Organ transplantation: Worldwide News Blog - Transplantation d'organes : le Blog des News du monde entier

ACCESS THE ORGAN TRANSPLANTATION WORLDWIDE NEWS BLOG. Please note that this worldwide press review is bilingual (English and French).

ACCEDER AU BLOG DES NEWS CONCERNANT LES DONS ET GREFFES D'ORGANES.

A propos du Blog des News :

Cette revue de presse internationale est bilingue (français - anglais) !

====> Officiellement créée le 5 mai 2005 par décret dans le cadre de la loi de bioéthique du 6 août 2004, l'Agence de la Biomédecine a été inaugurée mardi 10 mai 2005. Elle marque une 'étape décisive en matière de bioéthique', a déclaré Philippe Douste-Blazy. Carine Camby prend la direction de l'Agence de la Biomédecine après avoir assuré celle de l'Etablissement Français des Greffes.

====> Quelles sont les positions actuellement défendues dans la presse publique et scientifique concernant les transplantations, dans le monde entier ?

Journal of Medical Ethics: scientific press (white papers) on organ transplantation ethics

The Journal of Medical Ethics (JME) is an international peer review journal for health professionals and researchers in medical ethics.

Aims and Scope:
Journal of Medical Ethics is a leading international journal that reflects the whole field of medical ethics. The journal seeks to promote ethical reflection and conduct in scientific research and medical practice. It features original articles on ethical aspects of health care, as well as case conferences, book reviews, editorials, correspondence, news and notes. To ensure international relevance JME has Editorial Board members from all around the world including the US, Europe, Australasia and Far East. JME is the official journal of the Institute of Medical Ethics.

You'll find below a selection of JME articles on transplantation ethics.
Source: JME Online.



1.-) "Defining death in non-heart beating organ donors", 2003, J. Med. Ethics N° 29, p. 182-185. Authors: N. Zamperetti, R. Bellomo, C. Ronco.

"Our proposal is that, for the time being, the definition of death should rest on the currently applied criterion of irreversible (however defined) asystole, with the open admission that it does not define 'death', but only a moment, in the process of dying where organ retrieval can be allowed."

2.-) "Death, dying and donation: organ transplantation and the diagnosis of death", Journal of Med. Ethics, 2002, N°28, p.89-94.
Authors:
H Kerridge 1, P Saul 2, M Lowe 3, J McPhee 4 and D Williams 5
1 Haematology Department, Bone Marrow Transplant Unit, Royal Free Hospital, Hampstead, London, UK
2 Intensive Care Unit, John Hunter Hospital, Newcastle, NSW, Australia
3 Faculty of Medicine, University of Fiji, Fiji
4 Clinical Unit in Ethics and Health Law, Faculty of Medicine and Health Sciences, University of Newcastle, NSW, Australia
5 Neurology Department, John Hunter Hospital, NSW, Australia

"Refusal of organ donation is common, and becoming more frequent. In Australia refusal by families occurred in 56% of cases in 1995 in New South Wales, and had risen to 82% in 1999, becoming the most important determinant of the country's very low organ donation rate (8.9/million in 1999).

Leading causes of refusal, identified in many studies, include the lack of understanding by families of brain death and its implications, and subsequent reluctance to relegate the body to purely instrumental status. It is an interesting paradox that surveys of the public continue to show considerable support for organ donation programmes—in theory we will, in practice we won't (and don't).

In this paper we propose that the Australian community may, for good reason, distrust the concept of and criteria for 'whole brain death', and the equation of this new concept with death of the human being. We suggest that irreversible loss of circulation should be reinstated as the major defining characteristic of death, but that brain-dead, heart-beating entities remain suitable organ donors despite being alive by this criterion. This presents a major challenge to the 'dead donor rule', and would require review of current transplantation legislation. Brain dead entities are suitable donors because of irreversible loss of personhood, accurately and robustly defined by the current brain stem criteria."

3.-) "An antidote to the emerging two tier organ donation policy in Canada: the Public Cadaveric Organ Donation Program", Journal of Med. Ethics 2005, N° 31, p.188-191. Author: Stephen Giles, Toronto General Hospital, Canada.

"In Canada, as in many other countries, there exists an organ procurement/donation crisis. This paper reviews some of the most common kidney procurement and allocation programmes, analyses them in terms of public and private administration, and argues that privately administered living donor models are an inequitable stopgap measure, the good intentions of which are misplaced and opportunistic. Focusing on how to improve the publicly administered equitable cadaveric donation programme, and at the same time offering one possible explanation for its current failure, it is suggested that the simple moral principle of 'give and you shall receive', already considered by some, be extended further. This would allow for those who are willing to sign up to be a public cadaveric donor be given a priority for receiving an organ donation should they ever require it. It is argued that this priority may provide the motivation to give that is so far lacking in Canada. This model is called the Public Cadaveric Organ Donation Program."

4.-) "It is immoral to require consent for cadaver organ donation", Journal of Med. Ethics 2003, N°29, p.125-127. Author: H E Emson.

This article defends the opinion that a dead body is a republic. Hence consent should not be required for cadaver donation.

"In my opinion any concept of property in the human body either during life or after death is biologically inaccurate and morally wrong. The body should be regarded as on loan to the individual from the biomass, to which the cadaver will inevitably return. Development of immunosuppressive drugs has resulted in the cadaver becoming a unique and invaluable resource to those who will benefit from organ donation. Faced with the biological reality, the moral error of any concept of property in the body, and the quantitative failure of voluntary organ donation, I believe that the right of control over the cadaver should be vested in the state as representative of those who may benefit from organ donation.

How one regards the dead human body, the cadaver, is in part governed by one’s familiarity with it. At the present time, very few people ever see a cadaver which has not in some way been altered after death, and even fewer touch, handle, deal in any way with the dead human body. In developed countries, death itself most frequently occurs away from the home, in an institution, under the supervision of professional caregivers. For most people, ideas concerning the cadaver, its nature, the proper way to deal with it, are formed under these conditions.

As a pathologist specialising in forensic pathology, for 50 years I have been at the other end of the spectrum of experience. In my daily work I have been privileged to examine the cadaver in all its stages after death from the immediate postmortem moments through all the stages of decomposition to bare bones. Working in a relatively small community, I have sometimes been charged with examining the body of someone I have known in life, which is never an easy task. These experiences have moulded my ideas as to what the cadaver is, what it represents, and how it should be treated. My beliefs are by no means unique, but I believe the experience which has formed them is unusual and because of this, important. Reading the works of ethicists who pronounce upon these matters, I wonder how many of them have ever viewed and touched a human cadaver, or seen a decomposing body.

Out of all this I have become what I understand is termed a dichotomist, one who believes that the body and soul are separate, different entities. I use the term "soul" for want of a better, not knowing a word which does not in some way carry implications of the soul’s origin, nature, value, and destination. I wish to imply none of these, nor to intrude here my own religious beliefs. For the purposes of this discussion, the soul to me is a non-physical, immaterial entity which animates the body and gives it what we know as life. In knowing and experiencing a person, we cannot separate body and soul, because we always know them together. From the moment of birth until that of death they are inseparable and intertwined to form the person, the human being. At death the soul departs from the body—I have watched this occur—and here I express no beliefs whatsoever as to what happens to it at that point; where it goes, if anywhere, what its future is, if any. What is clear to me is, that without the soul, the body is not and can never again be a part of the person. The cadaver is not, what the body has been.

The body, on the other hand, is more easily defined and described. This, the physical entity animated by the soul, is formed of chemical elements and compounds, organised into tissues and organs, combined in a marvellous complexity and with the soul, it is the human person. In this combined state, the person is alive; without the soul, the body is dead, with all that implies. From the moment of conception the component parts of the body are formed from material drawn from the external physical world, in active interchange and dynamic equilibrium with the biomass, the sum total of living organisms on the planet, and with some of its inorganic matter. We study the human person from its earliest beginnings, through growth, differentiation, maturity, decline, disease, and death. The life of the metazoan animal Homo sapiens, as we know it—and this is only one of the ways of considering the human being—is finite; senescence starts with the zygote, and corporeal death is its inevitable end.

After death the human body decays, a process with which few are familiar and which excites revulsion which is both instinctive and learned. The instinctive part of this revulsion I think is easily explained, as an inherited reflex acquired by ancestral experience that rotten meat is not good to eat. Embedded very deeply in the nature of humanity there is another element to this, a belief that death is not the end of the soul and that the life of the body can somehow persist or be restored. This was expressed in the burial practices of the earliest humans, in the staining of bones of the deceased with red pigment as a symbol of continuing or resurgent life. Such practices have been elaborated by many different cultures, as in preservation and veneration of the bones of ancestors; burial with grave goods, food, slaughtered animals, and slaves, and mummification and embalming, to retain a simulacrum of continuing life, the last a common practice in many contemporary societies including our own. All these seek in some manner to deny the fact of death, or at the very least to delay its acceptance, to spread this as a process over a period of time, and to come to admit it gradually rather than as an instant blow at a single temporal point. Such practices often contrast oddly an expressed belief in an afterlife in a better world, with profound reluctance to leave this one. Many religions express belief in some form of "the resurrection of the body" but so far as I am aware, at the present time, this is only rarely interpreted as a strict physical reconstitution of its elements as at the moment of death. There is too much practical human experience for this, and however belief in a resurrection is interpreted, an element of symbolism is for most people inescapable.

