Reader Pliny the in Between sent me a link to this article, which I thought worth mentioning because of its unusual stance—a stance that, I realized, comes directly from Catholic Church’s uniform opposition to assisted dying. The upshot of the article, which comes from the “Pro-Life Healthcare Alliance“, is that we should not donate organs after we are declared brain-dead.

As you can see from the list of committee members at the bottom (and from my further investigations), the members are largely, if not wholly, Catholic.  This makes me fairly certain that the “no organ donation” slant comes from the religious view that such donations, which of course cause the “death” of the rest of the body when the brain is already dead, are a prohibited form of euthanasia.  Reader Pliny added this note with the link:

In your copious spare time, this article is worth skimming as an example of lying for Jesus.  The author’s horror stories reveal a deep lack of knowledge regarding the legal definitions of brain death.  None of the pseudo-patients she describes would have satisfied brain death criteria.  I’m thinking about writing something up about this topic.

I’ll have a say here as well. The article in question is called “Organ donation refusal, Q&A” by Julie Grimstad, the Executive Director of “Life Is Worth Living, Inc.”, a Catholic pro-life organization which opposes not only abortion, but assisted dying, which they call “euthanasia.” Her piece makes the following four points. I emphasize, though, that I am not a doctor, and though I’ve done my best to educate myself and pass that along, I may have made some errors. Readers are invited to correct any that they find.

1. There are dangers in donating an organ, like a kidney, to help a relative or a stranger.  Here’s how they scare you out of that:

Single kidney donation is the most frequent “living donor” procedure. Other organs that may be taken are one of the two lobes of the liver, a lung or part of a lung, part of the pancreas, or part of the intestines. The donor faces the risk of an unnecessary major surgical procedure and recovery. Sometimes there are adverse psychological outcomes or other consequences such as reduced function, disability, or problems getting medical insurance coverage at the same level and rate as previously. A small percentage of “living donors” die as a result of donation. All of these risks must be weighed along with the benefit the donated organ may be (no guarantee here either) to the organ recipient.

Note that the altruistic aspect of this procedure is not mentioned at all—only the risks to the donor (which are usually minimal).

2. “Brain death,” the usual criterion for determining death, and how death is declared, doesn’t mean that the patient is really “dead.” This depends on redefining death as the cessation of all physiological functions, even if the patient stands no chance of recovering, much less regaining consciousness. Their take:

Are organ donors certainly dead before their organs are removed?

The simple answer is “no.” Before organ transplantation was possible, physicians cautiously determined death, based on irreversible cessation of both cardiac and respiratory functions, in order not to treat the living as dead. Today, “brain death” is declared while a patient still has a beating heart and is breathing (albeit with the aid of a ventilator) because removal of vital organs must be done before they begin to deteriorate due to loss of blood circulation. Vital organs are useless if physicians wait to remove them until they are certain the patient is dead.

Tissues (such as bone, skin, tendons, cartilage, connective tissue, corneas, and heart valves) do not require continuous circulation of blood to remain useful for purposes of transplantation. Therefore, tissues may be taken up to several hours after death is certain.

I discussed these issues with my own doctor, Alex Lickerman, who told me several things about brain death. What that means is death of the brainstem, usually caused by head trauma. When the brainstem is destroyed, the underlying process has also usually destroyed the brain tissue above it, usually due to massive head trauma or vascular occlusion.

A defunct brainstem destroys the nerves that keep the heart beating and the lungs breathing (there is occasionally some endogenous heart rhythm caused by the heart’s own pacemaker). In such cases, patients are kept alive with a ventilator. (The definition of brain death varies among U.S. states.)

Because of the near-impossibility of someone recovering whose brainstem is dead, but also the ability of doctors to keep circulation and respiration going with ventilators and other means, the organs can still remain viable, and so can be used for donation. Waiting until all the organs die, which could take weeks, will make them useless for donation. (Donated organs include corneas, hearts, livers, pancreases, kidneys, and lungs.) Donors are typically young people with healthy organs who have suffered brainstem death due to head trauma (motorcycle accidents are a typical cause).

Doctors have several ways to test for brainstem death. Here are some common ones. (For these and others, see the Massachusetts General Hospital Guide to declaring brainstem death, or the American Academy of Neurology’s (AAN) guidelines, both of which show how seriously doctors take this issue.)

a. Lack of oculocephalic reflex. With the patient’s eyes held open, the head is turned rapidly to the side. If the brainstem is functional, the eyes will not turn with the head, but remain looking forward. The failure to see this, so that the eyes turn with the head, is a good indication of brainstem death, and doesn’t depend on consciousness.  Also, pupils will not respond to a bright light shined in the eye if the brainstem is dead.

b. Touch a Q-tip to the cornea.  The patient will not blink if the brainstem is dead. This is a reflex, not a conscious act.

c. Apnea testing. Turn off the ventilator. If the patient stops breathing without mechanical aid, the brainstem is dead.

d. EEG shows no electrical activity in the brain as a whole. 

There are other criteria as well. Although there may be very rare cases of patients recovering if they fail these tests, Alex doesn’t know of any, and I deeply suspect the two cases cited in the article.

It is NOT the case, despite what the article implies, that doctors are eager to declare patients dead so their organs can be harvested. ER doctors have no incentive to rush the patient to transplant surgeons. Rather, their mission is to help the patient and to deal with the family and with the patient’s or medical guardian’s wishes—should those be recorded.

Notice that the article redefines “death” not as “brainstem death” but as “organ death.” This means, of course, that no organs can be harvested under this definition:

The vast majority of organs for transplant are taken from patients who have been declared dead. A declaration of death does not always mean that the patient is certainly dead. Morally, organs and tissues may be taken from Patient A only after death is certain. (This “dead donor rule” is one of the basic ethical principles guiding organ donation.)

