It's worrisome when you stop thinking of the person who is dying as a patient but rather as a set of organs, and start thinking more about what's best for the patient in the next room waiting for the organs. -Gail A. Van Norman, M.D., anesthesiologist 1
Since I first started in medical ethics and serving on hospital ethics committees, I have seen the discussions devolve from "what is right?" to "what is legal?" to "can we tweak the old rules to fit this particular situation?" -Nancy Valko, R.N., Catholic bioethicist2
Although presumed consent is an extremely effective way to increase the supply of organs available for transplant, it may not be an easy sell politically. Some will object to the idea of "presuming" anything when it comes to such a sensitive matter. -Cass Sunstein and Richard Thaler3
Several years ago, when I was working at a hospital in the Cleveland, Ohio, area, employees were asked to attend a seminar sponsored by a regional organ donation center. One of the presenters talked about how organ donation was consistent with many religious worldviews. Christians are often encouraged to do so, citing the New Testament scriptural verse, "Greater love has no man than this, that a man lay down his life for his friends" (Jn. 15:13). Catholic newspapers and church bulletins have been noted for their general support of organ donation, appealing to the heroic level of altruism and charity of such an act. The Catechism of the Catholic Church states: "Organ donation after death is a noble and meritorious act and is to be encouraged" (no. 2296).
While working at the aforementioned hospital, my unit manager approached me with a document that I was to read and sign, explaining the facility's policy regarding organ procurement. (My signature on the document, by the way, was to confirm that I had read and understood the policy, not that I agreed with it.) The document mentioned notifying the organ donation center thirty minutes prior to the death of the patient. Curiously, I asked my manager how anyone knew a patient would be dead in thirty minutes. The policy suggested to me that deaths were scheduled. She looked at me like a deer in headlights.
Perhaps my question was a bit nave. At that time, I had not explored the issue of organ donation to any great depth. I recently told this story to a Catholic bioethicist who suggested that the document was merely instructing the medical staff to notify the organ donation center thirty minutes before removing a "brain dead" patient from life support. And this may very well have been the case. But how? "Brain death," as defined by the Uniform Determination of Death Act (UDDA) of 1981, is "irreversible cessation of all functions of the entire brain, including the brain stem."4 "Brain death" as defined by the UDDA is the basis for the "dead donor rule." I was already aware of the concept of "brain death" and its connection to the legal definition of death. My curious questioning of my manager, I believe, was motivated by an intuitive "red flag." So legally, then, the hospital policy may not have been referring to removing someone from life support who is "brain dead."
The issue of "brain death" has been a source of controversy and conflict in Catholic circles for several years. Some Catholic physicians, bioethicists, and scientists believe that "brain death," however determined, is not justification for removal of organs from persons. Others see no problem with it, as long as the tests to determine "brain death" are reliable.5 Furthermore, support for a concept of "brain death" is still strong inside the walls of the Vatican.6 Pope John Paul II stated in 2000 that "the criterion adopted in more recent times for ascertaining the fact of 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."7 John Shea, M.D., retired Catholic physician and bioethicist, referred to this statement as "only a superficially apparent endorsement."8 Because of continued controversy, John Paul II re-opened the debate five years later regarding "brain death," and Pope Benedict XVI has followed suit in reviving the debate.9 Currently, there is no consensus on diagnostic criteria for brain death.10 In other words, a person diagnosed as "brain dead," and thus meeting a legal definition of death, at one healthcare facility, could be considered alive at another facility.
