New act regulating human organ transplantation could facilitate organ donation
BMJ 2002; 324 doi: https://doi.org/10.1136/bmj.324.7345.1099 (Published 04 May 2002) Cite this as: BMJ 2002;324:1099All rapid responses
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In a recent letter in this forum [1] Professor Michael Potts speaks
of a “disturbing trend” concerning discussions of brain death and the
moral acceptability of removing vital organs from patients who are so
severely brain-damaged that they are permanently unconscious or in a
persistent vegetative state. Readers should be aware, however, that Potts
advocates the rather unusual (indeed, contrarian) position that mere death
of the brain is not per se death of the person, and that death ought not
to be declared unless the entire brain as well as the respiratory and
circulatory systems have completely ceased operating [2].
This position
puts him in surprising agreement with some radical utilitarian
philosophers such as Professor Peter Singer who also view the concept of
brain death as artificial and contrived [3]. The difference is that while
Singer takes the position that organ harvesting from these individuals is
acceptable, Potts does not. Singer believes that all lives are not equally
valuable and that some lives in a state of permanent unconsciousness may
(under certain circumstances) be utilized for organ transplantation. By
contrast, Potts sees all human life as sacred, regardless of the quality
of that life or whether or not the individual is permanently unconscious.
He holds the view that human life is of special intrinsic value and
believes that that actions which directly end the life of any human being,
even one in a permanent unconscious state, are morally wrong, regardless
of possible beneficial consequences (and perhaps even regardless of any
"autonomous prior choice" of the individual involved).
[1] Michael Potts, More than a "Semantic Question"
http://bmj.com/cgi/eletters/324/7345/1099#22142
[2] Michael Potts et al. (eds.), Beyond Brain Death: The Case Against
Brain Based Criteria for Human Death. Boston: Kluwer Academic Press, 2000.
[3] Peter Singer, Rethinking Life & Death: The Collapse of Our
Traditional Ethics. New York: St. Martin's Press; 1996
Competing interests: No competing interests
Editor - Dr. Woodcock declares that misdiagnoses of brain stem death
are not made when current procedures are followed (1). However, the brain
blood flow (BBF) cannot reach the lowest values (capable of triggering
neuronal necrosis) in patients with progressive intracranial hypertension
without crossing the range of ischaemic penumbra - when all synapse-
dependent functions are reversibly suppressed. Just as in brain stem death
(and brain death), both deep coma and cephalic areflexia are to be
observed when the BBF is within that range, and yet irreversible damage
may not be established for up to 48 h (2).
The sudden and severe respiratory acidosis induced to assess the
respiratory reflex causes secondary hypotension (systolic blood pressure
lower than 90 mmHg) in 39% of patients despite the recommended oxygenation
procedures (3). The apnoea test can actually induce an irreversible
collapse of intracranial circulation rather than a transient reduction of
the BBF, as indicated by comparison of clinical data obtained from victims
of severe head trauma who were (4) or were not (5) subjected to apnoea
testing.
The literature shows a large percentage (up to 70%) of cases of
severe head trauma in deep coma (GCS = 3) and with fixed, dilated pupils,
who have recovered to normal daily life (6) following the implementation
of moderate hypothermia (33 degrees Celsius) for no longer than 24 hours.
In contrast, 48-hour hypothermia provides only modest results, and longer
periods (up to 72 hours) of lowered body temperature are even detrimental
to the older patients (7). As the only therapeutic measure capable of
reducing brain oedema (8), timely hypothermia may aid the recovery to
normal life of the subset of patients in global ischaemic penumbra who
would be made unrecoverable by apnoea testing.
References:
1. Woodcock TE. New act regulating human organ transplantation could
facilitate organ donation. BMJ 2002; 324: 1099.
2. Coimbra CG. Implications of ischemic penumbra for the diagnosis of
brain death. Brazilian J Med Biol Res 1999; 32: 1538-45.
3. Jeret JS & Benjamin JL (1994). Risk of hypotension during
apnea testing. Arch Neurol, 51: 595-9.
4. Obrist WD, Jaggi JL, Langfitt TW & Zimmerman RA (1981).
Cessation of CBF in brain death with normal perfusion pressure. J Cerebral
Blood Flow Metab, 1(Suppl 1): S524-5.
5. Jørgensen PB, Heilbrun MP, Boysen G, Rosenklint A & Jørgensen
EO. Cerebral perfusion pressure correlated with regional cerebral blood
flow, EEG and aortocervical arteriography in patients with severe brain
disorders progressing to brain death. Eur Neurol 1972; 8: 207-12.
6. Metz C, Holzschuh M, Bein T, Woertgen C, Frey A, Frey I, Taeger K
& Brawanski A (1996). Moderate hypothermia in patients with severe
head injury and extracerebral effects. J Neurosurg, 85: 533-41.
