Map of life expectancy at birth from Global Education Project.

Thursday, August 14, 2008

Jack, you dead . . .

Or is you?

I am a bit of a skeptic about some organ transplantation on essentially cost-benefit grounds, but putting that aside for now, there is the question of when it's okay to "harvest" (as they say) the organs from the unfortunate donor. (Living donors are an entirely different story, with its own ethical twists and turns.)

As usual, the New England Journal of Medicine drives a media feeding frenzy, this week on some envelope pushing that's been happening on the question of death, in pursuit of fresh, rosy-cheeked human hearts. There are a couple of free access pieces in the new Journal, but since I know you're busy, you may find Robert Veatch's contribution sufficient to give you the gist.

The question of when a person is dead didn't perplex people very much until the late 20th Century. No pulse was an adequate criterion. Once we could restart stopped hearts, and keep hearts beating indefinitely that wouldn't beat on their own, that didn't work any more. Occasionally that becomes a problem when family members don't want to turn off the switch for somebody who has no hope of recovery, but you don't actually have to be dead for current ethical principles - including principles endorsed by the Catholic Church, by the way - to endorse allowing death to happen by ending mechanical intervention.

It's a different problem, however, when doctors are hovering over the mortal clay hoping to grab the heart and other used parts for the use of somebody else. Currently, the person has to be officially dead before they can open up the chop shop. The criterion of brain death is one that the public seems not to find problematic. That means that the entire brain is not producing electrical signals, basically. If you're brain dead, you're already in the junk yard.

The difficulty is that not everybody whose organs are potentially usable is brain dead, in fact most such people are not. They may even have enough brain stem left that they would keep breathing on their own. But their higher functions -- the cortical activity that makes us human -- are gone, and the family is ready to cut the switch. Those people aren't officially dead until their hearts have stopped - yes, cardiac death still counts as death. But since we can restart stopped hearts, mere cardiac arrest does not count as death either. The heart has to be stopped long enough that it can't be restarted. But, but, but . . .

If you waited that long, it wouldn't be any good to the next person. So, the new concept is that the cardiac arrest is irreversible because nobody has any intention of restarting the heart, at least not in the body of person A. But of course they do intend to restart it in person B, and they follow through on that intention. So could person A truly have been dead at the time his or her heart was removed, given that said heart could indeed be restarted and person A was not brain dead?

The bioethicists writing in the journal propose two different solutions:

1) Decide that it's okay to harvest organs from people who are alive, provided that they are in the process of being allowed to die -- which, BTW, implies that the act of harvesting the heart is what kills the person; or

2) Redefine death to include the condition of having a stopped heart which nobody intends to restart until it ends up in person B.

Practically, these amount to the same thing: they endorse the identical actions. Veatch things (1) cannot possibly be ethical however, since we aren't allowed to kill people for the benefit of somebody else, so he's going with (2). Seems like nothing but bullshitting around with words to me. The fact is, we've crossed a line, and now we need to figure out exactly how to draw the new one.

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