Skepticism about "brain death" is certainly understandable, given the documented cases of persons actually coming back to life after being diagnosed as brain dead. Consider the November 2007 case of Zack Dunlap, a 21-year-old man who was involved in an ATV accident. He was declared "brain dead" 36 hours after his accident. A brain scan apparently showed a complete absence of blood flow to his brain. After receiving knowledge of this finding, and knowing that Zack had signed an organ donor card, his parents agreed to donate his organs.11 However, Zack began showing signs of life, and physicians who were at first skeptical about any chance of recovery cancelled the organ donation and eventually transferred him to a rehabilitation facility. Four months later, he had a complete recovery and was planning to return to work.12
In May 2008, Val Thomas, 59, suffered two heart attacks and had no brain waves for more than 17 hours. She was placed on a ventilator, as she was being considered for organ donation. At one point, rigor mortis had set in - a sure sign of death. However, while her family was saying their goodbyes, she woke up and started talking. Thomas was transferred to the Cleveland Clinic for an evaluation, but physicians there could find nothing wrong with her.13
So when is a person actually dead? Perhaps a better question is, "When does the soul leave the body?" Are we to believe that when a person is diagnosed as "brain dead," yet they have other signs of life such as a heartbeat and a blood pressure, that they are dead? And when a "brain dead" woman is able to nourish her unborn child and bring him to full term to be delivered, is she to be considered, perhaps, soulless?
As doctors, scientists, and ethicists explore these questions, one thing remains certain: A person's death is not to be hastened for any reason, not even to benefit the life of another. Yet it seems, unfortunately, that this is occurring more frequently in our country and around the world, owing to an increasingly dominant secular ethics in which the ends justify the means. Furthermore, many secular ethicists believe that morality must change as technology evolves.
In the summer of 2007, a California woman, Rosa Navarro, filed a complaint in a county superior court against an organ transplant doctor and a hospital because she believed that she was deceived about her disabled son's care and that he was murdered for the sole purpose of harvesting his organs.14 Navarro's son Ruben had a rare disease, Adrenoleukodystrophy, that affects the brain and the adrenal glands, causing neurological and muscular problems that worsen with time.15 The disease left Ruben confined to a wheelchair. Court papers allege that he developed a medical problem, so he was transferred to Sierra Vista Medical Center for evaluation and was admitted. He was eventually placed on a respirator.16 Ruben was assigned to the care of Dr. Hootan Roozrokh, who Mrs. Navarro believed was Ruben's "treating doctor." However, according to the complaint filed in court, Roozrokh was actually working for a California organ-harvesting company.17 The court complaint said that Roozrokh informed Mrs. Navarro that nothing could be done for her son and that he was going to die. She was also falsely informed that her son had to be removed from the respirator after five days. Believing Ruben had no chance of survival, Mrs. Navarro agreed to donate his organs. She did not, however, consent to her son being removed from the respirator.18
The court complaint said that Ruben was taken into surgery, where he was removed from the respirator. However, he continued to breathe. At the direction of Roozrokh, Ruben was given a lethal dose of morphine and Ativan. (Morphine, if given in large doses, can depress respiration to the point of complete absence of breathing. This, in turn, would eventually cause the heart to stop beating.) But Ruben continued to breathe, so he was given several more doses of morphine. The surgeons finally gave up and wheeled him away without putting him back on a respirator. Ruben died nine hours later.19
Dr. John Shea commented, "If the allegation [in the court complaint] is true, that [the physicians] gave lethal doses of morphine three times, I can't see how that can be interpreted in any other way than deliberate homicide."20
This case leads to some important questions: If three lethal doses of morphine were not enough to kill Reuben Navarro immediately, and instead he died nine hours later, how hopeless was his condition? Is it possible that he was somewhat conscious of what was happening and was fighting for his life?
Ruben Navarro was the victim of the abuse of another means of organ procurement from potential donors known as "non-heartbeating organ donation" (NHBD), also known as "donation after cardiac death" (DCD). It is also referred to as the "Pittsburgh protocol," as it was developed by the University of Pittsburgh. DCD has been the subject of intense scientific and ethical debate, yet it has been flying quietly beneath the public radar. This method is being implemented more frequently in response to a gap between the supply and demand for organs. Simply put, there are not enough "brain dead" potential donors. Keep in mind as well that organ procurement is a lucrative, billion-dollar industry. DCD is essentially redefining death.