7. Clifton GL, Miller ER, Choi SC, Levin HS, McCauley, Smith Jr KR,
Muizelaar JP, Wagner FC, Marion DW, Luerssen TG, Chesnut RM, Schwartz M.
Lack of effect of induction of hypothermia after acute brain injury. N
Engl J Med 2001; 344: 556-63.
8. Schwab S, Spranger M, Aschoff A, Steiner T, Hacke W. Brain
temperature monitoring and modulation in patients with severe MCA
infarction. Neurology 1997; 48: 762-7.
Competing interests: No competing interests
EDITOR – Tom Woodcock’s letter raises the issue of the
acceptability of bypassing the issue of whether a "brain dead" person is
dead in order to morally justify removing the person’s organs. Whether a
person is dead is much more than a "semantic question"; it has to do with
whether an individual is a living person with the moral and legal
protections which pertain to living persons, or whether the individual is
a corpse who lacks such protections. His letter, as well as D. John
Doyle’s reply, are representative of a disturbing trend in the discussion
of brain death and the moral acceptability of removing vital organs from
such patients. The position they espouse is similar to that of Robert
Truog [1], who believes that even though "brain dead" individuals are not
dead, it is still morally acceptable to harvest their organs. If one
holds to a strictly utilitarian conception that human life is not
intrinsically valuable, but valuable only in terms of its social utility,
it is easy to reach such a conclusion. Alternatively, one might argue
that removing the organs of a "brain dead" individual is morally
acceptable because his or her "quality of life" is so poor or because the
prognosis is grave. These arguments are wrongheaded.
Actively killing the "brain dead" or anyone else by removing vital
organs promotes treating living persons as means to an end, in the most
extreme way, by taking their lives. It is a violation of the fundamental
end of medicine to "do no harm" to the patient. It weakens the
psychological barrier against viewing other, less disabled, lives as no
longer being "worthy" to live. Society, and the practice of medicine
itself, is held together, to a large extent, by respect for human life.
Claiming that the line between life and death is only a "semantic
question" or supporting killing some patients, no matter how disabled, for
their organs diminishes respect for human life.
Truog R. Is it time to abandon brain death? Hastings Center Report 1997; 27, no. 1:29-37.
Competing interests: No competing interests
Editor - Whether or not "the irrecoverable loss of neurological
function that defines a person" is a diagnosable state acceptable (as a
concept of death) to philosophers, we can - and must - be clear about the
science where concepts based upon the death of the brain stem are
concerned. The relevant fact is that the tests prescribed for the
diagnosis of the syndrome known as "brain stem death" lack the power to
diagnose, with the necessary certitude, the true and total death of the
brain stem [1,2]. One of those tests - the apnoea test, upon which Pallis
used to lay such emphasis - is now known to be capable of exacerbating the
brain damage [3]. It may even prove lethal. It may, by its use in many
patients diagnosed "brain dead" or "brain stem dead" by means of protocols
of which it is an essential part, have ensured the fulfilment of the fatal
prognosis attached to that diagnosis in the past.
Since the apnoea test is of no possible medical benefit to the
patient so tested, and may do him great harm, its use contravenes the
fundamental principle which governs good medical practice. Ergo - the
diagnosis of "brain stem death" is no longer ethically possible.
The "1300 cases of brain stem death" mentioned by Sundin-Huard are,
of course, not relevant to this discussion. The diagnosis of "brain death"
or "brain stem death" was made in those patients on a variety of different
criteria (involving apnoea testing in most or all of them)at various times
after the commencement of mechanical ventilation. The criteria currently
in use allow the diagnosis (and certification of death for transplant
purposes) on the basis of negative responses to a few tests of brain stem
function within a few hours of the onset of coma.
David W. Evans
1. Evans DW, Hill DJ. The brain stems of organ donors are not dead.
Catholic Medical Quarterly 1989; 40: 113-121
2. Evans DW. The demise of "brain death" in Britain. In 'Beyond brain
death : the case against brain based criteria for human death', Eds. Potts
M, Byrne P, Nilges R, Kluwer Academic Publishers 2000
3. Coimbra C. "Brain death" and "brain stem death". Response to :
Ethical debate : brain stem death etc., Inwald et al. (BMJ 6 May 2000),
bmj.com 29 Apr 2002
Competing interests: No competing interests
EDITOR – The original redefinition of death to include brainstem death [BSD] did indeed have utilitarian drivers and may therefore be questionable. Woodcock’s arguments for a change in the law and title claim that this could facilitate organ donation also warrant scrutiny however.
