I reported the other day that Nature editorialized in favor of loosening the rules to allow living patients to be killed for their organs (more about which, soon). And now, we see more advocacy for lethal medicine in The Journal of Medical Ethics, an international publication. From the article by Dr. F.G. Miller (No link, here’s the abstract):
Revisiting the still-provocative essays of Jonas on brain death and organ donation helps in mapping present and future ethical and policy options. Four options seem most salient. First, we can follow the lead of Jonas by adopting a stance of deontological rectitude that abandons vital organ procurement from brain-dead, but still-living patients. This position is logically tidy and unassailable if its major premise is endorsed: (1) doctors must not kill patients; (2) brain-dead patients are alive; (3) procuring vital organs from brain-dead patients would cause their death; therefore, (4) this practice is wrong and must cease. However, the validity of the first premise is debatable; and if applied consistently, it would have drastic consequences. For not only would it put a stop to the life-saving practice of vital organ transplantation using the organs of brain-dead individuals; it also arguably would rule out the routine practice of deliberately stopping life-sustaining treatment, assuming the reasonable, but unorthodox, view that this practice involves causing death.
Amazing. For years bioethicists have said removing unwanted life support isn’t killing. And they are right, since death comes from the underlying disease. But now, it is because we want more organs? This is surreal.
Here is what is going on: The very crowd–or better stated, their successors–who assured us that brain death was dead, are now saying it isn’t. And the reason for both arguments is the same–to increase the supply of organs. But if brain dead isn’t dead, the only ethical answer is to stop killing patients, not find new ones to terminate.
Miller goes through some other possible scenarios, for example, suggesting that people have a time limit on life support, which would permit killing for organs once their time was up:
A second position attempts to justify vital organ donation while maintaining (at least nominally) the dead donor rule by appealing to a distinction between the death of the human being and the death of the biological organism. According to this position, Jonas is right that the brain-dead patient is biologically alive; however, what matters ethically with respect to vital organ procurement is whether the human being has ceased to exist. In this ‘‘higher brain’’ position, the permanent loss of consciousness is regarded as the death of the human being. Once human life has ceased, stopping life-sustaining treatment is appropriate (or imperative), and there can be no ethical objection to extracting vital organs beforehand.
Like heck there can’t! Miller then suggests a third possible approach:
A third position justifies vital organ donation while retaining the traditional cardiopulmonary criteria for determining death by biting the bullet of abandoning the dead donor rule. As suggested above, this position sees vital organ procurement from ‘‘brain-dead’’ but still-living patients as exposing them neither to harm nor violating their rights as long as it is connected with a previous plan to stop life-sustaining treatment and proper consent, both for stopping treatment and organ donation. Stopping life-sustaining treatment when justified is a legitimate act of causing the patient’s death; procuring vital organs before treatment withdrawal is justified on essentially the same ethical grounds of self-determination and nonmaleficence.
Miller also notes that we could keep the status quo, that brain dead patients are dead, for which he says there is “no plausible and coherent [philosphical] account.”
This blatant bait and switch tactic has been used in bioethics for decades to undermine the sanctity and equality of human life. (We should only dehydrate those in PVS/But if the seemingly PVS aren’t really unconscious, all the more reason to dehydrate because they are suffering, etc.)
In the true bioethics tradition of proposing radical changes, but hedging to keep such advocacy from coming back to haunt, Miller then concludes with telling us what he really wants (in my italics):
Where do we go from here? We face an unsettled and unsettling situation characterised by the moral imperative to continue vital organ transplantation, the entrenched norm that doctors must not kill, and the increasingly transparent fiction that the brain dead are really dead. In at least the near future it is probable that we will continue to muddle through. In the longer run, the medical profession and society may, and should, be prepared to accept the reality and justifiability of lifeterminating acts in medicine in the context of stopping lifesustaining treatment and performing vital organ transplantation.
In other words, Miller thinks we will one day agree to kill for organs. I disagree. Miller’s prescription will destroy what little public faith remains in the organ transplant sector. That is why I intend to cast as bright a light on these articles as I can: It is the best way to prevent killing for organs ever from happening. since American people simply won’t stand for it. This, in turn, will help retain the necessary public support for organ transplant medicine.
Oh, and considering the ongoing debate how the weak and vulnerable would fare under Obamacere, here’s an interesting tidbit: Miller is a bioethicist at the National Institutes of Health.
October 3rd, 2009 | 4:46 pm
Wesley, do you have a link to the article by Jonas that he is talking about?
October 3rd, 2009 | 5:26 pm
No. Sorry.
October 3rd, 2009 | 5:39 pm
Amazing. For years bioethicists have said removing unwanted life support isn’t killing. And they are right, since death comes from the underlying disease. But now, it is because we want more organs? This is surreal.