However acceptance of death is denied or delayed, the human body is inexorably destined to decay as the beginning of a recycling process. Its constituent components are broken down by various means into simpler forms, and these in turn are recycled into the bodies of later generations of living things. We die and decay—or are burned—to come up again as wheat or roses, which in turn may form the bodies of future generations of people. Were this not so I would not be alive to write this, nor you to read it; the elements which might have formed us would all have been locked up in the indestructible physical remains of the first generation of living organisms. Decay is the inevitable and necesssary consequence of finite corporeal mortal life.

Viewed from this point, the human body can only legitimately be regarded as on extended loan from the biomass, to the individual of which it forms a part, and any view of it as property which can be owned and disposed of must be examined very seriously, questioned, and modified. Our culture accepts as a fundamental principle that while the body is animated by the soul, the person resulting from this union has a right to the preserved integrity of the body which is a necessary part of his or her total being. This is expressed in law, in our society, by prohibitions against killing, wounding, or even such minimal assault as threatening to touch the body without the person’s consent. But how we should view the cadaver after death is a very different and much more questionable matter.

In that part of the ethics of our society which is expressed in law, there is no concept of the cadaver as property which may be disposed of for gain. The law, formed over a period of time before the possibility of transplantation existed, at present charges someone with the responsibility to dispose of the cadaver in accordance with society’s customary practice and the requirements of public health, and gives this person powers to do so, but the cadaver is not his or her property. Until very recently there was no significant value in a human cadaver, and no legitimate use for it save its quantitatively very minor utilisation in dissection as a part of the training of physicians and surgeons. All this changed, recently, suddenly and dramatically, with the invention of immunosuppressive drugs which block the bodily rejection of transplanted organs and tissues, and make organ transplantation possible as a practical and effective treatment of human disease. The change is tremendous, unprecedented, unparalleled in our experience. The difference—for example, between chronic haemodialysis and kidney transplantation for the treatment of renal failure, is the difference between existence and life. From the strictly practical viewpoint, from being an object without intrinsic value destined only for disposal, the cadaver became at one leap a vital resource, something quite new in human experience. This quantum jump in technological capability brought with it, as all such advances inevitably do, totally new ethical problems. These in their turn can and must be tackled, and possibly solved, and faced with the unprecedented, it can only be done by fundamental examination of our basic beliefs, and their reconciliation with immutable physical facts.

One thing which must be considered at the very beginning, is the problem of immediacy. To be effective, an organ for transplantation must be removed as soon after death as possible. But it may be very difficult for relatives to accept that their loved one’s body, maintained in a semblence of life by artificial respiration, is in fact dead and will obviously be so when the respirator is turned off. Added to this, there is acceptance of death as a process, not as an event; a fact which those close to the deceased come to accept gradually and which in its fullness may take years. Some progress towards reconciling these facts—for human emotions are facts with which we must deal—and resolving this dilemma, can be made when the death of an individual is known to be inevitable but can be postponed for a short time during which the family can come to terms with it. A great deal more could be done by the more gradual and diffuse processes of public education, but while the problem can be lessened, it inevitably will remain.

The cadaver has now become, to those who may receive its organs as replacement for their own which have failed, quite literally a source of continued life restored to something close to its fullness, and qualitatively different from existence maintained by mechanical means. In discussing this I shall limit myself to kidney transplantation, the commonest procedure which has become routine. Again, one wonders if some of the ethicists who pronounce on this, have ever met with and talked to patients who have experienced both existence maintained by haemodialysis, and life restored by transplantation. There is this real difference. This situation requires re-examination of basic beliefs; to whom does the cadaver "belong", and who should morally have rights to determine its disposal? To the deceased, it is something that has been a vital component of the person but now is no longer and is no more needed. To the bereaved family, it is a remaining part of the beloved deceased person, emotionally tremendously evocative, hallowed by individual experience and by centuries of belief and tradition. To the potential recipient of its donated organs, it is the very new hope of restored life.

I do not think that the concept of ownership or property in the human body is an accurate, defensible, or moral one, and I believe that the body should be regarded morally as on loan from the biomass to the individual of whom it is, during life, a part. Previously a matter of only academic interest, this is now of immense practical importance. I have no problem with the right of the individual to bodily inviolability during life; integrity of the body is a necessary part of integrity of the person, together with the individual freedoms that are commonly stated in charters of rights and the like. I am deeply concerned with the right of the person to govern disposal of their body after death, when separation of body and soul is irrevocably complete, and the individual is incapable of reconstitution. The person no longer exists, the soul has departed, and the individual who was but is no longer has no further use for the body which has been part of him or her during life. The concept of the right of a person to determine before death, the disposal of their body after death, made sense only when there was no continuing use for that body; it makes neither practical nor moral sense now, when the body for which the dead person no longer has any use, is quite literally a vital resource, a potential source of life for others. Another way of looking at the cadaver, is to liken it to a dress or a suit of clothes hanging in a closet, worn by the person during life, evocative of pleasant experiences and happy times, but now no longer needed by the one who has died and useful only as a memorial by the bereaved. If it can help to keep the living warm, should not this be done? Is this not both practically and morally, its right utilisation?

If this argument is correct, then it is even more morally unacceptable for the relatives of the deceased to deny utilisation of the cadaver as a source of transplantable organs. Their only claim upon it is as a temporary memorial of a loved one, inevitably destined to decay or be burned in a very short time. To me, any such claim cannot morally be sustained in the face of what I regard as the overwhelming and pre-emptive need of the potential recipient. It is particularly unacceptable when the deceased has during life expressed consent for cadaver organ donation, and still unacceptable if he or she has expressed no opinion. The need of the potential recipient, the benefit which may accrue to him or her, to me trumps and surpasses all other considerations. The proportionate benefit is too great to be subordinate to anything else. This can be expressed in a simple parable. A rich man has a loaf which he does not need, which he cannot eat, for which he has no use. To a poor man, starving, the gift of this loaf would be the gift of life itself. But the rich man says: "I will not give you this loaf; I will drop it on the dunghill to decay, or fling it in the fire to burn". This is to me a specific analogy of the denial of organ donation, of the conscious refusal to grant it. In many instances the denial is not conscious, a positive act, but a negative omission, a failure to consider and decide upon the possibility before it becomes real. It is commonplace that there is a great gap between the proportion of people in a society who favour organ donation, and the much smaller proportion who do anything about it.

In my opinion the human cadaver, at the point at which life departs, should become a resource for those who may benefit from donation of its organs. Our society has conspicuously failed to achieve this by voluntary means, and the increasing length of the queues for donated organs testifies eloquently to this failure. On the other hand, a majority of the community express their belief that cadaver organs should be used for transplantation. Faced with this contradiction and the dilemma so caused, it appears to be morally and practically necessary for society to act to overcome this failure, and this could best be done by making the human cadaver the charge and responsibility of the state, to determine its best disposition. Without going into detail, it might be done by establishing an organisation for this purpose, under the authority of the state but at "arm’s length", very strictly separated from government and politics. The rights and responsibilities of disposal of the cadaver should be vested in this organisation. When the cadaver has been used, if possible, as a source of transplantable organs it may, if the family wishes, be reconsigned to their care, for such religious and social observances as they desire. Practically, this might be welcomed by many, as removing the necessity for an agonising decision by the family. Also practically, it is impossible for the family, in such circumstances, to be able to tell what has been done; after routine autopsy the body is reconstituted so that there is no outward sign, to ordinary observation such as that at an open coffin funeral or memorial service, that any examination has been performed. Legally, this might be regarded as an extension of the doctrine of Parens patriae, the assumption by the state of parental responsibility when this is necessary, on behalf of the persons benefiting from organ donation and transplantation. Morally, I regard the rights of the potential recipient, because of the benefits accruing, to be pre-emptive over all others.

In this situation, the idea of consent and its corollary, refusal are not morally applicable. One may be able to give or refuse consent to a procedure which affects oneself, but organ donation affects no one physically; no human person is involved as donor. To grant the right and power of consent to an individual who may be affected emotionally, is to elevate the possible emotional affect of one person, as more important than the physical life of another. The imbalance of benefit is too great to permit of this, and I find it morally unacceptable. To require consent for cadaver organ donation from the one of whose person in life the body is a part, is unacceptably to extend control of that body beyond legitimate limits. To require consent from the relatives of a previously living person is unacceptably to extend their control over matters where the good of others should be the predominant concern. The concept of consent in this situation is morally incorrect.

This having been said, in a society which places predominant value in autonomy, it may not be possible to enact in law what is morally correct. Should this matter ever attain the status of a legislative proposal, as it has in some countries, it might be a practical necessity to extend the principle of autonomy to a right to refusal of cadaver organ donation, to a living individual—to legitimise, in effect, the attitude of the rich man in my parable. To me this would be immoral, but it might be necessary to condone this limited immorality, commonly expressed as the right to opt out, or to refuse, to the individual. It would be a limited sacrifice to the much greater good."

5.-) "Is the body a republic?", Journal of Medical Ethics 2005 N°31, p.470-475. Author: Simona Giordano, Institute of Medicine, Law and Bioethics (IMLAB), School of Law, University of Manchester, UK.