The practice of DCD involves removing a patient - one who is typically not "brain dead," perhaps in some instances not brain-injured in any way - from life support and foregoing any attempts to resuscitate them. The surgical team waits for the patient to stop breathing, followed by cessation of his or her heartbeat. When the heart stops beating, the surgeons monitor the potential donor for "autoresuscitation" - sometimes referred to as the "Lazarus phenomenon" - synonymous to "coming back to life." If the heart does not re-start within two minutes - although some facilities wait only 75 seconds - the surgical team begins organ procurement. The advantage to the organ recipient of such short waiting times is receiving vital organs that have been subjected to a minimal amount of ischemia, or lack of blood flow, thus minimizing damage to the organ and maintaining its viability as much as possible.21
Interestingly, one of the impetuses for the development of DCD, in addition to the gap between supply and demand of organs, is the "desire from patients and families to donate organs from unsalvageable patients not meeting formal brain death criteria."22 In other words, the patients are deemed "hopeless," a subjective judgment that opens up a Pandora's box. Comatose and "vegetative" patients, because their conditions are often deemed irreversible, are most at risk for being targeted for DCD.
In the summer of 2008, the Journal of Intensive Care Medicine published an article, which I cited above, issuing a strong criticism of DCD. Their findings have received little attention in the mainstream media. The researchers unequivocally claim that there is little evidence that DCD meets the "dead donor rule." They say that the two-minute waiting period after cessation of the heartbeat is "arbitrary" and too short. "Autoresuscitation," they write, "has been documented in the medical literature after more than 10 minutes of circulatory arrest and discontinuation of resuscitation in humans."23 They also write, "The medications and/or interventions for the sole purpose of maintaining organ viability can have unintended consequences on the timing and quality of end-of-life care offered to organ donors."24 For one thing, removing a patient from a respirator causes a period of oxygen deprivation. If the organ procurement procedure fails, is it not possible that unnecessary damage could be done to that patient, perhaps even to the brain?
John Shea, M.D., has acknowledged and written about many problems he sees with both "brain death" criteria and DCD. He expresses concern about how many bioethicists and the healthcare industry ignore or deny the possibility that the potential organ donor many be alive. Shea believes, as does Professor Joseph Seifert from the International Academy of Philosophy in Lichenstein, that "even if a small, reasonable doubt exists that our acts kill a living human person, we must abstain from them."25
It seems as though the medical community involved in organ procurement has lost sight of some very important facts about the unresponsiveness of patients slated for organ procurement. As nurses, we have traditionally been taught to regard the comatose or otherwise unresponsive patient as though they can hear us. Furthermore, it is generally accepted that hearing is the last thing to go. I have personally experienced simultaneous awareness and paralysis while awaiting surgery - an experience that was horrifying, particularly because I was struggling to breathe. To remove a person from a respirator for organ procurement when it is possible that they will be aware of what is happening, I believe, is unthinkable. Could they perhaps have been denied the information of what they could expect with the donation of their organs? Would this not be a lack of informed consent, something that Americans expect from healthcare providers?
In a recent interview with Catholic bioethicist Nancy Valko, R.N., she stated, "Evil is a ravenous, expansive creature. Once you decide to tolerate a little bit of evil . . . it expands of its own accord. It knows no limits." The Obama administration appointed "Regulation Czar" Cass Sunstein, who coauthored a book entitled Nudge: Improving Health, Wealth, and Happiness. In it, he discusses changing current laws that require "explicit consent" from potential organ donors to "presumed consent." He argues that the reason more people do not donate their organs is because they are required to choose donation.26 He supports a law that will automatically sign Americans up as potential organ donors unless they actively opt out. The Eagle Forum states that this reveals Sunstein's philosophy "that the government owns your organs and you have to request permission for them not to be taken from you after you die."27
If the government owns your organs, it owns you. With the danger of government-run healthcare on the horizon, one's humanity - one's personhood - will become increasingly eclipsed by the healthcare industry. Shea writes that even "brain death" can be used for purely utilitarian reasons for organ procurement. However, and again, DCD is implemented to target those who don't meet the "dead donor rule."
