Transplanting medical ethics

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Melanie Phillips

Like a number of other similar heretics, I believe that — upsetting as this may be to many, and provoking once again the fury of transplant surgeons — people from whom organs are harvested for transplants are not necessarily dead. I was long ago persuaded that the definition of brain death failed to exclude some cases where there was still some activity in the brain, and that certain disquieting features of organ harvesting – such as the practice of sedating the ‘brain-dead’ person to avoid inflicting any suffering during the procedure – demonstrated that, in the view of certain doctors at least, such patients were not dead at all.

Now, a staggering article in Critical Care Medicine by Robert Truog and Walter Robinson admits that the definition of brain death is merely an artificial construct to allow transplants to take place – but then goes on to say that organs should nevertheless be harvested from people who are not dead:

Brain death is essential to current practices of organ retrieval because it legitimates organ removal from bodies that continue to have circulation and respiration, thereby avoiding ischemic injury to the organs. The concept of brain death has long been recognized, however, to be plagued with serious inconsistencies and contradictions. Indeed, the concept fails to correspond to any coherent biological or philosophical understanding of death. We review the evidence and arguments that expose these problems and present an alternative ethical framework to guide the procurement of transplantable organs. This alternative is based not on brain death and the dead-donor rule, but on the ethical principles of nonmaleficence (the duty not to harm, or primum non nocere) and respect for persons. We propose that individuals who desire to donate their organs and who are either neurologically devastated or imminently dying should be allowed to donate their organs, without first being declared dead. Advantages of this approach are that (unlike the dead-donor rule) it focuses on the most salient ethical issues at stake, and (unlike the concept of brain death) it avoids conceptual confusion and inconsistencies.’

So ‘do no harm’ in these instances apparently means taking the organs out of living individuals on the grounds that they are either about to die or are ‘neurologically devastated’ — and thus as good as dead. In other words, a living person who has no sensation and no apparent prospect of functioning as a sentient individual is deemed to be no longer alive and can be duly cannibalised.

This monstrous reasoning is remorselessly deconstructed by another article in the Journal of Medical Ethics by M Potts and David Evans. Starting with a laconic acknowledgement of the moral doctrine which most of us naively and wrongly imagined still applied in this society:

‘The “standard position” on organ donation is that the donor must be dead in order for vital organs to be removed, a position with which we agree’

they argue strenuously that

‘removing vital organs from living patients is immoral and contrary to the nature of medical practice.’

The fact that they have to make such an argument at all is itself an eye-opener. But first they rightly address the premise from which Truog and Robinson start, that brain-dead patients are not necessarily dead – an assertion previously dismissed out of hand by the medical profession. Potts and Evans write that Truog and Robinson

‘…note that the concept of brain death “fails to correspond to any coherent biological or philosophical understanding of death”. We believe this claim well founded. There were never sound empirical grounds for criteria of death based on the loss of testable brain function while the body remains alive. One difficulty is the near impossibility of diagnosing—with the necessary certainty—the “irreversible cessation of all functions of the entire brain, including the brain stem” while the rest of the body remains alive. The Harvard tests—essentially of brain stem mediated reflexes and ventilator dependence in patients whose coma appeared irremediable—clearly lacked the power to make that diagnosis. The many protocols now in use worldwide fail similarly. Indeed, their very number proclaims the fact that the syndromes they diagnose cannot be one and the same true entity. And prominent among the variations is the apnoea test, which may lead to the misdiagnosis of respiratory centre failure if inadequately stimulating and, if stringently applied, may itself be the cause of death.’

Then, addressing the argument that it would be permissible to use as donors at least two classes of patients who had given prior consent: the ‘permanently unconscious’ and the ‘imminently dying’, with society determining the ‘minimal threshold of lively existence below which donation would be permitted’, they robustly declare:

‘We believe that removing vital organs from a still living donor is the taking of innocent human life. The argument that such removal is morally no different from “allowing to die” by removing a ventilator is seriously flawed. When a ventilator is removed from an apnoeic comatose patient, it is the disease or injury that causes the loss of the patient’s ability to breathe spontaneously. As Margaret Somerville notes: “the withdrawal of life support treatment such as respiratory support involves a situation of multiple causation in which one cause (respiratory failure) is sufficient to cause death; the other cause (turning off the respirator) is not sufficient in the absence of respiratory failure”. The situation is different when vital organs are removed from a patient. Removing a vital organ, such as the heart, directly causes the death of the patient, and is not merely allowing the effects of disease or injury to take their course. It is the organ removal surgery that kills the donor. In addition, withdrawal of life support may be an acceptable omission of burdensome treatment, rather than an act that is more likely to involve an intent to kill the patient. The issue in removing vital organs from brain dead individuals is not, therefore, whether to withdraw burdensome life support from a dying patient but whether such organ removal is a morally acceptable form of killing.’

That is indeed the issue. What in heaven’s name have we come to as a society, to have arrived at the horrific and degraded situation where we have developed ‘a morally acceptable form of killing’ — and cannot even acknowledge truthfully that that is what we are doing?

Posted by melanie at July 5, 2005 07:20 PM
http://www.melaniephillips.com/diary/archives/001309.html

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