The acceptance of BSD as synonymous with death is not based solely on the inevitability of cardiac standstill as suggested, but on the objectively measured irrecoverable loss of neurological function that defines a ‘person’ rather than a physiological preparation, in association with permanent loss of ventilatory drive. Cardiac activity is present before BSD, during the evolution and diagnosis of BSD, and persists for an indeterminate time thereafter if all appropriate support is provided. It is unclear therefore how the literature referred to, identifying this potential latter feature, invalidates the diagnosis of BSD or organ procurement or warrants a change in the law. Since the cases of persistent cardiac activity were not associated with a return of brain function, this including ventilatory effort, Woodcock furthermore does not justify his presumption that harvesting should take place under anaesthesia, contrary to professional guidelines.
It is further uncertain how such proposals could be accommodated within the current position at law. If the patient was considered living rather than dead, organ retrieval would be the cause of death, and being premeditated, would constitute murder. Informed consent, regardless of the inability at law for any family member to give such for an incompetent adult, could not alter this fact, but could conceivably render the relatives culpable as accomplices. Such proposals would not furthermore end discussion as to a definition of ‘death’, the classic observation of lack of cardiorespiratory activity rendered somewhat obsolete in an era of advanced medical technology. Since the associated ethical problems were identified before organ procurement was countenanced from this group of patients a redefinition of death to accommodate a moral good of either ceasing support or retrieving organs appears preferable to changing our definition of what is acceptable on the living. If this path were to be followed, the semantic question of what constituted ‘living’ would replace Dr.Woodcock’s uncertainty as to ‘death’ and there would be little to stop the debate extending to procurement from even lesser degrees of PVS patients, who are considered ‘alive’ in the eyes of the law. Such considerations and the associated medical and legal sophistry would hardly induce public confidence in today’s climate, where the principle cause of lost organs is relative’s refusal, this fuelled by stray medical opinion questioning the process. It is therefore difficult to see how Dr.Woodcock’s proposals can ‘facilitate organ donation’.
Competing interests: No competing interests
Editor - I note in Woodcock's discussion of the 'unanswerable
semantic question' the claim is made that brain stem death will inevitably
lead to asytole in a short space of time is erroneous and without
physiological support. The claim is supported with reference to a meta-
analysis of 56 cases of brain death who, with maximal support, survived
from 2 months to 14 years with varying qualities of life(1). One would
hope that the technological marvels of today's intensive care could indeed
achieve this sort of outcome in at least 56 individuals. I refer Dr
Woodcock and the rest of your readers to an earlier meta-analysis by
Pallis(2). This study reviewed 1300 cases of brain stem death who were
ventilated only as physicians were still coming to grips with the concept
itself. Pallis reports that all of these patients lapsed into asystole
within 72 hours. He argues that this supported his thesis that brain stem
death is death and he provided most erudite discussion of the
physiological mechanisms supporting (or not) supporting this process.
It is important to realise that the premise that colleges base their
acceptance of brain stem death as death upon is "that at that moment of
testing, having followed the criteria and without further support" that
person's brain stem is dead. Of course the "without further support" is
tacit and often area of confusion for families and health professionals
alike. I refer you to the excellent article in this journal by Swinburn et
al on just this point(3).
1. Shewmon DA. Chronic "brain death": meta-analysis and conceptual
consequences. Neurology 1998; 51: 1536-1545.
2. Pallis C. Brain Stem Death-The Evolution of a Concept. The Medico-legal
Journal 1987; 2: 84-107.
3. Swinburn JMA; ALI SM; Banjeree DJ; Khan; ZP Discontinuation of
ventilation after brain stem death. BMJ 26 June 1999; 318:1753-1755
competing interests: None
Competing interests: No competing interests
Much has been written about criteria for the diagnosis of brain death
[1,2]. However, one important situation that appears to be rather ignored
in the literature concerns the patient with a massive head injury who
meets the criteria for brain death only imperfectly, perhaps because a
small patch of neurons in a brain-stem nucleus are still operating
intermittently. In real-world clinical practice such patients have zero
chance of survival and so are usually withdrawn from life support, their
organs going to waste. I would suggest, however, that some persons -
including myself - would be willing to allow organ retrieval to be
performed in such a setting (i.e., a setting of "near-complete" brain
death) rather than have the organs go to waste. I invite debate on this
issue.
1. Van Norman GA. A matter of life and death: What every
anesthesiologist should know about the medical, legal, and ethical aspects
of declaring brain death. Anesthesiology 1999; 91:275-287
2. Lazar NM, Shernie S, Webster GC, Dickens BM. Bioethics for
clinicians: 24. Brain death. CMAJ 2001;164:833-6
Competing interests: No competing interests
Tom Woodcock suggests that we may avoid the "unanswerable semantic
question" of whether those with irreversible loss of brain stem function
are dead by changing the law to permit relatives to consent to the removal
of their organs without a diagnosis of death. A problem with this
solution is that whilst any patient is alive we are obliged to act in his
or her best interest. Removing someone's heart is not compatible with
this obligation. There would need to be many other legal changes
(including changes to the law on homicide, presumably) in order to
facilitate Woodcock's idea.
