The criteria of death questioned
An article published on 3rd September 2008 in the first page of the Osservatore Romano, the daily newspaper of Vatican, caused a bit of a furore questioning that the current concept of the brain death is sufficient to declare the death. This article is published on the occasion of the forty anniversary of the ”report” of Harvard (1968), which replaced the cardiovascular arrest as a sign of clinical death by that of the flat electroencephalogram. Now, according to the author of the article, the ”scientific justification of such choice is questioned by new researches” and this “forty anniversary of the new definition of brain death seems to be the occasion to reopen the discussion both at the scientific level as well as in the heart of the Catholic Church”. The challenge for the author is to ask about the legitimacy of organ procurement, not as such, but as it is practiced today with the current criteria of death. It raises the question to know if the dead person, the ”organ donor”, is really dead when the organs are removed. Based on publications and expert analyses, the article questions this ”certainty”. Citing the cases of pregnant women in a irreversible coma being maintained alive to enable the birth of the child, the article states that ”the idea that the human person stops existing when the brain does not work (…) is in contradiction with the concept of the person from the catholic doctrine and with the directives of the Church faced with the cases of persistent comas”. Father Federico Lombardi, director of the press room of Vatican observes that the article is ”an interesting and weighty contribution” but it ”cannot be considered as the position of the Magisterium of the Church” and cites the speech by Jean-Paul II of 29th August 2000 to the participants in the international congress of the transplantation society.
Ethical procurement
In this speech, Pope John Paul II reminded that, in the Encyclical letter Evangelium vitae, he suggested that a way to promote a real life culture ”is the organ donation, made under an ethically acceptable form, which enables ill people, sometimes exempted from hope, new health and even life perspectives” (No 86). Nevertheless, he also specified in his speech that ”as any human advance, this particular field of medical science (…) raises also some critical points”. From one hand, in order this procurement is ethical, it is necessary to have an informed and free agreement from the donor and then from the receiver. From another hand, for removing vital organs, we need, to preserve the dignity of the donor, the moral certainty of his clinical death, in other words answer the question: ”when may a person be declared as dead with certainty?”. ”Everybody knows that the approaches aiming at declaring with certainty the death have moved the traditional cardio respiratory signs towards what we call the ”neurological” criterion”, this means ”the total and irreversible cessation of all brain activity (in the cerebrum, the cerebellum, and the brain stem)”. Pope reminded then that the Church does not make technical decision about these criteria but limits to check that this data given by the science respects the dignity of any human person and he carried on specifying ”that the criterion recently adopted to ascertain the death, namely the complete and irreversible cessation of all brain activity, if rigorously applied, does not seem to conflict with the essential elements of a sound anthropology”.
Moral certainty
John Paul II underlined that the ”criteria” to ascertain the death which is used by the medicine ”must not be understood as the technical and scientific determination of the exact moment of the death of a person, but as a mean scientifically certain to identify the biological signs which show that a person is effectively dead”. Health professionals being responsible for ascertaining the moment of death ”can use these criteria on a case by case basis, to reach a degree of assurance in ethical judgement that the moral doctrine describes as ”moral certainty””. This ”moral certainty” is considered as the necessary and sufficient basis to act in an ethically correct way. Only where such certainty exists, and where informed consent has already been given by the donor or the donor’s legitimate representatives, is it morally right to initiate the technical procedures required for the removal of organs for transplant.
Irreversible coma, brain death
The Quotidien du Médecin (Physician daily newspaper) from 8th September 2008 reminds that the committee of Harvard medicine school in charge of examining the brain death established in 1968 the concept of irreversible coma: ”absence of receptivity and reaction, absence of movement and respiration, absence of reflexes, flat electroencephalogram (EEG), no modification of the results of tests repeated 24 hours later, and exclusion of hypothermia and CNS depressants”. In France, the legal definition is fixed by a decree of the 2nd December 1996 relating to the organ and tissue transplantation. According to this decree, in case of persistent cardiac or respiratory arrest, three clinical criteria are necessary to make the diagnosis of death: ”total absence of awareness and spontaneous motor activity, abolition of all brain stem reflexes, total absence of spontaneous ventilation”. Finally, to confirm the irreversible character of the brain death, we perform two EEG at 4 hours interval which have to be areactive or we perform an angiography showing the arrest of the brain circulation. We remind that the brain is made of the brain stem, the cerebellum and the cerebrum. The brain stem is responsible for several functions among which the regulation of the respiration and heart rhythm. The cerebellum coordinates the movements and the equilibrium. The cerebrum includes, from one hand, the diencephalon enabling the general sort of sensitive information and the superior control of hormones and viscus and from another hand, the two hemispheres, responsible for conscious sensations, voluntary motricity and superior functions (intellectual faculties, emotions…).
Non heart beating removal
Commonly, if the criteria of brain death are accepted to perform an organ procurement, some countries authorises the non heart beating removal. This way, in France, the Agency of Biomedicine authorises, since October 2006, for experimental purposes and ”with all discretion”, this type of procurement. This technique consists in removing organs from persons with cardiac arrest, after a thirty-minute resuscitation and the diagnosis of non resuming heart beatings during at least five minutes. Nine university-hospital teams participate in this program: Angers, Bordeaux, Lyon, Marseille, Nancy, Strasbourg, and, in Paris, the Saint-Louis, Pitié-Salpêtrière and Bicêtre hospitals. This technique enables increasing the number of potential donors and thus performing more grafts for organ applicants. For all that, this initiative disturbs health professionals. Some denounce the ”race against time” imposed by this technique, the procurement should be done 120 minutes maximum after heart stops beating (against 1 or 2 days after an authenticated brain death). Manager of the working team at the AP-HP ethics section, Marc Guerrier underlines the difficulty to talk about organ donation to a family a few minutes after the diagnosis of death and the difficulty the personnel has to face, who, from one hand, does its best to resuscitate the patient, and from another hand, establishes a file for a possible procurement. A story which disturbs again: In June 2008, a 45-year-old man who cannot be resuscitated after cardiac arrest, woke up when we were about to remove some of his organs.
The necessity of a debate?
Pr Allan Kellehar, from the University of Bath (Great Britain), calls for modifying the definition we have of the death which only relies on medical terms. According to him, a debate is necessary to know if it is really fair the brain death is the central key to disconnect a patient and to remove his organs. Today, the death is more difficult to determine because it is technically possible to keep a person alive in the state of brain death for a predetermined duration. This debate seems to be essential because the use of brain death criterion results from a pressure made by some physicians, dictated, at least partially, by the need of organs. For Dr Richard Nicholson, from the Bulletin d’éthique médicale, this debate is necessary to distinguish what is socially acceptable from what is simply medically ”practical”…