Organ Donation and Harvesting

While someone declared 'brain dead' is considered to be legally dead, their heart is still beating and they may feel pain when their organs are removed without anaesthetic.
  • 'Only a beating heart is acceptable for transplant.'
  • 'If the 'brain dead' patient is warm then the hypothalamic function of the brain, which controls body temperature, is functioning.'
  • 'Treatment to preserve harvestable organs often increases the injuries and may even kill the patient.'
  • 'Due to a shortage of donors, the definition of death may be amended to classify those in irreversible coma and PVS as dead.'
  • 'Many recipients die of diseases caused through immune suppression, similar to AIDs diseases rather than organ rejection.'
Brain death and the dead donor rule (patients may not be killed through organ retrieval) are clinically and legally accepted in most countries as prerequisites for organ removal. Yet, many adults are unaware of, misinformed about, or hold beliefs that are not in line with official definitions of brain death.

In a telephone survey of 1,351 adult residents of Ohio, in the United States, conducted by Dr. Laura Siminoff, PhD, and her colleagues, participants were asked to assess whether the patient in each one of three hypothetical scenarios (brain dead, in a coma, in a persistent vegetative state [PVS]) was dead and whether they would be willing to donate that patient's organs.

Two-thirds of participants (66%) did not know that someone who was brain dead is considered to be legally dead and nearly 60 percent mistakenly thought that the respirator is stopped before, rather than after, organs are taken.

The majority (86 percent) identified the brain dead patient in the first scenario as dead, 57 percent identified the patient in a coma as dead, and 34 percent identified the patient in a PVS as dead. Most who said that the patient was alive were not willing to donate that patient's organs.

Although the data in the study by Siminoff, Burant, and Youngner of public attitudes toward "brain death" and organ donation suggest that many seem to view "brain death" as "as good as dead" rather than "dead" (calling the dead donor rule into question), the study shows that understanding an individual's definition of death is neither a straightforward task nor a good predictor of views about donation. 1

A Catholic Dilemma
The Catholic Church teaches that the removal of organs that would "directly bring about the disabling mutilation OR DEATH of a human being, even in order to delay the death of other persons" is intrinsically evil. 2 The Catholic Church regards the definition of death as being a true biological death, which include the destruction/cessation of the circulatory system (heart) and respiratory systems (lungs) as well as the neurological system.

There are two types of organ transplantation that are acceptable to the Catholic Church:
  1. Tissue, a paired organ (i.e. you have two of them like for example, a kidney is a paired organ) or Bone Marrow from a living person The tissue or organ must not be essential for the life or health of the donor such as two kidneys
  2. Tissue after death e.g. the cornea, heart valves, skin, bone and connective tissue (tendon and ligaments)
Unpaired Vital Organs such as the heart or the liver after a declaration of brain death, must be harvested while the heart is beating; there is normal blood pressure and temperature; there are normal salt and water balances and many internal organs and systems are functioning to maintain the unity of the body.

During the hour it takes to remove a heart for transplant, the heart is still beating. Only a beating heart is acceptable for transplant. Such determination of brain death is based on absence of functioning of the brain. A measure of life is the continuing hypothalamic function which controls body temperature. If the patient is warm then that part of the brain is functioning.

Harvesting the Living
The September, 2004 issue of the Kennedy Institute of Ethics (KIEJ). dealt with organ transplants and about expanding donation beyond brain death and non-heart beating organ donation (NHBD) by redefining death and/or providing exceptions to the dead donor rule.

In one article the author speculated on whether agreement could be reached where there could be a public policy permitting organ procurement of those in irreversible coma or PVS when proper consent is obtained.

Many of the articles dealt with a study showing the public's contradictory attitudes and confusion about terms like "vegetative state" and "brain death". Some of the authors wanted to make use of the confusion to promote such radical changes in organ donation.

