I mentioned earlier a standard test that is widely used for the diagnosis of brain stem death. This is where life support machines are disconnected for a 20 minute period, after which brain activity is looked for. This is called the “apnoea” test. One body of scientific research suggests these “brain death” tests not only falsely attribute death to the donor but also injure the falsely diagnosed patient and delay crucial treatment.
Possibility of Recovery After Brain Death
Associate Professor Cicero Galli Coimbra, Head of the Neurology and Neurosurgery Department at the Federal University of Sao Paulo, Brazil published a study indicating that where there is brain damage there is often an area of the brain that is destroyed, but that there is also often an uninjured section as well. Quite often this uninjured section has no apparent function. Between the two there is a “penumbra,” a sort of bridge where the brain cells although not functioning are recoverable. He claims that given time the penumbra can connect the two sections, allowing some recovery of brain function to take place. He also claims that in severe cases a person may be wrongly declared “brain stem dead” or “brain dead”, when in fact recovery may still be possible. Coimbra recommended that the30 year-old procedures for the diagnosis of brain death should be urgently reviewed.
Coimbra shows there are two ways of treating severe brain injury that may produce recovery in apparently hopeless situations. One is to allow the patient time for possible recovery to come about, and the other is the use of induced hypothermia to reduce the brain’s use of oxygen, thus giving doctors more time to treat the patient before further damage occurs due to any lack of oxygen. When reading Coimbra’s report I found his use of hypothermia particularly interesting, as I had already come across a similar use of induced hypothermia in other contexts.
In 1998 research on animals demonstrated that some life remains in the brain after oxygen flow ceases, as well as the possibility of some brain function recovery at room temperatures for 9-24 hours . At hospital cooling temperature (induced hypothermia) the possibility of recovery can remain for up to 20 times longer than this, possibly up to 20 days! The diagnosis of brain stem death is regularly made well within this time frame. At present the normal practice is to wait only five minutes after the heart stops before diagnosis of death.
In May 2007 Newsweek Healthcarried an article stating that heart cells can remain alive for several hours even without oxygen, and that it is the sudden resumption of the oxygen supply, as attempts are made to resuscitate the individual in hospital, that causes apoptosis, killing the cells and causing death. This, if correct, would mean that standard emergency protocols are incorrect, possibly causing death rather than saving lives. A slow resumption of oxygen supply, together with induced hypothermia, appears to bring dramatic results. In hospital trials on 34 cardiac arrest patients in 2006 the normal rate of recovery and hospital discharge of 15 percent was increased to an incredible 80 percent. This research continues.
The cases cited above signify that the possibility of recovery may well still exist when organs are being removed for donorship.
The difficulty in ascertaining whether a potential organ donor is dead was exemplified in a University of Bonn Medical Centre study where two out of 113 who were initially thought to be mortally brain-damaged defied the fatal prognosis and made recoveries. The study involved neurosurgical patients mostly suffering brain trauma injury, and intracranial haemorrhage. The decisions to terminate further treatment were made after stringent and extensive brain activity testing had been carried out. Yet despite this, two such “end of life” diagnoses were subsequently reversed and the patients made unexpected recoveries.
Conclusion: Can One Agree to be an Organ Donor?
This writer would have serious doubts regarding our ability to know either that healthy, reusable organs are being removed after death or in a way that respects personal choice such that it is ethically acceptable to the Catholic Church. The above accounts serve to demonstrate just how little we still know about our bodies, and just how wrong we can be, and often are. What else do we not understand, or are we wrong about? The report we cited concerning recovery from heart attack, if proved correct by more trials, would mean that for years now our health professionals have been killing heart attack patients, whilst trying to save their lives. Coimbra demonstrates that we might cause brain death by testing for it. Events in Bonn prove that even with the most exhaustive tests we are stillunable to diagnose brain death effectively.
In considering all the facts we also need to remember the tremendous amount of medical research and development that is going on all the time: the new discoveries, the new procedures and the new drugs. Significant advances are being made in the fields of drug development, bioengineering and nano-engineering, to name but a few. Adult stem-cells are now being used to grow new body-parts that can be implanted with no risk of rejection, the latter being the single largest cause of organ rejection and subsequent death. All these developments are certain to reduce the requirement for donor organs in the future, and must be born in mind by prospective recipients and donors alike.
The key question that must be answered by all of us now is: If we allow ourselves to be organ donors can we be confident that our organs and tissue will be removed following our deaths in an ethically acceptable manner? In light of the information from medical researchers I would have to say that at this moment in time we cannot. If then the proposed assumed consent legislation becomes law, and we have decided that at the moment we cannot in conscience be organ donors, then we should express our wish not to donate.
It is a tragedy that the uncertainties discussed above are removing from us our ability to give to others one of our greatest gifts, our organs and the possibility of extended life. However, the pace of scientific development is fast and it may be that soon we will be able to change our views on this, and again allow our organs to be transplanted after our death.
In the meantime we need to encourage medical researchers to continue in their search for greater clarity concerning what constitutes medical death, and governments to legislate in such a way as to protect the sanctity of life, and respect for the individual. A good way to start this would be to make one’s opposition to the introduction of assumed consent known to the British Government.
Pope John Paul II, Address To The Participants Of The Society For Organ Sharing, Transplantation Proceedings, Vol.23, No. 5 (October),
Byrne et al, The Homiletic and Pastoral Review, April 1999.
Pope John Paul II, Address to the 18th International Congress of the Transplantation Society, 2000.
"cf. Meilaender, Gilbert, The Giving and Taking of Organs, First Things, March 2008, where he emphasises that humans are called to live their bodily life as a personal gift to others and that “presumed consent ... does go a long way toward treating persons as handy repositories of interchangeable parts to others.”
Younger, Anderson and Schapiro, Transplanting Human Tissue - Ethics, Policy and Practice, Oxford University Press, 2004.
Byrne Paul, 1998, Ethics of Organ Transplantation, Human Life International, Reports.
Lock Margaret, 2002, Twice Dead, University of California Press, Los Angeles.
Pope John Paul II, 1991, Address to the First International Congresson the Transplant of Organs, Rome.
Pope John Paul II, 1995, Evangelium Vitae, Vatican City, Rome.
Pope John Paul II, 2000, Address to the 18th International Congress of the Transplantation Society, Vatican City, Rome.
cf. Dr Peter Docherty, Catholic Medical Quarterly, Feb 2008, which chronicles the recent cavalier approach of the Italian medical and
juridicial establishment towards a 10-year old in a coma.
Keep, Phillip, 2000, UK physicians urge potential organ donors to be anaesthetised even after certified brain dead, Transplant News,
Personal communication 19.2.07
Evans David, 2002, Brain death is a recent invention, BMJ 2002;325:598, London
Deng Mario, 2000, Effect of receiving a heart transplant: analysis of a national cohort entered on to a waiting list, stratified by heart failure
severity, Department of Cardiothoracic Surgery, Muenster University.
Coimbra Cicero, 2001, Implications of ischemic penumbra for the diagnosis of brain death, University of Sao Paulo.
Stammberger, et al., 1998, Effect of a short period of warm ischemia after cold preservation on reperfusion injury in lung allotransplantation,European Journal of Cardio-Thoracic Surgery, 13, Orlando.
Newsweek Takes Chilling Look at How More Heart-Attack Victims Come
Back to Life http://seniorjournal.com/NEWS/Health/2007/7-07-16-NewsweekLooks.htm