"The ethics of post-mortem organ retention and use is widely debated in bioethics and law. However, the fundamental ethical issues have often been inadequately treated. According to one argument, dead bodies are no longer "persons". Given the great benefits dead bodies offer to human kind, they should be automatically treated as public property: when the person dies, the body becomes a public thing (a res publica, a republic). This paper articulates the ethical issues involved in organ and tissue retention and use, both in the case in which the deceased’s wishes are known and in the case in which the wishes are not known. It contends that a dead body is not a republic. The state should maximise availability of organs and tissues by inviting or requiring citizens to make an informed and responsible choice on the matter."

Role of brain death and the dead-donor rule in the ethics of organ transplantation

Abstract:

The "dead-donor rule" requires patients to be declared dead before the removal of life-sustaining organs for transplantation. The concept of brain death was developed, in part, to allow patients with devastating neurologic injury to be declared dead before the occurrence of cardiopulmonary arrest. Brain death is essential to current practices of organ retrieval because it legitimates organ removal from bodies that continue to have circulation and respiration, thereby avoiding ischemic injury to the organs.



The concept of brain death has long been recognized, however, to be plagued with serious inconsistencies and contradictions.

Indeed, the concept fails to correspond to any coherent biological or philosophical understanding of death. We review the evidence and arguments that expose these problems and present an alternative ethical framework to guide the procurement of transplantable organs. This alternative is based not on brain death and the dead-donor rule, but on the ethical principles of nonmaleficence (the duty not to harm, or primum non nocere) and respect for persons. We propose that individuals who desire to donate their organs and who are either neurologically devastated or imminently dying should be allowed to donate their organs, without first being declared dead. Advantages of this approach are that (unlike the dead-donor rule) it focuses on the most salient ethical issues at stake, and (unlike the concept of brain death) it avoids conceptual confusion and inconsistencies. Finally, we point out parallel developments, both domestically and abroad, that reflect both implicit and explicit support for our proposal.

© 2003 Lippincott Williams & Wilkins, Inc.

Source:
Critical Care Medicine. 31(9):2391-2396, September 2003.
Truog, Robert D. MD, FCCM; Robinson, Walter M. MD, MPH
Copyright © 2005, Society of Critical Care Medicine. All rights reserved.
Published by Lippincott Williams & Wilkins.

Does it matter that organ donors are not dead? Ethical and policy implications

LAW, ETHICS, AND MEDICINE

ABSTRACT
The "standard position" on organ donation is that the donor must be dead in order for vital organs to be removed, a position with which we agree. Recently, Robert Truog and Walter Robinson have argued that (1) brain death is not death, and (2) even though "brain dead" patients are not dead, it is morally acceptable to remove vital organs from those patients. We accept and defend their claim that brain death is not death,



and we argue against both the US "whole brain" criterion and the UK "brain stem" criterion. Then we answer their arguments in favour of removing vital organs from "brain dead" and other classes of comatose patients. We dispute their claim that the removal of vital organs is morally equivalent to "letting nature take its course", arguing that, unlike "allowing to die", it is the removal of vital organs that kills the patient, not his or her disease or injury. Then, we argue that removing vital organs from living patients is immoral and contrary to the nature of medical practice. Finally, we offer practical suggestions for changing public policy on organ transplantation.

--------------------------------------------------------------------------------

Abbreviations: EEG, electroencephalogram; UDDA, uniform determination of death act

Source :
J Med Ethics 2005;31:406-409 © 2005 BMJ Publishing Group Ltd & Institute of Medical Ethics

M Potts2 and D W Evans1
1 Queens’ College, Cambridge, Cambridge, UK
2 Philosophy and Religion Department, Methodist College, 5400 Ramsey Street, Fayetteville, NC 28311-1498, USA

Correspondence to:
Professor M Potts
5400 Ramsey Street, Fayetteville, NC 28311 – 1498, USA;
gratiaetnatura@yahoo.com

Brain death is not death

The Nasty Side of Organ Transplanting:

Dr David Wainwright Evans, Cardiologist, Queens College, Cambridge, United Kingdom, suggests that organ donors diagnosed "brain dead" may still be alive:

"There were never sound scientific or philosophical grounds for a redefinition of death based on the loss of testable brain function while the body remains alive 1. Pressure for a viable heart for transplantation nevertheless resulted in a diagnosis of death on some such basis in Cape Town 2, in 1967. There followed “a euphoric, uncontrolled epidemic of heart transplantation around the world”3. This, together with demand for other organs which, to be viable in recipients, required that they be perfused until their removal, necessitated “the production of a set of legal and philosophical justifications”2 for procedures which would otherwise be seen as assault.



The story of how the Harvard Brain Death Committee produced, in 1968, a facilitating redefinition of death based on “irreversible coma” with “no discernible central nervous system activity” makes interesting reading4. The ease with which their novel redefinition of death became incorporated into American law, and subsequently accepted in many other countries, gave food for thought. It seemed to resist attacks upon its inconsistencies and contradictions because of its utility - indeed its perceived necessity to some transplant practices.

That is, until last year [2003]. Fittingly, the paper formally admitting that the concept of brain death - as this new form of death became widely known - “fails to correspond to any coherent biological or philosophical understanding of death” came from the Harvard Medical School too 5.

While the philosophical arguments about concepts of death may be for others, the possibility of diagnosing - with the necessary certainty - the “irreversible cessation of all functions of the entire brain, including the brain stem”, while the rest of the body remains alive, has always been the concern of the doctor. That “whole brain” definition was the requirement stipulated in the quaintly named Uniform Determination of Death Act (1981) if death were to be certified on other than the universally accepted cardiorespiratory basis. The Harvard tests - essentially of brainstem mediated reflexes and ventilator dependence, with or without EEG, in patients whose coma was believed irremediable - clearly lacked the power to make that diagnosis. The many protocols in use worldwide failed similarly. Indeed, their very number6 proclaimed the fact that the syndromes they diagnosed could not be one and the same entity7. And prominent among the variations was the apnoea test, which might lead to the misdiagnosis of respiratory centre failure if inadequately stimulating. If stringent, it might prove lethal 8.

Truog and Robinson acknowledge that many patients currently diagnosed “brain dead” do not, as a matter of fact, meet the American legal requirements governing that practice. They say that many of them retain demonstrable brain function - and that this knowledge, which should be uncomfortable to those certifying death on the basis that there is none, is set aside on the premise that it is not “significant”. That practice is reminiscent of the stance assumed by those who foisted “brain death” upon us here in the UK in 1979. They simply promulgated a set of prognostic criteria, first published in 1976, with a directive that they were to be used thenceforth as criteria for the diagnosis of death9 . The illogicality of that change of use was pointed out in 1980 10. The diagnosis (of “brain death”) was crucially dependent upon the absence of specified brainstem reflexes. Other persisting brainstem function, such as blood pressure control, was to be ignored. EEG activity was not to be sought. If demonstrated, it was to be set aside as of no “significance”. Such was the pretence to knowledge of our marvellous brain’s function which did not, and still does not, exist.

The term “brain death” was formally abandoned, in this country [the UK], in 1995 11. But comatose, ventilator-dependent patients are still being certified “dead” for transplant purposes using similar tests. These are now held to diagnose the irreversible loss of the capacity for consciousness, although no sound scientific evidence has been advanced to support that claim.

Nor, since these patients are not exposed to the anoxic drive stimulus, do they have the power to diagnose the irreversible loss of the capacity to breathe. That being so, the merits and demerits of the new conceptual basis for certifying these patients dead should be of no practical concern to the doctors who care for them.

Where requests for the organs of such patients are concerned, Truog and Robinson (like others12,13) propose the abandonment of all obfuscation about their status in the dying process. They suggest that people should be allowed to donate their organs when they become “neurologically devastated or imminently dying”, without first being declared dead. This refreshing call to face the facts has implications for the validity of the “consent” given by those led to believe that their offer of organs will not be taken up until after their death. But it may be that more will be prepared to register as prospective donors on the proposed new basis if it is fully and frankly explained - and the necessary legislation enacted after open debate."

Source:
Article by Dr. David W Evans - Retired Physician (sometime Consultant Cardiologist at Papworth Hospital)
27 Gough Way, Cambridge, CB3 9LN - and Queens’ College, CB3 9ET (DWEvansMD@tinyworld.co.uk)
Competing interests : None

References

1. Beyond Brain Death : the Case Against Brain Based Criteria for Human Death. Eds. Potts M,
Byrne PA, Nilges RG. Kluwer Academic Publishers, Dordrecht, 2000

2. Hoffenberg R. Christiaan Barnard : his first transplants and their impact on concepts of death.
BMJ 2001;323:1478-80 (and see bmj.com ‘Rapid responses’ to this article)

3. Smith T. Clinical freedom. BMJ 1987;295:1583

4. Singer P. Is the sanctity of life ethics terminally ill? In: Brain Death, Ed. Machado C. Elsevier Science B.V. 1995, 231-243

5. Truog RD, Robinson WM. Role of brain death and the dead-donor rule in the ethics of organ transplantation. Crit Care Med 2003;31:2391-96

6. Wijdicks EFM. Brain death worldwide : accepted fact but no global consensus in diagnostic criteria.
NEUROLOGY 2002; 58:20-25

7. Evans DW. ‘Open letter to Professor Wijdicks’, bmj.com ‘Rapid responses’ 11 Dec 2002

8. Coimbra CG. Implications of ischemic penumbra for the diagnosis of brain death. Braz J Med Biol Res 1999;32:1479-87

9. Conference of Medical Royal Colleges and their Faculties in the UK. Memorandum on the diagnosis
of death. BMJ 1979;I:332

10. Evans DW, Lum LC. Brain death. Lancet 1980 (November 8th):1022

11. Working Group convened by the Royal College of Physicians and endorsed by the Conference of
Medical Royal Colleges and their Faculties in the United Kingdom. Criteria for the diagnosis of brain stem death. J Roy Coll Physns Lond 1995;29:381-2

12. Kerridge IH, Saul P, Lowe M, McPhee J, Williams D. Death, dying and donation : organ transplantation and the diagnosis of death. J Med Ethics 2002;28:89-94

13. Woodcock TE. New act regulating human organ transplantation could facilitate organ donation.
BMJ 2002;324:1099

La mort encéphalique : la position des neuro-psychiatres en Allemagne

Quelle est la situation en Allemagne ?
Le site internet PubMed, qui répertorie des résumés de publications scientifiques récentes, dans différents pays (langue de ce site : anglais essentiellement, mais aussi espagnol, allemand et quelques traductions de résumés en français), permet de mener une recherche très précise concernant la mort encéphalique en vue du prélèvement des organes. Des points de vue scientifiques sur la question sont exposés, commentés, débattus. La situation n'est pas identique pour chaque pays, et le consensus n'est pas encore atteint.



