Catholic Medical Quarterly Volume 62(3) August 2012 p11-12

Practical medical ethics

Brain Death Controversy Continues.

Dr Stephen Brennan FRCP.

At our Ethics Committee meeting before Council back in April 2011, Fr Stephen Wang led us to look again at the “Brain Death” controversy around the use of organs for transplantation. Whilst kidneys can be taken from a body well after the heart has stopped beating, heart & lungs need to be taken whilst the circulation is still working. It seemed, over a decade ago, that we had reached a situation where we could define a person as “Brain Dead” (no pain or gag responses, negative caloric ear testing, and flat EEG) so that organs donated for transplantation could be taken whilst the heart was still pumping. In those days, most of us were satisfied that such a person was “dead”, and if there was no question of organ donation, they would have had their ventilator-support switched off, and been allowed to die in the natural way. We did understand that, if organs were to be donated, then the switching off of the ventilator would be delayed whilst arrangements were made for the removal of the organs, after which, of course, the patient couldn’t be ventilated and was completely dead.

Pope John Paul II had seemed to support this view at a Transplant Conference in 2000, when he said that: “when rigorously applied”, brain death criteria, “do not seem to conflict with the essential elements of a sound anthropology” (i.e. a sound study of our beliefs). but he went on to say that this judgement must reach “moral certitude”.

In February 2011, a professor of Catholic Medical Ethics, E. Christian Brugger (LifeSiteNews.com- 4/2/11.Rome) declared that there was NO moral certitude that a brain dead patient was really dead, and the Pope was not in a position to pronounce on such matters, which were of a scientific nature. However he quoted Pope John Paul II telling a Conference that “death is a single event consisting in the total disintegration of that united and integrated whole that is the personal self”. Brugger then goes on to quote research by Dr Alan Shewmon, which demonstrates that “brain dead” patients on ventilator support do many of the things which living people do: respire; fight infection; heal wounds; maintain temperature etc. We knew all this by simple observation, and obviously we wanted the vital organs to remain “alive” for successful transplantation, which was surely the wish of the donor.

In 2009, Pope Benedict XVI gave an address to another transplant conference and warned that the principle of moral certainty in determining death must be of the highest priority for doctors. He went on to say that donation of organs can only be licit, if it does not “create a serious danger” to the health of the donor; “there must not be the slightest suspicion of arbitrariness. Where certainty cannot be achieved, the principle of precaution must prevail.” Informed consent was emphasised, so that it was a “gift” from the donor, and there was no suggestion of coercion.

In 2010, another conference on Brain Death, with international medical, neurological and philosophical experts, roundly condemned the brain death criteria, saying that they result in the deaths of patients by the premature removal of organs.

The Linacre Centre for Healthcare Ethics in the UK, way back in 2002, in its response to a Department of Health consultation paper, “Human Bodies, Human Choices” was very cautious about Brain Death criteria, saying that “they were insufficient for establishing the death of the body”; they emphasised the need for the public to be fully informed about these matters, so that true consent would be given. They suggested there ought to be a cessation of removal of organs from “heart beating donors”, until these matters had been thoroughly aired with the public.

Our own discussions at this meeting were lively and varied. For many organs, such as kidneys and corneas, organ removal can occur after the heart has stopped and death has occurred. We were all quite happy with that situation and observed that in the past, a diagnosis of brain stem death had been used as part of deciding to turn off the ventilator and then the harvest the organs. All were happy where the ventilator support is removed shortly BEFORE the organs are removed, so that death was more certain, and ways could surely be found to ensure the organs were preserved for donation. “Brain Death” is more of a “prognosis” than a determination of death; a matter of “medical opinion” rather than “certainty”.

But more modern practice, involves removal of organs often under general anaesthetic (outcomes are better with the brain dead person anaesthetised), and for heart lung and heart-lung-liver transplantation, involves removal of the beating heart. This is a real challenge for us all. At least to some, it looks like evisceration of the living.

Clearly option 3 is unacceptable. Is option 2 morally sound or sophistry? Option 1 is principled, but does seem likely to end with more than one death.

It was agreed that these matters must be got out into “The Market Place”. While it often seems that Catholic teaching wants to prohibit “advances”, we should put forward well thought out views with humility, and make sure everyone knows what the problem is.

Dr Steve Brennan. Consultant General & Respiratory Physician, and Secretary of the CMA(UK).