Should organs from patients in permanent vegetative state be used for transplantation? International Forum for Transplant Ethics

Brain death

Since the Harvard report of 1968, the concept of brain death has become widely recognized throughout the world. Most developed countries have accepted brain death as constituting death of the individual, and allow such patients to be used as ‘heart-beating’ organ donors. Although the US and most other countries accept a ‘whole-brain’ definition of brain death, the concept of brainstem death has been adopted in the UK. This article describes the UK diagnostic criteria in detail, and compares these with the criteria used in other countries. Management of the brain dead organ donor is described, and controversies relating to the concept of brain death are also discussed.

Organizing Death: Remembrance and Re-collection

Much writing on death contrasts its existential significance with our strategies of avoidance. These strategies, it is argued, are manifested in the practices and institutions of modern life and have led to the sequestration of death. This is felt to have separated us from something vital, a belief that seems to, implicitly or explicitly, rest upon claims of (lost) authenticity. But this seems a rather cool account that somewhat conveniently disposes of the dreadful effects of death and is at odds with our sense of its lurking inevitability. The tension between death as both sequestered and shattering is therefore the focus of this paper. It recognizes that death is both absent and present and that this condition is inadequately conveyed by its disposal in the modern organizations of sequestration. Rather, it sees death as being temporarily dispersed through a network of different relations. However, this network is unstable; what was (re)collected may be disturbed. Consequently, I show how our engagement with death is affected by this organization; death ‘moves’ us because of movement in this network. Therefore, I have two propositions: (i) that controlling and concealing death involves a process of organization and (ii) that death erupts when this organizing breaks down.

Imminent brain death: point of departure for potential heart-beating organ donor recognition

PURPOSE

There is, in European countries that conduct medical chart review of intensive care unit (ICU) deaths, no consensus on uniform criteria for defining a potential organ donor. Although the term is increasingly being used in recent literature, it is seldom defined in detail. We searched for criteria for determination of imminent brain death, which can be seen as a precursor for organ donation.

METHODS

We organized meetings with representatives from the field of clinical neurology, neurotraumatology, intensive care medicine, transplantation medicine, clinical intensive care ethics, and organ procurement management. During these meetings, all possible criteria were discussed to identify a patient with a reasonable probability to become brain dead (imminent brain death). We focused on the practical usefulness of two validated coma scales (Glasgow Coma Scale and the FOUR Score), brain stem reflexes and respiration to define imminent brain death. Further we discussed criteria to determine irreversibility and futility in acute neurological conditions.

RESULTS

A patient who fulfills the definition of imminent brain death is a mechanically ventilated deeply comatose patient, admitted to an ICU, with irreversible catastrophic brain damage of known origin. A condition of imminent brain death requires either a Glasgow Coma Score of 3 and the progressive absence of at least three out of six brain stem reflexes or a FOUR score of E(0)M(0)B(0)R(0).

CONCLUSION

The definition of imminent brain death can be used as a point of departure for potential heart-beating organ donor recognition on the intensive care unit or retrospective medical chart analysis.

Brain death, states of impaired consciousness, and physician-assisted death for end-of-life organ donation and transplantation

In 1968, the Harvard criteria equated irreversible coma and apnea (i.e., brain death) with human death and later, the Uniform Determination of Death Act was enacted permitting organ procurement from heart-beating donors. Since then, clinical studies have defined a spectrum of states of impaired consciousness in human beings: coma, akinetic mutism (locked-in syndrome), minimally conscious state, vegetative state and brain death. In this article, we argue against the validity of the Harvard criteria for equating brain death with human death. (1) Brain death does not disrupt somatic integrative unity and coordinated biological functioning of a living organism. (2) Neurological criteria of human death fail to determine the precise moment of an organism's death when death is established by circulatory criterion in other states of impaired consciousness for organ procurement with non-heart-beating donation protocols. The criterion of circulatory arrest 75 s to 5 min is too short for irreversible cessation of whole brain functions and respiration controlled by the brain stem. (3) Brain-based criteria for determining death with a beating heart exclude relevant anthropologic, psychosocial, cultural, and religious aspects of death and dying in society. (4) Clinical guidelines for determining brain death are not consistently validated by the presence of irreversible brain stem ischemic injury or necrosis on autopsy; therefore, they do not completely exclude reversible loss of integrated neurological functions in donors. The questionable reliability and varying compliance with these guidelines among institutions amplify the risk of determining reversible states of impaired consciousness as irreversible brain death. (5) The scientific uncertainty of defining and determining states of impaired consciousness including brain death have been neither disclosed to the general public nor broadly debated by the medical community or by legal and religious scholars. Heart-beating or non-heart-beating organ procurement from patients with impaired consciousness is de facto a concealed practice of physician-assisted death, and therefore, violates both criminal law and the central tenet of medicine not to do harm to patients. Society must decide if physician-assisted death is permissible and desirable to resolve the conflict about procuring organs from patients with impaired consciousness within the context of the perceived need to enhance the supply of transplantable organs.