In the Dead Donor Rule: Lessons from Linguistics, D. Alan Shewmon says:
"Depending on context, some death-related events may constitute a more obvious discontinuity than others and more justifiably may be considered "death" within that context. There is no reason to assume J priori that there must be an overarching, unitary concept of death from which all diagnostic criteria must derive. Regarding organ transplantation, the relevant question is not "Is the patient dead?" but rather "Can organs X, Y, Z ... be removed without causing or hastening death or harming the patient?"3
In Harvesting the Living?: Separating "Brain Death" and Organ Transplantation, Courtney S. Campbell agrees that, due to the critical shortage of transplantable organs available, organ 'recovery' should be expanded, abandoning the dead donor rule, to allow for harvesting pre-mortem [i.e. before death].
"The chronic problem of organ scarcity should prompt bioethicists to engage in constructive dialogue about the relation of the social sciences and bioethics, to examine the social malleability of the definition of death, and to revisit the question of the priority of organ transplants in the overall package of healthcare benefits provided to most, but not all, citizens."4
A commentary in the September, 2004 issue of the Kennedy Institute of Ethics Journal by Daniel M. Hausman, looked at Polling and Public Policy. The commentary looked at five reasons why one might want to conduct a survey concerning people's beliefs about death and the permissibility of harvesting organs:
  1. simply to learn what people know and want
  2. to determine if current law and practice conform to the wishes of the population
  3. to determine the level of popular support for or opposition to policy changes
  4. to ascertain the causes and effects of popular beliefs and attitudes
  5. to provide guidance in determining which laws and practices are ethical
Hausman expressed qualms about how well surveys in general can perform with respect to the fifth objective, and provided specific reasons to doubt whether this survey is informative from the perspective of a moral philosopher concerned with the nature of death and the contours of a permissible system of organ procurement.5

Reconsidering the Dead Donor Rule
The Abstract for Norman Fost's article Reconsidering the Dead Donor Rule: Is it Important That Organ Donors Be Dead? read:
The "dead donor rule" is increasingly under attack for several reasons. First, there has long been disagreement about whether there is a correct or coherent definition of "death." Second, it has long been clear that the concept and ascertainment of "brain death" is medically flawed. Third, the requirement stands in the way of improving organ supply by prohibiting organ removal from patients who have little to lose - e.g., infants with anencephaly - and from patients who ardently want to donate while still alive - e.g., patients in a permanent vegetative state.

One argument against abandoning the dead donor rule has been that the rule is important to the general public. There is now data suggesting that this assumption also may he flawed. These findings add additional weight to proposals to abandon the dead donor rule so that organ supply can he expanded in a way that is consistent with traditional notions of ethics, law, public policy, and public opinion. 6
Also in the September, 2004 issue of the KIEJ, was a paper by Robert M. Veatch, setting out two possible strategies for legitimising organ harvesting. One was to make exceptions to the dead donor rule permitting procurement from those in PVS or at least those who are in irreversible coma while continuing to classify them as living.

The other strategy he suggested was to further amend the definition of death to classify one or both groups as deceased, thus permitting procurement without violation of the dead donor rule.

Veatch pointed out that permitting exceptions to the dead donor rule would require substantial changes in law and would weaken societal prohibitions on killing.

He suggested that it would be easier and less controversial to further amend the definition of death to classify those in irreversible coma and PVS as dead.

Veatch recommended the incorporation of a conscience clause to permit those whose religious or philosophical convictions support whole-brain or cardiac-based death pronouncement would avoid violating their beliefs while causing no more than minimal social problems. 7

Compulsory Harvesting of Organs
In 1999, Professor John Harris, an international authority on bioethics from Manchester University, caused an uproar when he said that the bodies of the dead should become public property so they can be used to make up for the growing shortage of transplant organs.

Professor Harris also called for a change in the law to allow people to sell live organs.

He could see no reason why religious groups should oppose his views and said people should only be allowed to put a ban on the use of their organs for transplant after they had died for the strongest of reasons. 8

Need for anaesthesia
In response to Harris' statement in 1999, Dr. David J. Hill, a Consultant Anaesthetist from Huntingdon, Cambridgeshire wrote a letter to the Editor of the Independent:
Sir:
Post-mortem examinations are carried out on dead bodies; organs are harvested from living ones, in spite of Professor Harris's use of the term "cadaver".

