What you don't know can kill you!
By Paul A. Byrne, M.D.

You've probably seen TV commercials, billboards, and magazine articles encouraging you to give the "gift of life" through vital organ donation. It saves lives. It gives meaning to a wasteful, tragic death, But before you fill out an organ donor card) here are a few things to think about.

Vital organs (from the Latin vita, meaning "life1') are those organs like the heart, liver, lungs and pancreas that are necessary for life. In order to be suitable for transplant, they need to be removed from the donor before respiration and circulation cease. Otherwise these organs are not suitable, since damage occurs within a brief time after circulation of oxygenated blood stops. Removing vital organs from a living person prior to cessation of circulation and respiration will cause death. Portions of some vital organs can be removed without causing death of the donor, e-g., one of two kidney, a lobe of a liver, a lobe of a lung. But certain other vital organs, like the heart, cannot be removed without killing the donor.

Since vital organs are not useful once the person is dead, and taking them causes death, how is vital organ removal possible?

THAT'S WHERE "BRAIN DEATH" COMES IN.

Before 1968, a person was considered dead only when breathing and the heart stopped. In the 1950s and 60s when surgeons developed the ability to transplant vital organs, the medical community faced a legal and ethical dilemma: vital organs must be taken from a living body, but removing vital organs will cause death.

In 1968, a committee at Harvard Medical School formulated an alternate definition of death; "brain death." They decided that when certain criteria are fulfilled (for example:no response, coma, and need for a ventilator to support breathing), the patient can be declared "brain dead.'' Thus, even when the heart is pumping and the lungs are oxygenating blood, vital organs then could be removed without legal difficulty.

In 1980, the Uniform Determination of Death Act (UDDA) was approved. According to the UDDA, death may be declared when a person has sustained either "irreversible cessation of circulatory and respiratory functions" or "irreversible cessation of all functions of the entire brain, including the brain stem." Since then all 50 states consider cessation of brain function, functions or functioning to be death.

At least 40 different sets of criteria for "brain death" have been adopted in the United States and elsewhere. Thus, if a hospital has a potential donor, doctors at that hospital can choose among more than 40 different sets of criteria for declaring "brain death," whichever set that will best suit their current need.

DEAD OR "BRAIN DEAD"? WHAT'S THE DIFFERENCE?

If you were to compare a dead body with a "brain dead" body, you would find that the dead body is pale, cold, stiff, and unresponsive. There is no heartbeat, no body functions, no breathing, and no movement. A "brain dead" body is warm and flexible. There is a beating heart, normal color, temperature, and blood pressure. Most functions continue, including digestion, excretion and maintenance of fluid balance with normal urinary output. The body will often respond to surgical incisions. In a long enough period of observation, the body may grow, cough, gag, grimace, or set the jaw.

There have been numerous instances of pregnant women with head injuries being declared "brain dead," yet with careful medical management, they have been able to carry the child to birth. In one of the longer recorded instances, the child was carried for 107 days.

In other cases, during the excision of vital organs, doctors find they need to use anesthesia and other drugs to control muscle spasms, blood pressure and heart rate changes and other bodily protective mechanisms common in live patients.

Hospitals allow "brain-dead" patients to occupy a bed; insurance companies cover expenses as they do for other living patients. If the patients' organs are suitable for transplantation, any transfer of the patient to another hospital is covered by insurance. If they are used for teaching purposes or vital organ donation, they (the "brain-dead" patients) receive life support procedures, antibiotics and other drugs, or anything else necessary to maintain their organs in a healthy state. Insurance also covers this.

Interestingly, in cases of suspected homicide, attorneys hesitate to file charges until the patient is truly dead, even if the patient has been declared "brain dead." But in the meantime, if someone else would act to "finish the job," this "new aggressor" could possibly be held or prosecuted for murder, since the patient is alive, but legally "brain dead." Other discussion with legal experts suggest that since the victim is legally dead, the case for murder by the second assailant would not be tenable since the victim is already legally dead. However, the second assailant could be liable for intent to mutilate the "corpse," which in some jurisdictions is the property of the victim's family.

Legally "brain-dead" patients are considered corpses or cadavers, and are called such by organ retrieval networks. The corpses can be used for teaching, for trying out new procedures, and for vital organ harvesting. Yet these same "corpses" are carrying unborn children to successful delivery. Certainly this is extraordinary behavior by a "cadaver"

It appears that "dead" is not the same as "brain dead." So if "brain dead" persons aren't dead, what are they?

MORE MORAL DILEMMAS FROM FLAWED CRITERIA OF DEATH

Sometimes a potential organ donor does not meet the criteria for "brain death," but has sustained certain injuries or has an illness suggesting that death will occur soon. Such cases brought about the development of "Non-heart-beating donors" (NHBD): mechanical ventilation is discontinued and certain drugs are used to lower the blood pressure and cause the patient to be pulseless. As soon as circulation stops, death is declared, and after a few minutes (the exact number of minutes varies in different institutions) the body can be resuscitated to restore cardiac and respiratory activity. This cannot be accomplished in the remains of someone who is truly dead. After this procedure, called "reanimation," the organs can legally be used for transplant, or if the organs are not suitable, the "cadaver" can be used for teaching purposes. A ghastly business!

It seems clear that in certain cases we are playing games with human lives for utilitarian gain. So glaring is the reality of this issue that there are those who now argue that doctors should not be burdened with determination of death criteria, since the good of organ donation outweighs the harm (killing) done to the donor. Scary, isn't it?

GOVERNMENT INVOLVEMENT

The federal government is deeply involved in transplant programs for reasons that are unclear. A federal mandate issued in 1998 states that physicians, nurses, pastors, and other healthcare workers may not speak to a family of a potential organ donor about transplantation without first obtaining approval from the regional organ retrieval system. If there is the possibility of vital organs available for transplant, a trained "designated requester" visits with the family first, even if the family adamantly opposes organ donation. If someone at the hospital speaks to the family first, the hospital risks losing its accreditation and 1 or federal funding.

Why the "designated requester"? Studies show that these people have greater success obtaining permission for organ donation. They're trained to sell the concept, using emotionally-laden phrases such as "gift of life," "your loved one's heart will live on in someone else," and other similar platitudes, all empty of any true meaning.

WHERE DOES THE MONEY GO?

The donation and transplant industry costs billions of dollars a year, according to several sources (e.g., a 1996 series by Forbes Magazine). But it's difficult to obtain financial data. One thing is clear: donor families do not receive any monetary benefit from their gift of life."

SOMETHING TO THINK ABOUT

Based on what you've just read, take a moment to ponder the following:

• Why can health insurance cover intensive care costs on "brain dead" patients?
• Why do "brain dead" patients often receive intravenous fluids, antibiotics, ventilator care, andother life support measures?
• Why is it wrong to tell families their "brain-dead" loved one is dead?
• Why do "brain-dead" organ donors often receive anesthesia and other drugs to stop natural physical responses when they're undergoing vital organ harvesting?
• How can "brain dead" patients have normal body functions, including vital signs, if they're dead?
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• How can a "brain-dead" pregnant mother deliver a normal, healthy infant?
• Why does a ventilator work on a "brain-dead" person, but not on a dead person?
• Why is it wrong to carry out burial or cremation of a "brain-dead" person?
• Are "brain-dead" persons really dead?
• Are they alive?