Thursday, April 16, 2009

Not Dead Yet

Another issue that directly impacts the end-of-life discussion is one that has been brought to the forefront by both the advancement of medical technology and a pragmatic approach to the value and "dignity" of human life -- organ donation.

Both Anita Kuhn (Touchstone, October 2008, p. 46) and (Salvo, Spring 2009, p. 33) provide similar, complementary reflections on this topic and the moral questions that it brings to bear on the value of human life.

If you are anything like me, you may have considered it an altruistic act to check the little box on your driver's license form that designated you as an "organ donor." It could well be -- but you need to understand a few things before you do so ... like what being an organ donor entails. The catch is that dead organs are useless for transplantation. The few minutes that you wait to determine that someone (or you) is indisputably dead may be hugely meaningful in defining the difference between waiting on a person's death -- and killing him.

Here's what I mean.

Traditionally, organ donation has assumed that the donor in question be dead. Now, this may seem like an obvious prerequisite to you as a potential donor but it is not so clear-cut to the physician who is looking to harvest an organ. The key word here is "dead." What does it mean to be dead?

It used to be that the criteria for determining death, cold, blue and stiff, was pretty simple. But, as medical technology advanced to the point that organ donation became more viable, transplant medicine demanded that vital organs not be degraded beyond a useful state -- a state that "cold, blue and stiff" often violates. So, in 1968, a Harvard committee proposed a more updated definition of death based on the brain dead criteria that has become a part of the national lexicon.

Though we may cavalierly refer to those who annoy us as having already met this criterion while still seeming to be completely alive, the humor in that comparison vanishes when the actual definition of a patient with "devastating neurological injury" comes into play. The reason being that those who meet the brain dead criteria with entirely ...
intracranial [injuries may] look very much alive: they are warm and pink; they digest and metabolize food, excrete waste, undergo sexual maturation, and can even reproduce ... the arguments about why these patients should be considered dead have never been fully convincing.

So, more recently, yet another definition of death has been put forward for organ donor candidates -- the notion of cardiac death that is defined as an "irreversible cessation of cardiac function." But, once again, what does that mean? Is a patient whose heart has stopped really in an irreversible state if that same heart can be transplanted into another person who goes on to live with it beating in his/her chest? As Kuhn points out, "the word 'irreversible' has [come] to be interpreted to mean 'we won't try' to resuscitate rather than 'we can't.'"

Consider this:
In March, 2008, 21-year-old factory worker Zach Dunlap of Frederick, Oklahoma, was declared dead after horrific head injuries following an ATV accident. Doctors had confirmed there was no blood flow to his brain, but just before they connected the life support to begin the [organ] retrieval process, his cousin, a nurse, got a reflex response when he scraped a knife across Zach’s foot. Dunlap later told the Toronto Star that he heard the doctors declare him dead! It was obviously a simple misdiagnosis -- but how often does that happen? Of course, if the patient has vital organs cut out of him first, who would know?

The upshot of this discussion is that you must understand what organ donation entails before you or someone you love makes the decision to be an organ donor. You must understand what criteria the attending physician is applying to your case before they decide whether or not the donor is "dead enough" for their taste. Remember, the removal of vital organs kills the patient and doctors today are doing just that simply because they have the patient's permission. Those of us who value human life from beginning to end must be very careful before we grant anyone that permission. In today's world, if a doctor is taking one patient's organs to use on another patient, he/she is doing so precisely because the first patient is not really dead yet.

The ethical tradeoff is always given as a balance between saving one life and the higher moral objective of making multiple organs available to allow that many other lives can be saved. But the removal of vital organs is a completely different question than the more common debate about withdrawal of life support. The former is a "surgical invasion of the patient and a directly lethal action" while the latter involves only the "removal of something exterior to the patient."

Offering another the vital organs that may prolong their life is an admirable goal. But ending another valuable human life to do so must be done with full awareness of the issues in question.

Think before you check the box.

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