He should know what most of those carrying donor cards do not. At the time of harvesting they will remain on life-support, be warm, pink and breathing with a ventilator, have a heart beat and pulse, and have some brain activity. They will also be responsive to pain, requiring paralysing drugs, blood transfusion and anaesthetics for surgery.

Horrifyingly, not all will receive anaesthesia. This is a far cry from the cold, white, stiff lifeless body undergoing post-mortem examination. Presumed consent (now supported by the BMA) or Professor Harris's wish for compulsion would remove any need for such awkward explanations.
Harris also had an article published in the British Medical Journal in 2003 in response to a paper "A stronger policy of organ retrieval from cadaveric donors: some ethical considerations."9

The authors of that paper, Michael Rivlin and Clare Hamer replied:
"Whilst some of his comments are fair we believe others to be ill-judged. In this reply to Harris we not only defend our position but will raise a new argument to support our contention that organs should not be taken from the dead against their pre-mortem wishes. When this further argument is taken into account, it will be seen that Harris' proposal, although perhaps intuitively attractive, does not stand up to scrutiny on either moral or practical grounds."
Rivlin and Hamer proceeded to argue that our bodies are not like our estate: they are us, not simply our belongings, and that contrary to Harris' claim that the harms to the dead are 'trivial', they pointed out, "One way that the dead can be harmed is by thwarting their life's wishes and values and doing this is, we claim, far from trivial. "10

Donors may feel pain
Dr David Wainwright Evans, Cardiologist, Queens College, Cambridge, UK, suggests that organ donors diagnosed "brain dead" may still be alive. In A Sixty Second View of Organ Transplanting he makes the following points:
  • Heartbeat and blood pressure rise as the surgeon cuts into the supposedly dead organ donor, a similar reaction to a healthy person being attacked with a knife
  • Some doctors recommend administering anaesthetic, prior to harvesting, to prevent pain to supposedly "brain dead" donors despite the donor officially declared dead
  • Organ donors get inferior treatment than organ keepers. This happens because treatment to preserve harvestable organs increases the injuries and may even kill the patient
  • An organ recipient's body experiences the transplanted organ as a malignant invader to be killed. Doctors administer drugs to stop this rejection which then creates similar immune deficiency diseases to AIDS victims
In The Nasty Side of Organ Transplanting Norm Barber writes:
"Anaesthetists trained to prevent pain during surgery may assuage their doubts and the distress of other theatre staff by anaesthetising donors to prevent possible pain. But hospitals and donation agencies bitterly resent medical staff using anaesthetic because they spend their working lives trying to persuade distressed friends and relatives that the patient has actually died. But many medical experts doubt this."10
Healing Treatments Denied To Potential Donors
In Chaper 3 of The Nasty Side of Organ Transplanting, Dr Yoshio Watanabe, an academic and cardiologist at the Cardiovascular Institute, Fujita Health University School of Medicine in Toyoake, Japan, says that applying the damaging apnoea test before hyperventilation and hypothermia treatment may constitute murder or at least a malpractice suit. He says a large fluid drip and drugs to increase blood pressure to maintain organs for harvesting actually accelerate brain injury.11

Barbiturates, for unknown reasons, protect the brain from damage when circulation has slowed or stopped due to brain injury or heart failure. People experiencing barbiturate overdoses have been known to go up to an hour without a heartbeat then revived without noticeable brain damage.
Barbiturates and other drugs also mask reflexes and brain activity making a living brain appear dead so a requirement for brain death diagnosis is that the patient isn't on these brain-protecting drugs. Therefore, patients registered as donors may be deprived of certain protective drugs so doctors can, with more ease, later declare them brain dead. This denial or withdrawal of protection allows the brain to become further damaged pushing it closer to brain death making it a disadvantage to be listed as an organ donor. A brain injured patient listed as a non-donor or organ keeper may get superior treatment in a hospital trauma unit than a potential organ donor.