Voici un point récent sur la situation en Allemagne, du point de vue de deux neuro-psychiatres, diplômés de l'Université de Cologne, département de Neurologie :

"The diagnosis of brain death: medical and legal aspects with special reference to the German Transplantation Law (TPG):"

"The diagnosis of brain death following total and irreversible cessation of all cerebral functions is based on anthropological assumptions and conventions as well as on the exact medical diagnosis of total loss of brain function. The question whether individual life ends after cerebral function is irreversibly lost cannot be answered by medical definition alone. Clear and unrefutable legal definitions of death and the cessation of the rights of the individual must be provided before organs may be harvested from brain dead individuals. Acceptance of these definitions by the general population is of paramount importance for the practice of organ donation. In the first part of this article, the legal definition of death and the provisions of the German transplantation law are critically reviewed. The legal statements deal with the question of the definition of death and how death can be detected. The provisions of the German transplantation law are referenced with special attention to the provision of prior consent to the removal of organs following after the diagnosis of brain death. The provisions of the German constitution with respect to the preservation of the personal rights of the individual are discussed in the light of organ harvesting. The second part deals with the medical procedure of determining brain death in adults. The medical statements pertain to the diagnostic steps to be taken in the diagnosis and determination of brain death. The prerequisites for entering the diagnostic procedure to determine brain death are described. The clinical signs of total and irreversible cessation of brain function are listed, and the technical examinations to corroborate the clinical signs of brain death as accepted in Germany are delineated. In the perspective of the authors, individuals having suffered brain death still possess the protection of their personal human rights according to the German constitution since it cannot be conclusively demonstrated that total loss of brain function alone constitutes the cessation of life in the sense of the German constitution."

Source :
Haupt WF, Hofling W, Klinik und Poliklinik fur Neurologie der Universität zu Koln, Germany.
Fortschr. Neurol. Psychiatr. 2002 Nov; 70(11):583-90.

La mort cérébrale : résoudre les contradictions de la déclaration éthique de la mort

Voici un article scientifique traitant des contradictions de la déclaration éthique de la mort :

Canadian Journal of Anesthesia 50:725-731 (2003)
© Canadian Anesthesiologists' Society, 2003
Neuroanesthesia and Intensive Care

[Brain death: resolving inconsistencies in the ethical declaration of death:]

La mort cérébrale : résoudre les contradictions de la déclaration éthique de la mort :

"Objectif : Les premiers critères de mort cérébrale ont été formulés en 1968 pour répondre, en partie, aux inquiétudes soulevées par la recherche d’organes pour les greffes. Malgré 30 ans d’application, un certain doute subsiste chez les professionnels et le public sur la validité de la notion théorique à l’origine de cette façon de déterminer la mort. Notre revue aborde les perspectives historiques de la formulation des critères de mort cérébrale et des contradictions des critères cliniques actuels.

Méthode : La revue descriptive provient de la consultation de références dans MEDLINE et d’autres sources publiées.

Constatations principales : Le principal concept de la détermination de la mort est l’arrêt irréversible de la fonction cardio-pulmonaire ou neurologique. Cependant, il y a des contradictions dans les critères neurologiques de la mort entre les pays, entre les populations de patients et dans l’usage des tests de confirmation. Ces contradictions peuvent inquiéter le public et la profession médicale sur la validité de la détermination de la mort par des critères neurologiques.

Conclusion : La greffe d’organes est fondée sur l’acceptation publique et professionnelle du fait que le donneur soit décédé. Étant donné que les critères de mort cérébrale, ou de leur application, demeurent variables, nous croyons qu’il est raisonnable d’envisager la formation d’un consensus visant à traiter de ces contradictions. Autrement, l’utilisation standard des tests radiographiques confirmatifs, qui précèdent le prélèvement d’organes de donneurs répondant aux critères cliniques de mort cérébrale, devrait être considérée pour fournir la preuve concluante de la perte permanente et irréversible de la fonction cérébrale."

English version :

Brain death: resolving inconsistencies in the ethical declaration of death:

Christopher James Doig, MD MSc* and Ellen Burgess, MD
* From the Department of Critical Care Medicine and the Office of Medical Bioethics;
and the Division of Nephrology, Department of Medicine, Faculty of Medicine, University of Calgary, Calgary, Alberta, Canada.

"Purpose: The first criteria for the determination of brain death were developed in 1968 in part to address concerns that had arisen with the retrieval of organs for transplantation. Despite over 30 years of application, some professional and public doubt persists over the validity of the theoretical construct underlying this method of determining death. Our review will address historical perspectives on the development of brain death criteria, and inconsistencies in current clinical criteria.

Method: Narrative review from selected MEDLINE references and other published sources.

Principal findings: The primary construct of the determination of death is that either cardiopulmonary or neurological function irreversibly ceases. However, there is inconsistency in the neurological criteria for death between jurisdictions, between patient populations, and in the use of confirmatory tests. These inconsistencies may cause concern in the public or profession about the validity of the determination of death by neurological criteria.

Conclusions: Organ transplantation is premised on professional and public acceptance that the donor is dead. Given that the criteria for brain death or their application remain variable, we suggest that it is reasonable to consider a national consensus to address these inconsistencies. Alternatively, the standard use of confirmatory radiographic testing prior to the retrieval of organs from donors who meet clinical brain death criteria should be considered to provide conclusive evidence of permanent and irreversible loss of brain function."

AS A CONCLUSION :

"Increasing organ donation is an important and laudable objective. To do so at the expense of exploiting society’s most vulnerable cannot be supported despite the best of intentions. We share the opinion of Dossetor who states: "ethics dictates the following: organs should not be procured from bodies where there is life... no measures should be carried out on the dying person even with family consent, that are not directed at serving the best interests of the dying person... Our faith in the supposedly objective diagnosis of brain death leads us to remove organs from the dead body where the heart is still beating. We now need to take seriously the question of whether the criteria to establish brain death are as reliable as we claim them to be.

If they are not as satisfactory as we once thought, the whole matter should be brought into debate."

Revision received April 30, 2003. Accepted for publication March 17, 2003.

Christopher James Doig, MD MSc* and Ellen Burgess, MD
* From the Department of Critical Care Medicine and the Office of Medical Bioethics;
and the Division of Nephrology, Department of Medicine, Faculty of Medicine, University of Calgary, Calgary, Alberta, Canada.

Address correspondence to: Dr. Christopher James Doig, Rm EG23G, Foothills Medical Centre, 1403, 29th Street NW, Calgary Alberta T2N 2T9, Canada. E-mail: cdoig@ucalgary.ca

Qu'est ce qu'un donneur d'organes en état de mort cérébrale au Canada ?

"Le don d’organes et de tissus à l’unité des soins intensifs : des efforts concertés."

"En novembre 2002, un commentaire paru dans le Journal de l’Association médicale canadienne (1) a attiré notre attention sur les questions reliées au don d’organes et de tissus à l’unité des soins intensifs. Dans le résumé présenté par la Société canadienne de soins intensifs (SCSI), qui a conduit à une déclaration de principe sur le don d’organes et de tissus [disponible sur le site web de la SCSI (www.canadiancriticalcare.org)], la SCSI fait appel à la collaboration d’autres groupes dans un esprit de compréhension et de respect mutuels. C’est réconfortant de voir de tels liens se former. Une des initiatives a été de créer des liens plus étroits entre la SCSI et le Journal canadien d’anesthésie. Le résultat apparaît dans la publication, d’abord dans le présent numéro, d’une série d’articles écrits par les membres de la SCSI qui ont participé aux délibérations de notre groupe de travail sur le don d’organes et de tissus. L’article, intitulé Brain Death: resolving inconsistencies in the ethical declaration of death, correspond à l’examen personnel et professionnel de Doig et Burgess de l’évolution du concept de mort cérébrale depuis les premières discussions d’un comité de la Harvard Medical School, en 1968, jusqu’à aujourd’hui (2).