But the groundwork for this was laid a long time ago, right? And James Rachels (in)famous article against the killing/letting die distinction was published in 1975.
October 3rd, 2009 | 6:21 pm
Dr. Smith,
The trust you invest in the nature of the American people reflects ever so well upon _your_ nature, but I’m not so sure that it’s warranted by the “facts on the ground.” I can’t tell you how fervently I hope that my suspicion is a reflection of my cynical, pessimistic nature, and that I’m wronger than wrong.
Thank you for being a beacon of light….
October 3rd, 2009 | 6:30 pm
FWIW:
The essay Miller references is, I think, Jonas’s 1974, ” Against the stream. Comments on the definition and redefinition of death.” / _Philosophical Essays_, written in answer to the Harvard Committee’s 1968 report. A quote:
“We do not know with certainty the borderline between life and death, and a definition cannot substitute for knowledge. Moreover, we have sufficient grounds for suspecting that the artificially supported condition of the comatose patient may still be one of life, however reduced—i.e., for doubting that, even with the brain function gone, he is completely dead. In this state of marginal ignorance and doubt the only course to take is to lean over backward toward the side of possible life.”
October 3rd, 2009 | 11:43 pm
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October 4th, 2009 | 8:46 am
If you don’t want to be an organ donor, the best way to protect your rights is to sign up at DoNotTransplant.com. Organ procurement organizations in most states are required by law to check our online registry before harvesting anyone’s organs. If they find your name on our registry, they’re legally barred from taking your organs.
No other registry in the country will record your decision not to be a donor. State donor registries will literally not take “no” for an answer.
October 4th, 2009 | 11:11 pm
I’m no expert, I just had to do a lot of thinking after experiencing he Nancy Cruzan case here and another where a hospital fought parents to declare a boy dead (after a medical mistake) despite his monitor showing a rise in his blood pressure when his mother spoke to him. The hospital claimed he was only alive because of his blood pressure medicine. The headline in the newspaper after he died said “Brain dead boy dies on life suppot.” Try that one on for size. He “died” one day when the mom was gone and the hospital claimed “a crazy patient” from next door came and ripped out his feeding tube.
Anyway, it got me thinking and… Well, we do know that we could dig up an actually dead person and put them on all the medical paraphanalia in the world and we would still not be able to get ANY measurable signs of life, much less warmth or flexibility. So one who is NOT really dead still retains, if not on without help, at least what we might call “life ability” in response to medical aid, which is in fact, different than dead, and given that they aren’t really dead, isn’t it their right to what is left of their life, not to mention the possibility of improving? I’m not saying I know the answer in every situation, but I’m just saying…
Does that justify making them really dead by taking their organs, without which no machine or medical intervention stands a chance of retaining life or life ability?
Perhaps this boldness they are showing in the article explains the boldness with which our local Center for Practical Bioethics has decided to start pushing donating oneself for research on their Advance Care Directive questionnaire and the ACD itself, right next to where you document how you want to die.
October 4th, 2009 | 11:23 pm
They cannot harvest your organs without your consent or the consent of whoever holds your power of attorney. If you’re concerned about it, write a living will to say that you don’t want your organs harvested while you’re still alive.
Speaking for myself, I’ve happily signed my organ donor card. If there’s anything left useable after I’m gone, and I include brain death in “gone,” I hope to God they give it to someone who needs it. Eyes, liver, kidneys, blood, they want it, they got it. Silly and selfish to prolong other people’s suffering if I have the ability to help them out.
October 5th, 2009 | 9:50 am
Cruzan was a different case, though, because she breathed on her own and was not on any construal legally brain dead. Legal brain death requires, among other things, that the person not be able to breathe unassisted.
But it is interesting to see the bizarre inconsistencies in language regarding those who have been declared to have truly suffered brain death. I was googling this yesterday and found actual protocols, medical protocols, in official medical language, that referred to “the patient” over and over again even when referring to a situation where total and complete whole-brain death had been declared! This is odd, to say the least. It would be no more than a sort of necessary linguistic oddity of the situation, though, if there weren’t mounting evidence that, at a minimum, it is very difficult to declare total brain death with even high confidence. For example, I gather that some non-negligible percentage of patients declared totally brain-dead maintain temperature, which means that the diagnosis _must_ be wrong, because the hypothalamus is required for temperature maintenance.
October 5th, 2009 | 5:53 pm
“(No link, here’s the abstract):”
The article was fully available on the link to the right under “This Article”.