The article also misleadingly cites a report from a Committee at Harvard Medical School:

The insurmountable moral and legal problem is that stripping living patients of their organs is murder.

Yes, and doctors agree with that in general, but with the caveat that “living patients” are those with living brainstems. One exception is the existence of “persistent vegetative states,” in which there are signs of “arousal,” like the eyes being open but no sign of consciousness. Doctors can remove organs in such a state, but ONLY if the patient or the patient’s medical guardian has declared in advance that the patient does not want to be kept alive in such a condition.

4. Finally, the article claims that some patients declared dead have apparently recovered. Two cases are cited.

The first is that of Zack Dunlap, a 21 year old man who suffered brain trauma when his off-road bike rolled over. In this case, the patient was declared dead not using the criteria above, but via a PET scan, which measures metabolic activity in the brain via glucose uptake. As Steve Novella wrote on the Neurologica Blog, this is not a normal nor accurately calibrated way of determining brainstem death, and there is no case in which a PET scan has been independently tested to show that its results correlate highly with brainstem death. Novella argues that the declaration of brain death here could have also been subject to errors:

To summarize – in this case the clinical determination of brain death was made too early to be definitive. The only confirmatory test that was mentioned, the PET scan, is subject to technical errors that could have erroneously resulted in the absence of any signal. In this type of case (especially considering the age of the person) my personal recommendation would have been to either wait a couple of days after the edema mostly resolved, or to do more definitive confirmatory tests, like an angiogram for cerebral blood flow. I suspect that the patient was not thoroughly examined because the doctors were relying upon the PET scan, which was very likely in error. (Relying upon a false test always causes problems.)

The second case was that of 17-year-old Steven Thorpe, a British boy who suffered head injuries in a car accident. He was declared brain dead by four doctors, but another detected faint brain activity, and he eventually recovered. I can’t find much information about how brain death was determined, except that the doctors relied on CT scans, which aren’t designated by either the Massachusetts General or AAN’s guidelines as ways to determine brain death. We must remember, however, that those checklists may not be 100% infallible, though Alex Lickerman was unaware of anyone declared brain dead by conventional procedures having recovered. Very rare exceptions might occur.

The upshot of the article is given at its end:

Should I refuse to be an organ donor?

Yes, for the reasons stated above and because the Uniform Anatomical Gift Act (UAGA), as revised in 2006 and since adopted by most states, allows for patients who have never consented to be organ donors to be considered “prospective” donors unless they explicitly refuse. This means, if you have not explicitly refused to be an organ donor, you may be subjected to potentially harmful measures done solely to preserve your organs for transplant or to determine if you are “brain dead.” These things can be done without your family’s knowledge or permission. Your family may be left “in the dark” until asked for your organs.

The PHA suggests you carry an Organ Donor Refusal card at all times.

This, however, misrepresents the UAGA, at least if Wikipedia is correct, which describes who must make the decision to donate a patient’s organs:

UAGA governs organ donations for the purpose of transplantation, and it also governs the making of anatomical gifts of one’s cadaver to be dissected in the study of medicine. The law prescribes the forms by which such gifts can be made. It also provides that in the absence of such a document, a surviving spouse, or if there is no spouse, a list of specific relatives in order of preference, can make the gift. It also seeks to limit the liability of health care providers who act on good faith representations that a deceased patient meant to make an anatomical gift. The act also prohibits trafficking and trafficking in human organs for profit from donations for transplant or therapy.

In other words, the patient’s wishes (in a living will or on a driver’s license), or the expression of a medical guardian who has discussed the patient’s wishes (and those wishes are met in a given case), can lead to organ donation.

What should you do?

The article by Julie Grimstad is a pastiche of misrepresentations, all motivated by the religious notion that donating organs is a form of assisted suicide.  It neglects the fact that living donors save lives, often with minimal risk to themselves, and especially that families may feel that a patient who cannot recover can help save other people’s lives by donating organs—something that has been very comforting to many families.

If you wish to participate in organ donation, it’s important to have a “living will” that specifies what measures should be taken to preserve your life if you’re brainstem dead or in a persistent vegetative state, and to specify in both that document and on your driver’s license that you want to donate organs in such a condition. You should also have discussed your wishes with a medical guardian (you can specify this in your will), who can act on your behalf when you no longer can. I have done all this, and would be happy to donate my organs to save other people’s lives.

The only people who don’t are those religionists who see organ donation as a form of murder, which is unconscionable given the numerous safeguards used by doctors to determine who can be a donor. And, of course, there are those who think that if you donate organs, you’ll show up in Heaven minus a kidney or lungs.

*******

To finish, here’s the “about” statement of the Pro-Life Healthcare Alliance and and list of their committee members. Pro-Life Healthcare alliance:

The Pro-life Healthcare Alliance was formed in the summer of 2012 as a non-denominational, faith-based program of Human Life Alliance.

All of our efforts are directed toward renewing reverence for life within healthcare.

The Pro-life Healthcare Alliance (PHA) actively shares faith-inspired principles that guide the care, support, and protection of the life and dignity of all human beings, including those who are preborn. The PHA provides reliable pro-life information about medical decision making and the challenges facing pro-life healthcare providers and patients. Our speakers are willing to go anywhere they are invited.

We are in the process of establishing a support network of healthcare providers and organizations who subscribe to the pro-life healthcare philosophy. We seek to work together to pool our resources and courageously oppose imposed death, help vulnerable patients and their families, and renew reverence for life within healthcare and society.

PHA is led by a committee of pro-life leaders from all spheres of the pro-life movement. We invite you to join us in a mutually-supportive mission that honors the Creator of all life and renews the culture of life in healthcare.