Les raisons étaient nombreuses de créer un groupe de travail de la SCSI sur le don d’organes et de tissus, notre propre perception n’étant pas la moindre qu’en qualité de réanimateurs, nous ne sommes pas assez impliqués dans l’amélioration ou l’optimalisation du taux de donateurs d’organes et de tissus. Nous demeurons les médecins les plus susceptibles de participer aux soins prodigués aux donneurs d’organes potentiels à l’unité des soins intensifs (USI). De plus, les médecins de l’USI risquent d’être les plus concernés par toute stratégie introduite par les agences chargées d’améliorer le taux de donateurs d’organes et de tissus au Canada.

Parmi les stratégies possibles, il y a des changements à la législation pour permettre de fournir des renseignements, autrement restés confidentiels, sur des donneurs d’organes potentiels à des tiers. Il y a aussi de la possibilité d’un don d’organes de patients déclarés morts selon des critères cardiovasculaires, plutôt que l’habituel critère de mort cérébrale. Ces patients seraient des donneurs à coeur non battant (3). Cette façon de procéder est souvent utilisée aux Pays-Bas et dans quelques centres américains. Pour traiter de ces questions, et d’autres, nous avons réuni cinq personnes, non-médecins, et huit spécialistes de l’USI pour former un groupe de travail. Les non-médecins étaient : bioéthiciens (Kerry Bowman PhD, University of Toronto, Alister Browne PhD, Langara College, British Columbia), experts en droit de la santé (Jocelyn Downie SJD, Dalhousie University) et deux membres du public représentant la famille d’un donneur (Diane Craig, Ontario) et la famille d’un receveur d’organes (Lois Scott, New Brunswick). Les huit médecins de l’USI (Peter Dodek, Vancouver ; Paul Boiteau, Chip Doig, Calgary ; Catherine Farrell, Montréal ; Giuseppe Pagliarello, Ottawa ; Graeme Rocker, Halifax (président), Sam Shemie, Toronto et Gordon Wood, Victoria) représentaient six provinces et des centres de soins tertiaires ayant des intérêts communautaires tant adultes que pédiatriques.

Une fois composée l’ébauche de la déclaration de principe, de nombreuses versions ont traduit la ré- flexion en cours et la construction du consensus. La version finale du résumé a été distribuée en août 2002. Dans cette déclaration, nous souhaitions, par exemple, un moratoire sur les programmes de donneurs à cur non battant afin d’élargir la discussion et de débattre des questions éthiques soulevées par la situation. La SCSI s’est attirée quelques commentaires sur le conservatisme de sa position (ce qui ne nous a pas surpris), mais nous avons maintenu notre demande de nouvelle discussion. Pour cette raison, nous sommes heureux que le Journal canadien d’anesthésie ait accepté de publier prochainement un article sur les questions éthiques reliées à l’utilisation possible de donneurs à cur non battant. Dans les prochains numéros, le Journal va aussi publier des documents manuscrits sur l’élément culturel du diagnostic de mort cérébrale et sur la question controversée de la déclaration obligatoire de mort "imminente" qui permettrait de trouver des donneurs d’organes potentiels pour des organisations tierces. Aucun de ces articles ne prétend représenter la vision officielle de la SCSI sur le sujet en particulier, mais ils ont été présentés par leurs auteurs pour être publiés avec l’idée d’aborder certaines questions controversées auprès d’un auditoire plus large et de stimuler d’autres débats.

Une autre initiative de collaboration doit être soulignée. Répondant à la requête de la SCSI pour un dialogue et une collaboration sur les événements qui conduisent à la mort cérébrale, le Conseil canadien pour le don et la transplantation a parrainé en avril 2003 à Vancouver (4) un Forum canadien sur les lésions cérébrales graves menant à la détermination neurologique de la mort. Pendant le Forum, les spécialistes médicaux et non médicaux représentant la bioéthique, le droit de la santé, les soins intensifs, l’urgence, le milieu des sciences neurologiques, la transplantation, les soins palliatifs, les associations et collèges professionnels et le gouvernement fédéral, par Santé Canada et l’Institut canadien d’information sur la santé, ont évalué les politiques et les pratiques de traitement des patients gravement malades présentant des lésions cérébrales et/ou un mauvais pronostic neurologique. Un objectif était de formuler et d’utiliser une définition canadienne de la détermination neurologique de la mort, applicable de manière constante et fiable.

Pourquoi une telle approche est-elle nécessaire ? L’article de Doig et Burgess (2) présente une preuve assez claire des incohérences qui président actuellement au diagnostic de mort cérébrale. Un exemple manifeste est la différence observée entre les États-Unis et le Royaume-Uni. Les Américains ont adopté le concept de coma dépassé. Au R-U, un diagnostic de mort cérébrale est principalement fondé sur l’irréversibilité de la fonction du tronc cérébrale. Un rapport sur les débats du Forum canadien sur les lésions cérébrales graves paraîtra sous peu. D’autres collaborations similaires sont visées pour accroître, au Canada, la prise de conscience sur d’autres questions touchant le don d’organes (par ex., le recours, ou non, à des donneurs à cur non battant) en intéressant de nombreuses disciplines à prendre part à la clarification des enjeux clés, légaux ou éthiques, médicaux ou techniques.

Modifier une politique ou un comportement professionnel comporte la mise en oeuvre réussie de nouvelles stratégies. La diffusion de nouveaux renseignements est alors indispensable. La collaboration avec des journaux médicaux d’un vaste lectorat peut être une partie clé du processus. La SCSI est fière de faire partie de cette collaboration. Nous remercions le Journal canadien d’anesthésie d’avoir permis à la SCSI de présenter son travail à une plus large public intéressé à la réanimation. Nous attendons avec impatience d’autres initiatives qui bénéficieront, en définitive, aux patients et aux familles dont nous prenons soin."

Organ and tissue donation in the intensive care unit: collaborative endeavours:

"In November 2002 a Canadian Medical Association Journal commentary (1) drew attention to several organ and tissue donation-related issues in the critical care unit. In this summary of the Canadian Critical Care Society (CCCS) process that led to a position paper on organ and tissue donation, [available from the CCCS web-site (www.canadiancriticalcare.org)], the CCCS called for collaboration with other groups in a "spirit of mutual understanding and respect." It is heartening to see such collaborations taking shape. One initiative has been the forging of stronger links between the CCCS and the Canadian Journal of Anesthesia. This has resulted in the publication, beginning with this edition, of a series of articles by CCCS members who participated in our organ and tissue donation working group deliberations. In this edition of the Canadian Journal of Anesthesia, an article entitled "Brain Death: resolving inconsistencies in the ethical declaration of death" reflects Doig’s and Burgess’ personal and professional assessment of the development of the concepts of brain death from the early deliberations of a 1968 committee at Harvard Medical School up to the present(2).

There were many reasons to create a working group of the CCCS to address organ and tissue donation, not the least of which was our own perception that as critical care physicians, we were not sufficiently involved in processes to improve or optimize organ and tissue donation rates. We remain the physicians most likely to be involved in the care of potential organ donors in the intensive care unit (ICU). In addition, ICU physicians are the clinicians most likely to be affected by any strategies introduced by agencies charged with seeking to improve Canada’s organ and tissue donation rates.

Some of these potential strategies include changes to legislation to allow information about potential organ donors to be forwarded to third parties that would otherwise have remained confidential. Other strategies under discussion include consideration of organ donation from patients declared dead by cardiovascular criteria (rather than by conventional brain death criteria). These patients would become non-heart beating donors (3). This approach is often used in the Netherlands and in some US centres. To address these and other issues, we brought together five non-physicians and eight ICU specialists to comprise our working group. The non-physicians were: bioethicists (Kerry Bowman PhD, University of Toronto, Alister Browne PhD, Langara College, British Columbia) a health law expert (Jocelyn Downie SJD, Dalhousie University) and two members of the public representing the family of an organ donor (Diane Craig, Ontario) and the family of an organ recipient (Lois Scott, New Brunswick). The eight ICU physicians (Peter Dodek, Vancouver; Paul Boiteau, Chip Doig, Calgary; Catherine Farrell, Montreal; Giuseppe Pagliarello, Ottawa; Graeme Rocker, Halifax (Chair), Sam Shemie, Toronto and Gordon Wood, Victoria represented six provinces with both tertiary centre, community, adult and pediatric interests.

Once we had crafted our first draft of the position paper much iteration followed in course of reflection and building of consensus. The bound version of the executive summary was distributed in August 2002. In this position paper we called, for example, for a moratorium on non-heart beating donor programs in Canada to allow for wider discussion and debate of the ethical issues that arise in such a context. The CCCS has attracted some comments on its conservative stance on this issue (which we expected), but we stand by our call for wider discussion. For this reason we are delighted that the Canadian Journal of Anesthesia has agreed to publish an article in a later issue on ethical issues related to potential use of non-heart beating donors. In subsequent issues the Canadian Journal of Anesthesia will also publish manuscripts on cultural consideration in the diagnosis of brain death and on the contentious issue of mandatory reporting of "imminent" death to identify "potential" organ donors to third party organizations. None of these papers should be considered to represent the official view of the CCCS on the specific topic, but they have been offered for publication by their authors in the spirit of bringing some contentious issues to a wider audience to stimulate further discussion and debate.