October 5th, 2009 | 9:44 pm
It is truly tragic that organ transplantation has gone in this direction. It really does have the potential to bring hope and joy out of tragedy. But, when people in that field or in the bioethics field act in the ways indicated by this article, it makes potential donors very wary. This is something I continue to be conficted about. I had always planned to become an organ donor, but I planned this at a time when I thought that my doctors would not judge my life as being forfeit based on it’s percieved “quality.” I trusted my doctors not to “cut corners” and only harvest my organs if I were dead. Now, I do not have such trust.
October 5th, 2009 | 9:56 pm
Another thing that bothers me is this growing sense of entitlement that seems to surround organ donation, ie, that if you are dead, than some person is morally entitled to your organs and you/your family are doing something wrong if organ donation is not carried out. Usually, hard cold rationale is used to make this argument: that you are dead, and your family is just clinging to false hope if they don’t accept the diagnosis of brain death right away, or, even that people in a PVS state should be used as organ donors because they are “dead” too. Well, who says that the otherwise healthy person waiting for a transplant has any right to live at the PVS person’s expense? Why are they entitled to the PVS person’s organs just because all of their other faculties are functioning correctly? When it comes down to it, a life is a life and a death is a death and both people’s lives are equally significant. Our culture has purposefully forgotten this.
October 6th, 2009 | 2:07 am
To Padraig’s comment: My understanding is that in Washington state (and perhaps elsewhere?), there is actually a presumption of consent to organ donation and that to avoid procurement of one’s organs/tissue after death (or after “brain death”?), one has to have OPTED OUT via some state registry. There may be some exceptions to this – potentially including explicitly excluding organ donation on an advanced directive but many people don’t complete those ahead of time and count on their next of kin to be able to speak for them (like your typical teenager, 20-something year old, etc.) Expecting people to opt out–before one’s unexpected death at a young age–is unrealistic and thus seems unfair. Most unfair of all is the likelihood that fewer than 1 in 100 people in this state even know a thing about this! [It's possible that the regulations here have changed in the last couple years, though I doubt it; the original regulation was only put in place maybe 4 years ago.]
October 6th, 2009 | 1:54 pm
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October 6th, 2009 | 3:49 pm
Patricia, I can find no reference that shows any state in America uses an “opt-out” system such as you describe. All states have their own system but they’re subject to the federal National Organ Transplant Act of 1968, which demands some kind of written consent on the part of the donor.
Also, some states allow the living relatives to overrule the written consent if the donor is incapacitated.
All references I’ve seen indicate that there is a horrendous shortage of donated organs, and people are dying every day as a result. The sort of hysteria that Wesley and his ilk are stirring up does absolutely nothing to help that.
October 7th, 2009 | 5:55 pm
I have been a close witness to two deaths and the organ donor process. Both situations creeped me out and made me uncomfortable with the whole idea, though I had previously been more friendly toward it. In the second case the organ donor rep threatened a law suit on the grieving mother if she didn’t hand over her son’s body. They definitely imply that they have a right to the organs, and that you are some kind of cruel monster if you don’t agree. There is no concept of “gift”.
October 8th, 2009 | 12:47 am
Here in KC a couple of years ago a TV reporter called me to report that one of their cameramen had a child in ICU and had become aware of a situation. A 14 year old had been shot accidently and within 24 hours a trauma surgeon was badgering the family for organ donation. She said to the family “We have a 14 year old heart here and 14 year old lungs,” to which the mother said: “His name is Michael.” Then the mother said, “We’ve seen what you can do, let’s see what God can do.” The doctor said “Haven’t you heard? In this century God is dead.” The hospital told the family they were going to turn off life support unless ordered not to by a court. The family, which was very poor, said fine, see you in court. The judge ruled in favor of the family and told the public hospital to back off. The family was very distraught. Our pro-life group got involved, but not before I called a doctor I knew at that hospital to ask him if that trauma surgeon was capable of saying what the family alleged. He said yes. We contacted a pro-life neurosurgeon who agreed to see the boy for free. Examined him for one and a half hours. Told the family he was “truly gone” and the family accepted that knowing they could trust that doctor. The family did not donate his organs. This goes to the issue of donation being a gift vs. an obligation, especially an obligation demanded by a snotty, demanding, guilt-inducing surgeon within 24 hours of an unexpected tragic accident to a young man. And, I have heard of an “opt out” only donation law. I think it was Iowa. Perhaps it was only proposed and didn’t pass, but I do remember it being attempted or proposed.
October 31st, 2009 | 8:34 am
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November 5th, 2009 | 2:38 pm
Given that earthly life is not all there is and is actually a preparation for eternity, it’s high time to accept the reality that one needs to seriously prepare for rendering an account of one’s life before God in the event of one of one’s own unpaired organs starting to break down. Unpaired organ transplantation requires killing another person for the desired organ, pure and simple, so one is not entitled to an unpaired organ (heart, complete liver, etc.) transplant.
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