Science and society: death, unconsciousness and the brain

The concept of death has evolved as technology has progressed. This has forced medicine and society to redefine its ancient cardiorespiratory centred diagnosis to a neurocentric diagnosis of death. The apparent consensus about the definition of death has not yet appeased all controversy. Ethical, moral and religious concerns continue to surface and include a prevailing malaise about possible expansions of the definition of death to encompass the vegetative state or about the feared bias of formulating criteria so as to facilitate organ transplantation.

Irreversible apnoeic coma 35 years later. Towards a more rigorous definition of brain death?

The concept of brain death (BD) has been widely accepted by medical and lay communities in the Western world and is the basis of policies of organ retrieval for transplantation from brain-dead donors. Nevertheless, concerns still exist over various aspects of the clinical condition it refers to. They include the utilitarian origin of the concept, the substantial international variation in BD definitions and criteria, the equivalence between BD and the donor's biological death, the practice of retrieving organs from donors who are not brain-dead (as in non-heart-beating organ donor protocols), the proposal to abandon the dead donor rule and attempts to overcome these problems by adapting rules and definitions. Suggesting that BD, as it was originally proposed by the Harvard Committee, is more a moral than a scientific concept, we argue that current criteria do not empirically justify the definition of BD; yet they consistently identify a clinical condition in which organ retrieval can be morally and socially justified. We propose to revert to the old term of "irreversible coma" or, better yet, of "irreversible apnoeic coma", thus abandoning the presumption of diagnosing the death of all intracranial neurons and/or the patient's biological death. On the other hand, we think that a (re)definition of the vital status of donors identified on neurological criteria can only occur through a prior (re)definition of death, a task which is not only medical but societal.

Definitions and implications of death

Understanding the legal definition of whole-brain death is imperative for hematologists and oncologists who deal with end-of-life patients on a regular basis. At present, only whole-brain death in which there is no function of the upper brain or brain stem is legally recognized as legal death. Those advocating expansion of the current definition of death to encompass patients with higher brain death and brain-absent anencephalic infants cite increasing the organ pool and decreasing unnecessary treatment and costs as benefits. Those advocating a more narrow definition of death typically fear being misdiagnosed or prefer the traditional cardiopulmonary definition for personal and religious reasons. As medical technology advances, offering new hope to both the critically injured patients who might be potential donors and to those patients in need of donated organs, the definition of death will continue to be a topic of passionate debate.

Ethical issues in transplantation: living related donation in the setting of severe neurological damage without brain death

The waiting list for renal transplantation has grown at an alarming rate over the last 2 decades, resulting in increased waiting times and deaths on the waiting list. To increase the number of available organs for transplantation, aggressive public education programs have been developed. The federal government has strengthened hospital regulations ensuring referral of all potential donors to organ recovery agencies, and living donor programs no longer limit donation to genetically related donors and recipients. We present a case that illustrates the complex ethical issues that are integral to the field of transplantation and the allocation of a scarce resource: a 50-year-old man who has a daughter with end-stage renal disease has suffered a severe cerebral vascular accident but is neither brain-dead nor a candidate for "non-heart-beating" donation. Given his poor prognosis, should the father be able to donate his kidney to the daughter in his compromised condition?