Another collaborative initiative in organ and tissue donation should be highlighted. Responding to the CCCS request for discourse and collaboration around events leading to brain death, the Canadian Council for Donation and Transplantation sponsored a Canadian Forum on severe brain injury to neurological determination of death in Vancouver in April 2003 (4). During the Forum, medical and non-medical specialists representing bioethics, health law, critical care, the emergency department, neuroscience communities, transplantation, palliative care, professional associations and colleges as well as Federal representation through Health Canada and the Canadian Institute of Health Information evaluated policies and practices concerning the management of critically injured patients with brain injury and/or poor neurological outcome. One purpose was to create and implement a Canadian definition of a neurological determination of death that can be applied consistently and reliably.

Why is there a need for a such an approach? The article by Doig and Burgess (2) provides some stark evidence of the inconsistencies with which the current diagnosis of brain death is approached. One glaring example is the difference between the US and the UK. The US has adopted the concept of whole brain death. In the UK a diagnosis of brain death is based primarily on irreversible function of the brain stem. A report of the proceedings of the Canadian Forum on severe brain injury will be forthcoming shortly. Subsequent similar collaborations will be aimed at increasing awareness in Canada of other organ donation issues (e.g., use or non-use of non-heart beating donors) by involving the many disciplines that need to be part of processes aimed at clarifying key issues, whether legal or ethical, medical or procedural.

Change to policy or professional behaviour involves successful implementation of new strategies. Dissemination of new information is integral to this success. Collaboration with medical journals with wide readership can be a key part of that process. The CCCS is proud to be part of this process of collaboration. We are grateful to the Canadian Journal of Anesthesia for enabling the work of the CCCS to reach a wider audience with interests in critical care. We look forward to other initiatives that ultimately will be to the benefit of the patients and families we care for."

References:
1. Rocker GM. Organ and tissue donation in the intensive care unit. CMAJ 2002; 167: 1248–9
2. Doig CJ, Burgess E. Brain death: resolving inconsistencies in the ethical declaration of death. Can J Anesth 2003; 50: 725–31.
3. Campbell GM, Sutherland FR. Non-heart-beating organ donors as a source of kidneys for transplantation: a chart review. CMAJ 1999; 160: 1573–6.
4. Shemie SD, Doig C, Belitsky P. Advancing toward a modern death: the path from severe brain injury to neurological determination of death. CMAJ 2003; 168: 993–5.

Source:
Graeme Rocker, MHSc DM FRCP FRCPC
Department of Medicine (Respirology), Dalhousie University, Halifax, Nova Scotia, Canada.
Address correspondence to: Dr. Graeme Rocker, President, Canadian Critical Care Society, 4457 Halifax Infirmary, 1796 Summer Street, Halifax, Nova Scotia B3H 3A7, Canada. Phone: 902-473-6611; Fax: 902-473-6202; E-mail: gmrocker@dal.ca

Qu'est ce que la mort cérébrale / What is brain death ?

Vous trouverez ci-dessous l'article de A. Halevy et de B. Brody :
"Brain death: Reconciling definitions, criteria and tests". Annals of Internal medicine: 1993; n°119, p. 519-525

Cet article montre en substance que parler de "mort" est complètement inadéquat, n'existent que des stades du processus de mort.



MEDICINE AND PUBLIC ISSUES
Brain Death
Reconciling Definitions, Criteria, and Tests
Amir Halevy and Baruch Brody
15 September 1993 | Volume 119 Issue 6 | Pages 519-525

"Brain death has been discussed extensively for the last 25 years.Most investigators now believe that requiring death of the entire brain as the criterion for brain death in the Uniform Determination of Death Act and the standard clinical tests of brain death outlined in the Report of the Medical Consultants to the President's Commission have produced a satisfactory resolution of the issues surrounding the determination of death. However, we show that satisfying the standard medical tests does not guarantee that all brain functions have actually ceased and that there is tension between the legal criterion and the standard clinical tests. After considering and rejecting six possible reconciliations, we present an alternative approach that does not acknowledge any sharp dichotomy between life and death and incorporates the proposition that the questions of when care can be unilaterally discontinued, when organs can be harvested, and when a patient is ready for the services of an undertaker should be answered independent of any single account of death.



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The development of machines that mechanically sustain the life functions of respiration and circulation forced the medical community and society in general to re-evaluate the accepted definition, criterion, and tests of death. In certain cases, the classic definition of death as the permanent cessation of the flow of vital bodily fluids was no longer consonant with the classic criterion of death as the irreversible cessation of spontaneous respiration and circulation [1]. In addition, newly developed organ transplantation programs required a definition, criterion, and test of death that would facilitate the procurement of organs before they deteriorate.
Thus, the medical community began to develop alternative, brain-based accounts of death. The Harvard Report [2], published in 1968, was the first formal attempt to meet this need. Continued efforts to reach a consensus regarding brain death culminated in a report from the President's Commission for the Study of Ethical Problems in Medicine and Biomedical and Behavioral Research [3] and in two resulting documents, the clinical report of the medical consultants to the President's Commission [4] and the Uniform Determination of Death Act [5]. These efforts were largely successful, although doubts about the appropriateness of this brain-based account continued to be expressed in some countries [6,7] and in some religious communities [8].

The President's Commission considered three possible criteria for death: a nonbrain criterion, a whole-brain criterion, and a higher-brain criterion Table 1. The first criterion was most consonant with the definition of death as the permanent cessation of the flow of vital bodily fluids, the second with the definition of death as the permanent cessation of the integrated functioning of the organism as a whole, and the third with the definition of death as the permanent loss of what is essential to the nature of man (consciousness). Although the Commission chose to emphasize legislation derived from criteria rather than from definitions [3], it did refer in its justification to the brain's primacy in integrating body functions as well as in sponsoring consciousness. To quote the Commission: "This view gives the brain primacy not merely as the sponsor of consciousness (since even unconscious persons may be alive), but also as the complex organizer and regulator of bodily functions.Only the brain can direct the entire organism" [3].


Table 1. Alternative Definitions of Death

The whole-brain criterion was selected for practical reasons as well. From a practical standpoint, the higher-brain criterion suffered because no agreement could be reached about what portions of the brain are required for cognition and consciousness and because "even when the sites of certain aspects of consciousness can be found, their cessation often cannot be assessed with the certainty that would be required in applying a statutory definition" [3]. Moreover, adoption of a higher-brain criterion was too radical a departure from the traditional criterion and "one would desire much greater consensus than now exists before taking the major step of radically revising the concept of death" [3].

The Uniform Determination of Death Act provided the legal articulation of the whole-brain criterion of death as "irreversible cessation of all functions of the brain, including the brainstem" [5]. The choice of the word "functions" rather than "activity" reflected the view that "bodily parts, and the subparts that make them up, are important for the functions they perform" [3]. The President's Commission explicitly recognized that electrical and metabolic activity of groups of cells within an organ may continue after that organ has ceased functioning. However, the Commission stipulated that cellular activity is considered functioning when it is "organized and directed" [3]. We consider below still stronger requirements for when activity is considered functioning.

Less clear are the medical tests necessary to establish that the legal criterion is met. The Uniform Determination of Death Act stated that a "determination of death must be made in accordance with accepted medical standards" [4], but what are these standard tests? To meet the challenge of developing standard tests that clinicians could use to establish that the criterion of death had been met, the President's Commission created a panel of medical consultants.

The standard tests proposed by the medical consultants to the President's Commission are clinically based. The brain functions considered are cerebral and brain stem functions. Cessation of cerebral function is attested by deep coma without clinical response to any physical stimuli. Brain stem function is assessed by testing for cranial nerve function, including pupillary, corneal, oculocephalic, oculovestibular, and oropharyngeal reflexes, and by carrying out an apnea test to determine respiratory function. Irreversibility is determined by identifying the cause of the coma to exclude drug intoxication and hypothermia and by observing the patient for a specified period of time. Such tests as an electroencephalogram, a brain stem evoked potentials study, or a cerebral blood flow study are considered desirable when objective documentation is needed to substantiate these clinical findings but are not generally necessary for the determination of brain death.

We show that the standard clinical tests proposed by the advisors to the President's Commission do not ensure that all brain functions have actually ceased and do not therefore ensure that the whole-brain criterion of death has been met. We also show that many possible solutions to this discrepancy are unsatisfactory. We conclude by suggesting that an alternative approach is needed to deal with troubling cases.

The Problem

A review of published reports about brain death shows that many patients who meet the standard clinical tests for brain death still maintain some brain functioning and therefore do not satisfy the whole-brain criterion of death. Three areas of persistent functioning are neurohormonal regulation, cortical functioning as shown by significant nonisoelectric electroencephalograms, and brain stem functioning as shown by evoked responses.

Neurohormonal Functioning

The first evidence for continued brain functioning despite a patient's meeting the standard clinical tests for brain death is found in analyses of neurohormonal regulation. Anterior pituitary hormone levels have been studied by several investigators; much of the research has been motivated by a desire to optimally manage brain-dead donors. In one of the earliest studies, by Schrader and colleagues [9], normal hormonal levels were found, although other studies [10] have reported different results. Provocative testing provides the best evidence of intact neurohormonal regulation. Schrader and coworkers [9] evaluated several patients "with signs of brain death including the criteria set forth by the Ad Hoc Committee of Harvard". In two cases, an insulin-induced hypoglycemia test was done, and one of the patients showed a decrease in the glucose level that was associated with an immediate growth hormone response.