A second problem is that barbiturates and other reflex depressing drugs may already be present in the donor candidate. This could allow sluggish reflexes, due to drugs taken before the injury, to be wrongly interpreted as brain damage.12
'Brain Death' a tricky concept
Mother, Marge Will, relates the story of having heard a talk on 'Brain Death' by a doctor who explained that there are thirty-two different definitions of "brain death" in the US, and told his audience that the attending physician can accept any one of these to declare someone brain dead. He said he saw people fully recover after being declared brain dead.

Marge was glad she had heard this when, some time later, her oldest son was involved in a bad accident that resulted in severe brain trauma. One of the attending doctors gave him zero chance of survival. They wanted the parents to sign an organ donation sheet, but they declined, and instead told them in writing to do everything in their power to save him.
"We were afraid that if we signed the sheet, that would allow them to harvest his organs, and that they wouldn't try as hard to revive him.

Our son did survive. He's walking, talking, working, and driving, although with some disabilities. But he's not a "vegetable," as some doctors said he would be.

Years ago everyone knew when someone was dead: There was no pulse, no breathing, etc. But with the new brain death definitions, we now have something quite dangerous and deliberate on our hands." 13
Organ Rejection
A somewhat open secret that the transplant industry would rather that public, especially potential donors, not know is that many recipients die of diseases caused through immune suppression, similar to AIDs diseases, rather than from transplant organ failure.

By weakening the immune system's ability to kill the transplanted organ it also becomes too weak to kill anything else.

Clint Hallam was in a New Zealand prison serving time for financial fraud when he accidentally sawed off his hand. Transplant coordinators found him a brain-injured boy in France. Doctors declared the boy "brain dead", sawed off his hand and sewed it onto Clint's stump.

The anti-rejection drugs gave him diabetes and the transplanted hand attacked his skin and intestines in what is called Graft-Versus-Host Disease. The Hand looked so weird and failed to perform like a normal hand that eventually Hallam told the transplant doctors to chop it off.
"They were furious. They wanted to complete the experiment. The drug companies were also angry, as Clint was what they called a post animal-model clinical trial subject, or, as we call it, a guinea pig. The first one.

The surgeons followed Clint's orders and sawed The Thing off. They had to. He had command of the mass media that were waiting to do a horror story on The Thing.

Now that The Thing has gone Clint has become healthier and stronger no longer needing anti-rejection drugs. He does have just one hand but The Thing was useless anyway.

Oddly enough, the surgeons had considered the transplant a complete success. Their aim was to transplant a hand. Clint Hallam's personal health was a secondary matter.14
Donors
In New Zealand the family is given the final say even if the individual has registered as an organ donor. Men outnumber women as donors by two to one. In New Zealand 61% of donors are males and 39% females.

References:
  1. "Death and organ procurement: Public beliefs and attitudes," by Dr. Siminoff, Christopher Burant, and Stuart J. Youngner, M.D., in Social Science and Medicine 59, pp. 2325-2334, 2004.
  2. Catechism of the Catholic Church, 2296
  3. Shewmon, D. Alan, and Shewmon, Elisabeth S. 2004. "The Semiotics of Death and its Medical Implications. In Brain Death and Disorders of Consciousness," ed. C. Machado and D. A. Shewmon, pp. 89-1 H. Advances in Experimental Medicine and Biology, Vol. 550
  4. Courtney S. Campbell, "Harvesting the Living?: Separating "Brain Death" and Organ Transplantation"
  5. Daniel M. Hausman, Polling and Public Policy
  6. Norman Fost, "Reconsidering the Dead Donor Rule: Is it Important That Organ Donors Be Dead?"
  7. Robert M. Veatch "Abandon the Dead Donor Rule or Change the Definition of Death?"
  8. BBC News
  9. J Med Ethics 2003;29:130-134
  10. British Medical Journal
  11. The Nasty Side of Organ Transplanting Chapter Two
  12. Ibid Chapter Three
  13. Marge Wills, Letter to the Editor, This Rock Volume 15, Number 4, April 2004
  14. Ibid Chapter Four