Dr. Shea reminds us that the general public has not been properly informed about what really happens when organs are transplanted.28 Catholic healthcare providers and bioethicists should educate themselves - as well as their patients and students, respectively - thoroughly on these issues, particularly "donation after cardiac death." A thorough reading of Rady's, Verheijde's, and McGregor's critical analysis in the Journal of Intensive Care Medicine is a good place to start. The website physiciansforlife.org, also has several links to articles explaining organ donation. As Bishop Fabian Bruskewitz once said, "No respectable, learned, and accepted Catholic moral theologian has said that the words of Jesus regarding laying down one's life for one's friend (John 15:13) is a command or even a license for suicidal consent for the benefit of another's continuation of earthly life."29
1 Quoted in "New Trend in Organ Donation Raises Questions: As Alternative Approach Becomes More Frequent, Doctors Worry That It Puts Donors at Risk," http://www.physiciansforlife.org/content/view/1337/33. [Back]
2 Personal email from Nancy Valko, R.N., October 27, 2009. [Back]
3 Quoted in Aaron Klein, "Sunstein: Take organs from 'helpless patients,'" http://www.wnd.com/?pageId=112757. [Back]
4 National Conference of Commissioners on Uniform State Laws. (1981). Available at: http://www.docstoc.com/docs/9932726/UNIFORM -DETERMINATION-OF-DEATH-ACT. [Back]
5 Hilary White, "'Brain Death' is Life, Not Death: Neurologists, Philosophers, Neonatologists, Jurists, and Bioethics Unanimous at Conference," LifeSiteNews, February 26, 2009, http://www.lifesitenews.com/ldn/2009/feb/09022604.html. [Back]
7 Qtd. in John B. Shea, M.D., "Organ Donation: The Inconvenient Truth," September 2007, Catholic Insight, http://catholicinsight.com/online /bioethics/article_747.shtml. [Back]
11 Nancy Valko, "Was Zack Dunlap's Recovery a Miracle?" Voices Online Edition, Vol. XXIII, No. 2, Pentecost 2008, http://www.wf-f.org/08-2-Valko.html. [Back]
13 "Woman Wakes After Heart Stopped, Rigor Mortis Set In," Fox News, May 23, 2008, http://www.foxnews.com/story/0,2933,357463,00.html. [Back]
14 Elizabeth O'Brien, "Mother Alleges Doctor Murdered Her Handicapped Son to Harvest His Organs," LifeSiteNews, July 6, 2007, http://www.lifesitenews.com/2007/jul07070603.html. [Back]
15 For a more complete description of this disease, see http://www.ninds.nih.gov/disorders/adrenoleukodystrophy/ adrenoleukodystrophy.htm. [Back]
21 Mohamed Y. Rady, Joseph L. Verheijde, and Joan McGregor, "Organ Procurement After Cardiocirculatory Death: A Critical Analysis," Journal of Intensive Care Medicine, Vol. 23, No. 5, p. 304. Available online at: http://jic.sagepub.com/cgi/content/abstract/23/5/303. [Back]
22 Ibid. p. 304, emphasis added. [Back]
23 Rady, Verheijde, and McGregor, p. 305. [Back]
25 Quoted in Shea, "Organ Donation: The Inconvenient Truth." [Back]
26 "Cass Sunstein: Facts & Talking Points," Eagle Forum, http://eagleforum.org/pdf/2009/Sunstein.TalkingPoints.pdf. [Back]
28 John B.Shea, M.D., "Organ Donation: The Inconvenient Truth," Catholic Insight, September 2007, available from http://catholicinsight.com/online/bioethics/article_747.shtml. [Back]
29 Quoted in John B. Shea. [Back]