Quick, pull out your driver’s license. Is it marked with a small heart and the words “organ donor”? If so, you’ve opted to join your state’s organ donor registry. You likely did this by checking a box on some paperwork at the Department of Motor Vehicles, perhaps motivated by the promotional language of giving life and hope. While it is indeed a noble thing to donate your organs to save lives after your own death, and while this can only be done with consent, your decision may not have been properly informed.
In my home state of Vermont, the Vermont Ethics Network assures potential donors on its website that harvesting of vital organs “will only be pursued after death is legally declared.” This is true nationally. American protocol for organ harvesting follows the ethical principle of the “dead donor rule,” which forbids the harvesting of vital organs from the living.
Yet, death is a tricky thing to define. Traditionally, death was equivalent to cardiopulmonary arrest. Irreversible loss of consciousness came shortly before or after this irreversible loss of heart and lung function. But with the advent of the mechanical ventilator in the mid-20th century came a rising number of patients in a gray area.
Due to traumatic injuries, these patients have lost blood flow to their brains, entailing a permanent loss of breathing and brain activity, and by extension, consciousness. Normally, they would die within minutes, but with a ventilator pumping air into their body, their lungs will continue to exchange oxygen for carbon dioxide, and their hearts will continue to beat. These patients meet two of the three criteria for death, but not the primary criterion of cardiac arrest.
Faced with a rising number of ICU beds filled with patients beyond saving and the lack of donors for organ transplantation, a committee at Harvard Medical School proposed the concept of “brain death” in 1968, which was legally recognized in 1981 with the Uniform Determination of Death Act.
With UDDA, “irreversible cessation of all functions of the entire brain, including the brain stem” became a second medical and legal definition of death alongside the traditional one. Now, once proper tests were conducted to determine that the entire brain had lost all functioning, patients could be taken off of ventilators, causing cardiac arrest to ensue within minutes, thus freeing up ICU beds.
Brain-dead organ donors, however, are treated differently. For a vital organ to be transplantable, it must be suffused with oxygenated blood. If someone dies of heart failure, the window for harvesting organs is minutes. But if someone is brain dead and ventilated, their heart will keep beating and their organs will still be in usable condition for hours, if not days.
Yes, your heart is still beating when your organs are harvested. It isn’t the ventilator that keeps your heart pumping—it merely provides oxygen that the body would otherwise be unable to inhale. The body of a brain-dead person will, of its own accord, continue gas exchange and blood circulation like a living person. If a corpse were to be put on a ventilator, this would not happen.
According to Michael-Nair Collins, a bioethicist at Florida State University College of Medicine and a brain death skeptic, doctors have documented at least 30 cases where brain-dead pregnant women have been ventilated and fed “for up to 107 days to gestate a fetus.” On top of that, a 4-year-old boy and a 13-year-old girl were supported by a ventilator and feeding tube for 20 and four years, respectively. They both underwent puberty despite being brain dead.
While many who are brain dead will go into cardiac arrest within days, even while ventilated, there are many cases of “chronic brain death” like those mentioned above. Even if the patients do not have such dramatic cases, they are able to maintain homeostasis and heal from wounds and infections.
According to Dr. James L. Bernat, a neurologist and one of the most prominent supporters of the concept of brain death, “40% to 50% of brain-dead patients” display limb movement. Moreover, some brain-dead patients undergoing organ procurement surgery will demonstrate an increase in blood pressure and heart rate in response to surgical stimuli. It is as yet unknown whether these are signs of brain function or simply reflexes originating in the spinal cord.
According to Nair-Collins, as many as 50% of patients declared brain dead show signs of bodily activity that may originate in the hypothalamus of the brain.
Even granting that brain death is actually death, statistics such as these raise worries that the tests for brain death may not be accurate. For example, the apnea test is typically the final test in determining brain death, and one of the most controversial, as it requires turning off a patient’s ventilator for several minutes. Some medical and ethical professionals consider this to be a self-fulfilling prophecy because it will cause a buildup of carbon dioxide that the patient cannot exhale, potentially causing suffocation followed by cardiac arrest.
Given all this uncertainty surrounding brain death, how do organ donation advocacy groups handle this information with potential donors?
Not very well.
In its video touting organ donation as a respected practice in all major religions, Gift of Life Michigan includes the line: “One day, that [heart] beat we cherish so deeply will grow more faint until it stops…. There’s still hope, love, and so much life to share. You have that opportunity to share that life with the world through organ and tissue donation.”
This is downright false, considering the fact that the donor’s heart is still beating naturally during harvesting.
This is admitted, though misleadingly, in another video by the federal Health Resources & Services Administration:
“There’s a complete, irreversible loss of brain function. The patient is clinically and legally dead. Because machines have kept blood containing oxygen flowing to the organs, they can be passed along.”
A machine may be pumping air in and out of your lungs, but as previously mentioned, your body (not the machine) is performing gas exchange and pumping blood.
Although there is a great need for organs, and organ donation can save many lives, the lack of transparency surrounding the shaky nature of brain death on the part of medical organizations is unethical. Even though consent for donation is required, that consent, if based on the standard promotional spiel, is not informed consent. Doctors and educators ought to give patients and potential organ donors the whole truth, even if that truth is uncomfortable.
It’s certainly possible that may result in less donors. But those donors deserve to know what they are signing up for.