Competing interests: No competing interests
"Near-complete brain death" and ischaemic penumbra
Editor: In his letter to BMJ dated 4 May 2002 (1) Dr. Doyle states
that in some deeply comatose patients "a small patch of neurons in a brain
-stem nucleus are still operating intermittently" and deems such a state
as "a setting of 'near-complete' brain death". His opinion is that "in
real-world clinical practice such patients have zero chance of survival".
Dr. Doyle proposes that organ retrieval is to be permitted in such
circumstances and invites debate on this issue.
Dr. Doyle fails to consider that patients presenting any residual
brain stem function may be actually at the upper limit of global ischaemic
penumbra during the progression of intracranial or infratentorial
hypertension (2). In other words, their brain (or brain stem) blood flow
may be just entering the range of synaptic inactivation, when those less
complex neuronal circuits (e.g., involving a lower number of synapses with
high energy-demanding neurotransmitter systems) would be the last to
remain functioning. Because the threshold for triggering neuronal
necrosis has not been reached, such a residual brain stem activity should
rather be regarded as a predictive sign of good outcome (recovery to
normal life) in response to a 12 to 24-h hypothermic treatment (33 degrees
Celsius) for traumatic brain injury, and possibly for some other oedema-
related brain injuries.
Rather than considering those patients' state as "degraded and
hopeless" (3), and advising utilitarian retrieval of their organs (1), we
should update the scientific debate on the pathophysiology of deep coma,
particularly that associated with brain oedema and secondary intracranial
hypertension. Due to the implications of ischaemic penumbra for the
recovery from deep coma, particular attention should be given to the
detrimental effects of apnoea testing (4) and to the potential benefit of
moderate hypothermia (5) - the only brain oedema-reducing therapy so far
available (6).
This is my sixth contribution to "BMJ rapid responses" (7-11) since
Dr. Heafield first invited me for a debate on this subject (12). The
content of "Implications..." (2) was also presented in the Third
International Symposium on Coma and Death" (Havana, Cuba, February 2000).
Not even one single scientific argument has ever been presented to refute
the proposition that global ischaemic penumbra has been mistaken for -
and, during the apnoeic insult, consistently turned into - irreversible
brain damage.
References:
1. Doyle DJ. The Problem of "Near-Complete" Brain Death - 4 May 2002.
http://bmj.com/cgi/eletters/324/7345/1099#21858
2.Coimbra CG. Implications of ischemic penumbra for the diagnosis of
brain death. Brazilian J Med Biol Res 1999; 32: 1538-45 (reprint available
upon request).
3. Doyle DJ. Professor Peter Singer's Views on Brain Death - 29 April
2002.
http://bmj.com/cgi/eletters/320/7244/1266#21724
4. Jeret JS & Benjamin JL (1994). Risk of hypotension during
apnea testing. Arch Neurol, 51: 595-9.
5. Metz C, Holzschuh M, Bein T, Woertgen C, Frey A, Frey I, Taeger K
& Brawanski A (1996). Moderate hypothermia in patients with severe
head injury and extracerebral effects. J Neurosurg, 85: 533-41.
6. Schwab S, Spranger M, Aschoff A, Steiner T, Hacke W. Brain
temperature monitoring and modulation in patients with severe MCA
infarction. Neurology 1997; 48: 762-7.
7. Coimbra CG. Re: Brain stem death: inappropriate interpretation -
29 June 2000. http://bmj.com/cgi/eletters/320/7244/1266#8544
8. Coimbra CG. Medical procedures that do not survive transparent
scientific debate cannot be considered standard - 27 July 2000.
http://bmj.com/cgi/eletters/320/7244/1266#8964
9. Coimbra CG. Global ischaemic penumbra and irreversible loss of
brain (or brain stem) function. 17 January 2002.
http://bmj.com/cgi/eletters/323/7327/1478#18780
10. Coimbra CG. "Brain death" and "brain stem death" - 29 April 2002.
http://bmj.com/cgi/eletters/320/7244/1266#21747
11. Coimbra CG. Misdiagnoses of brain death and brain stem death -15
May 2002. http://bmj.com/cgi/eletters/324/7345/1099#22202
12. Heafield MTE Brain stem death: inappropriate interpretation - 12
June 2000. http://bmj.com/cgi/eletters/320/7244/1266#8312
Competing interests: No competing interests