Posterior pituitary function, specifically antidiuretic hormone secretion, provides the best documented evidence of preserved brain function. If the hypothalamus and neurohypophysis, structures on the brain side of the blood-brain barrier, were nonfunctional, then the patient should develop clinically apparent central diabetes insipidus because of the lack of antidiuretic hormone regulation. However, not all patients meeting the standard clinical criteria of brain death develop the syndrome. Mollaret and Goulon [11] in their original paper on "coma depasse" observed polyuria that behaved like diabetes insipidus in some of the cases. Grenvik and colleagues [12] reported that only 8.5% of their cases had the clinical manifestations of diabetes insipidus. Two series on the incidence of diabetes insipidus in children meeting the standard clinical tests of death showed clinical manifestations of diabetes insipidus in 87% [13] and in 38% [14] of patients. Further reducing the percentage of such patients with true central diabetes insipidus is evidence from two groups that assayed for antidiuretic hormone [15,16]. Hohenegger and colleagues assayed antidiuretic hormone in 11 patients meeting the standard tests of brain death who had clinical manifestations of central diabetes insipidus and found normal-to-increased levels in all 11 cases, effectively excluding the diagnosis of central diabetes insipidus.

This residual neurohormonal regulation is the most troubling of the three forms of functioning for three reasons. First, it is apparently found in most patients presumed to be brain dead using the standard tests. Moreover, this residual neurohormonal regulation clearly represents functioning and not merely activity. As noted above, the definition of functioning offered by the President's Commission was "organized and directed cellular activity," and this regulation certainly meets that definition. Bernat [17] proposed that only clinically observable (as opposed to measurable in the laboratory) activity that contributes to the functioning of the whole organism counts as functioning. In another report [18], he has suggested that only neuronal activity that executes the functions of the organism as a whole counts as functioning. A failure of neurohormonal regulation of antidiuretic hormone secretion certainly presents itself clinically at the bedside, and the preservation of that regulation is certainly essential to the functioning of the whole organism; therefore, neurohormonal regulation is functioning, even according to the most demanding accounts of functioning, and not merely activity. Finally, it is a component of the integrative role of the brain in regulating the rest of the body, the very role that is emphasized in the whole-brain definition of death.

Cortical Functioning

Second, electroencephalographic findings that indicate cortical functioning can continue in patients who meet the standard clinical tests for brain death. Rodin and coworkers [19] reported the case of a 71-year-old woman who met the standard clinical tests for brain death after surgery for a cerebellopontine angle tumor. Her electroencephalogram was "compatible with survival.... Except for unresponsiveness to external stimuli, it was of a type one finds in stuporous, or semicomatose patients and even showed suggestions of sleep spindles.... The electroencephalographic state would suggest that if there was cognition at all it would probably have been in the realm of dream type rather than waking reality". Deliyannakis and colleagues [20] described a patient who was in deep coma, was ventilator dependent with nonreactive pupils, and showed no response to any stimuli but had an electroencephalogram showing delta, theta, and alpha waves. Autopsy showed nearly complete destruction of the brain stem with relative sparing of the cortex. These two cases are now supplemented by a large series of 56 consecutive patients who met the clinical tests of brain death, including formal apnea testing [21]. Eleven patients had persistent electrical activity. Two patients had electroencephalographic findings resembling physiologic sleep patterns, in one case up to 168 hours after the standard clinical tests for brain death had been met. Autopsies on both patients showed extensive ischemic necrosis of the brain stem, with relative sparing of the cortex.

Thus, some unusual patients can meet all of the standard clinical tests for brain death and still have significant cortical functioning as shown by electroencephalograms. Although this functioning does not lead to any clinically apparent interaction with the environment, it clearly satisfies the definition of functioning offered by the President's Commission because it represents organized and directed cellular activity and is referred to by the medical advisors to the President's Commission as functioning [4].

Stem Functioning

Third, brain stem function, as shown by evoked potentials, can continue despite a patient's meeting the standard clinical tests for brain death. Brain stem evoked potentials, recommended by the medical consultants to the President's Commission [4] to assess "brain stem functions (italics supplied)" in certain cases, assess the functional integrity of the auditory and visual pathways, from the receptors through the stem to the cortex. Several cases have been reported in which patients met the standard clinical tests for brain death while exhibiting preserved evoked responses. Barelli and coworkers [22], using the standard clinical tests for brain death and isoelectric electroencephalography for 2 hours, reported two such cases. In the first case, a 28-year-old woman had cardiopulmonary arrest and, for a brief period, preservation of her central auditory pathways. In the second case, a 60-year-old woman had monaural persistence of some centrally originated waves up to 72 hours after determination of brain death by the standard clinical tests. Ferbert and colleagues [23] reported a case in which a 46-year-old man met the standard clinical tests for brain death. His electroencephalogram showed a slow alpha rhythm, and normal visual evoked potentials were elicited on flash stimulation.

Again, these evoked potential findings are evidence of brain stem functioning, which certainly satisfies the definition of functioning offered by the President's Commission (organized and directed cellular activities) and which was explicitly referred to as functioning by their consultants.

In summary, many patients meeting all of the standard clinical tests for brain death still have some cortical, midbrain, or stem functioning. Included in this residual functioning is some of the significant integrative functioning of the brain, the very functioning stressed by the President's Commission when providing its philosophical foundation for the whole-brain criterion of death. The issue then is deciding how to reconcile these clinical facts, the standard clinical tests currently used for determining brain death, and the intent and the philosophical foundation of the current legal criterion for brain death.

Six Possible Responses

Some investigators [17,18] have responded by redefining the concept of functioning so that some of the clinical phenomena we have described are not considered to be indicative of functioning. This strategy of redefinition does not work. In part, this is because neurohormonal regulation, the most prevalent of the clinical phenomena we have described, represents functioning according to these redefinitions. For example, neurohormonal regulation constitutes clinical functioning (one of the redefinitions) because its absence is strongly suggested by clinical examination. More crucially, it is because, as Veatch [24] has pointed out, no conceptual or moral basis exists for these redefinitions, so "holders of this view are already on a precarious slippery slope with no principled way to distinguish neurologic integration outside the brain from that inside the brain, and no obvious difference between one set of functions and another".

We consider six responses, each of which has certain advantages and disadvantages. We ultimately reject all of them in favor of an alternative solution that we find more satisfactory.

Too Few Exceptions

The first suggestion claims that we can ignore the problem because the discrepancies are found in only a few cases. Given that this is so, we should see the discrepancies simply as a reminder that the best clinical tests do not work in every case and that, in this imperfect world, we must settle for tests that work in the overwhelming majority of cases. There is one major difficulty with this suggestion. The evidence that we have described shows that neurohormonal functioning (which is the clearest example of residual functioning) is found in a significant number of cases after the standard clinical tests for brain death have been satisfied.

The Consensus Works

The second suggestion claims that we can ignore the problem because of 1) the pragmatic success of the current consensus and 2) the fact that no dissonance exists between the actual language of the current legal criterion (as opposed to its intent) and the standard clinical tests because the statute refers to "accepted medical standards" for determining brain death.

There are two major difficulties with this second suggestion. If we maintain the whole-brain criterion of death while ignoring clearcut examples of residual functioning, we make it difficult to respond to such advocates of the higher-brain criterion as Veatch [24], who call for disregarding all noncortical functioning. As Youngner [25] recently noted, the best argument for the higher-brain criterion is that the current consensus represents "a superficial and fragile consensus". Moreover, as he also notes, summarizing his earlier data [26], the fragile nature of the current consensus is responsible for great confusion about brain death among health care professionals involved in organ transplantation and "may be one of the factors impeding effective communication with families about their option to donate organs" [25]. Both of these problems indicate the difficulties that one encounters when one pretends that real problems do not exist.

Adding Tests

The third suggestion resolves the problem by adding additional tests to the standard clinical tests. As Barelli and coworkers have suggested [22], we could add a negative auditory evoked potential test before declaring patients brain-dead. More important, we could test for neurohormonal functioning. But there are prices to be paid for following this suggestion. First, the various envisaged tests and the resulting prolongation of the determination of death are expensive and their use as standard parts of the testing for brain death would add to the costs of an already overburdened health care system. Second, organ procurement would be hindered because more organ deterioration would occur while awaiting the satisfaction of the strengthened tests. Both of these problems would be worsened by continued technological advances. As new tests of brain functioning are developed, we would be forced to add them to the standard clinical tests, worsening both of the problems.

Poor Prognosis

The fourth suggestion, advocated by British investigators such as Pallis [27], resolves the problem by claiming that the satisfaction of the standard clinical tests means that the stem has ceased functioning, that no consciousness is therefore possible because of the destruction of the reticular activating system, and that asystole will occur within days. There is, however, one major difficulty with this "brain stem death" suggestion. Neither of its legitimate points ensure that the criterion of whole-brain death has been met. That there is no consciousness present simply means that the higher-brain criterion has been met, not the whole-brain criterion. That asystole will occur within days means only that the patient will be dead on all accounts within days; it says nothing about whether the patient is dead now.

The best way to understand the suggestion provided by Pallis [27] is to see it as offering another criterion for death, the "brain stem" criterion as opposed to the higher-brain criterion and the whole-brain criterion. The trouble is that these other criteria are supported by the justifying definitions presented earlier in our report, but no analogous definition of death has been developed to justify this brain stem criterion.

Only Respiration Counts

The fifth suggestion, advocated by the Israeli Chief Rabbinate in its recent decision to allow heart transplants [28], is a variation on Pallis' suggestion. According to this suggestion, because patients meeting the standard clinical tests of brain death have irreversibly lost the capacity to attempt to breathe on their own as a result of the destruction of their brain stems, they are dead because part of the classic criterion for death (irreversible cessation of spontaneous respiratory function) is met. The fact that they have continued functioning by other parts of the brain (for example, hormonal regulation) and by other parts of the body (for example, continued circulation) is therefore irrelevant.

The problem with this approach, as with Pallis' approach, is its lack of a justifying definition. It cannot appeal to the classic definition because the continued circulatory functioning means that a permanent cessation of the flow of vital bodily fluids has not occurred. This approach has no other justifying definition. It lacks any grounding except for those, such as the Israeli Chief Rabbinate, who can ground it in a long-standing legal tradition to which they adhere.

Higher-Brain Criterion

The final suggestion focuses on the fact that the whole problem relates to functioning that is independent of consciousness. We can resolve it by adopting a higher-brain criterion for death that requires only the irreversible cessation of conscious functioning. Given that the standard clinical tests ensure that such functioning has irreversibly ceased, they are adequate to ensure that death has occurred, according to this higher-brain criterion, even if considerable brain functioning is still present. This suggestion was advocated, even before the report of the President's Commission, by such investigators as Engelhardt [29] and Veatch [30]; since the report, it has been advocated by Youngner and Bartlett [31] and by Smith [32].

This suggestion, unlike Pallis' suggestion, can be supported by a justifying definition of death--the definition of death as the permanent loss of what is essential to human beings. This could be loss of personhood or loss of consciousness. There are many different conceptions of personhood, but all, except those that identify personhood with mere biologic functioning, require cortical functioning. Alternatively, this suggestion may deny the linkage with personhood but may assert that death consists of loss of conscious activity because that activity is what is essential to humans. Green and Wikler [33] have also attempted to support that criterion by appealing to the theory of personal identity, but that attempt has been appropriately challenged [34].

The difficulties with this proposal are not new, so we review only some of them. As Youngner and Bartlett [31] themselves recognize, adopting their approach means at least a theoretical willingness to bury or cremate vegetative patients who have lost all conscious functioning but who still breathe on their own. They provide various primarily aesthetic explanations about why we might not actually adopt such a practice. Many, however, might conclude that the objection is more than just aesthetic and rests on an intuitive understanding that such patients are not dead, even if they have lost their conscious functioning. Second, this suggestion has to struggle with how to understand patients like that of Rodin and colleagues [19], who had no stem functioning but some cortical functioning. Just how much cortical death is required before a patient is dead? How can this question be resolved in a nonarbitrary fashion? Finally, as one of us has argued elsewhere [35], it is unclear why humans have to maintain conscious functioning to be alive, given that members of many species are alive without ever having conscious functioning.

A New Proposal

The problem we have identified with the current consensus about brain death is not easily resolved. We believe that this difficulty is an indication of a fundamental misunderstanding in the current consensus, one that was first identified by Morison [36] 20 years ago during the initial debate about brain death. The consensus presupposes a sharp line between life and death and tries to identify that line with one or another criterion for death. The data we have presented challenge this consensus by showing that different aspects of brain functioning cease at many different times. Thus, any sharp dichotomy between life and death based on brain functioning, although convenient and appealing, is biologically artificial. We need an approach that recognizes this fact. This is the theoretical basis for our proposal.

There is, moreover, a practical reason for such an approach. The varying criteria for brain death were developed in response to the emergence of life support systems and transplantation technology. Three basic clinical questions emerged. One question is old: When is a patient ready for the services of the undertaker rather than those of the clinician? Two questions are new: When is it appropriate to unilaterally stop supporting patients (as opposed to stopping support at the request of a patient or surrogate)? and When can organs be obtained for transplantation? The creation of the varying criteria for brain death was an attempt to answer all three clinical questions (plus many other social questions about rights, roles, and responsibilities) with a single response based on a sharp life-death dichotomy. The problem of such a single answer to all three clinical questions is as follows: With loss of brain functioning on a continuum rather than at a discrete point, choosing an arbitrary point to call brain death and using it as the basis for a single answer creates undesirable results. For example, the loss of conscious functioning is one point at which some would be willing to unilaterally withhold support but at which few would be willing to accept burial or cremation. On the other end of the continuum, irreversible cessation of all functioning of the brain, including the brain stem, is a point at which nearly all would be willing to accept burial or cremation (after discontinuation of support and the resulting asystole), but adopting that point as an answer to all three questions, in view of the data we have presented, effectively eliminates organ transplantation as a viable option and forces society to needlessly expend limited resources. These practical reasons reinforce our theoretical reasons for denying, contrary to Kass [37], that death is an event that sharply differentiates between the living and the dead and provides a single answer for several different questions.

We propose a revision in the way in which we think about life and death. Rather than struggling with the impossible task of creating a single theoretically satisfactory and practically relevant criterion of death, we propose that each of the three above-mentioned clinical questions be answered on its own merits, with the realization that the three answers are not necessarily the same. We repudiate the attempt to answer all of them with a single definition of death. Table 2summarizes our answers. Let us elaborate on the rationale for them.


Table 2. Summation of the New Approach

The difficulties with the first question, which involves the point at which care can be unilaterally withheld or withdrawn, are highlighted by the recent Wanglie case [38]. Various reasons have been put forward about why, in certain cases (such as those involving vegetative patients), medical care can be withheld or withdrawn without patient or surrogate consent. Some investigators [39] argue that care can be withheld or withdrawn in these cases because it is futile. However, if the goal of a patient or family is to prolong mere biologic life, then care even of a vegetative patient accomplishes that limited goal and is not futile [40,41]. Others [38] assert that such care is not medically appropriate, but this stance begs the question of how to define appropriate care. Attempts to solve this problem by offering a different criterion for death are not, as we have argued, supportable.

We feel that, given the finite resources available for health care, appropriate use of social resources should serve as the justification for the unilateral withholding or withdrawing of care. For example, irreversible cessation of conscious functioning is a point on the continuum where the need to rationally use societal resources outweighs the desires of some persons for unlimited care. In such cases, the question of the unilateral withholding or withdrawing of care can be answered without any appeal to a criterion for death.

Our approach, unlike approaches based on some single criterion for death, allows for the appropriate consideration of the stewardship of social resources in unilateral decisions to withhold or withdraw care.

The second question concerns the donation of organs. The shortage of available organs has led to the consideration of using organs from vegetative patients [42] and to the proposal that we use organs from anencephalic infants [43]. It might be suggested that organs can be obtained from such patients if we adopt a new criterion for death. We rejected that argument above. But we also feel that the criterion for death is not where the discussion should be centered. For us, it should center around the attempt to balance the advantage of lives saved through increased organ availability (which argues for harvesting organs in such cases) against the need for public acceptance of organ donation (which may require forgoing harvesting organs in such cases). We feel, in view of these considerations, that the combination of irreversible cessation of conscious functioning with apnea is the appropriate point on the continuum for organ harvesting.

This is, in fact, close to the point at which we currently harvest organs, using the whole-brain criterion and the standard clinical tests. Our suggestion emerges from neither a new criterion for death nor some resolution of the dissonance between the whole-brain criterion and the standard clinical tests but from a practical attempt to balance saving lives and maintaining public acceptance of organ transplantation.

We feel that the question of when the patient is ready for the services of the undertaker involves a tradeoff between concern for family sensitivities and concern for preserving social resources. In view of the answers we have provided, the tradeoff is made easier. If medical care, including artificial hydration and nutrition, is unilaterally withheld or withdrawn, the vegetative patient will satisfy the classic criteria of irreversible cessation of respiration and circulation within 7 to 14 days, whereas the patient who is in addition apneic will satisfy the criterion within an hour. Little is to be gained in terms of conserving social resources by using the services of the undertaker before the classic criterion is met because the social costs of minimal care are relatively low and do not outweigh respecting the intuitive social feeling that breathing bodies should not be cremated or buried. This approach to the third question is advocated not as a theoretical account of death but as a practical solution to a balancing problem.

Each of these answers to the three questions has been widely advocated or adopted; what we have provided is a theoretical basis for combining them into one systematic approach, which has been lacking until now. We believe that such a theoretical basis is required for these proposals to be accepted by clinicians, ethicists, lawyers, and reflective members of society at large. We feel that medical care, including artificial nutrition and hydration, can be unilaterally withdrawn from vegetative patients. Organs may be harvested from eligible donors when the standard clinical tests are satisfied. In all cases, however, the undertaker's services should not be used until asystole occurs. Each of these key clinical decisions should be made at a discrete point, which we have justified above as the relevant point for making that decision; however, the point in time for each decision will not be the same because no sharp dichotomy exists between life and death. The possibility of combining these three positions rests on accepting Morison's insight that the sharp dichotomy between life and death is biologically artificial because death is a process rather than an event [36].

Acknowledgments: The authors thank Robert Arnold, MD, and Stuart Youngner, MD, for advice and support.

From Baylor College of Medicine, Houston, Texas.
Requests for Reprints: Amir Halevy, MD, General Medicine Section, Ben Taub General Hospital, 1504 Taub Loop, Houston, TX 77030.

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