'Brain Death' Debate Sets Off Ethics Alarm Bells
BRAIN DEATH' DEBATE SETS OFF ETHICS ALARM BELLS
by Mary Meehan
Special to the Register
THE FACTS: President Clinton's proposed National Bioethics Advisory Commission could reopen the debate over "brain death" and organ transplants.
THE IMPACT: Putting a spotlight on the transplant practice might increase the public's distrust of doctors involved in it.
"I'VE HEARD some very well-educated people express remarkable fears about what will happen to them," said Professor Thomas Murray of Case Western Reserve I University. He was referring to "public distrust" of medical professionals who recover human organs for transplant.
The issue could be revisited by the National Bioethics Advisory Commission that President Clinton plans to appoint this year. His Office of Science and Technology Policy is still making plans for the commission, with possible members suggested by medical and other groups.
At least two people being considered for the commission would like to redefine the concept of "brain death"-or simply make a blanket exception in current law- so transplant surgeons can take hearts, livers and kidneys from newborn anencephalic babies while the babies are still alive.
One potential commissioner, Dr. Robert Truog of Harvard Medical School, also believes that surgeons should be able to take organs from some people in "persistent vegetative state" (long-term coma).
Murray, a bioethicist recommended for the national commission, said that "I'd probably be on the careful side with those proposals," but that commission discussion of them "is probably appropriate. It's not as if we can pretend that people aren't talking about these issues."
An anencephalic child is missing a large part of his or her brain, but has at least a brain stem to support breathing. In the past, most anencephalic babies were miscarried or stillborn or died shortly after birth. Now many are aborted when prenatal testing reveals their condition.
Some European transplant surgeons have used organs from such aborted children.
There have been American attempts to take organs from anencephalic children who were born alive but later declared "braindead." Some transplant supporters want to take organs from such babies without even waiting for a diagnosis of brain death. Critics say this is clearly homicide. If it's accepted, they predict, it will be extended to babies who are born with other lethal handicaps.
Professor Richard Zaner of Vanderbilt University, one of the many academics suggested for the bioethics commission, has defended taking organs from anencephalic infants because, he claimed in a 1989 article, "these infants are neither actual nor potential persons."
Truog of Harvard and Professor John Fletcher of the University of Virginia, writing in the New England Journal of Medicine in 1989, advocated taking organs with parental consent as soon as the diagnosis of anencephaly is confirmed. They suggested that the babies wouldn't feel pain from the surgery, but remarked that "whether they or even brain-dead patients perceive pain is fundamentally unknowable."
Commenting on a similar proposal in 1992, Dr. Joyce Peabody of the Loma Linda University Medical Center told American Medical News that it "would mean that you would be removing hearts from babies that breathe, suck, kick and cry."
Rita Marker, director of the International Anti-Euthanasia Task Force, recently told the Register that people who advocate changing the law to permit this are "scavengers making what they want to do appear to be acceptable."
Truog and Professor Daniel Wikler, a bioethicist also suggested for the commission, both criticize the current standard of "whole brain death" that must be diagnosed before organs are taken. They have suggested replacing it with a "higher brain" standard, so that permanent loss of consciousness would be defined as death.
Truog believes that people should be free to reject the application of brain-death standards to themselves-and also free to provide that their organs may be taken for transplant if they should ever be in "permanent vegetative state."
In a 1988 article advocating death pronouncement for people in such a state, Wikler said that after pronouncement of death a living body would remain, "and its disposal is bound to raise questions." He suggested killing it by lethal injection instead of by organ removal.
While many proponents of a "higher brain" standard want more organs for transplant, they realize that reopening the debate on brain death could increase the public distrust that Murray mentioned. Some people already decline to sign organ donor cards for fear that their organs may be removed before they're really dead. Reasons for their fears include:
* Newspaper accounts of transplants often appear contradictory, saying that patients were declared brain-dead yet kept on "life support" until their organs could be taken-- or suggesting that someone died twice;
* Even some transplant supporters make a distinction between "brain-dead" and "dead- dead";
* There have been medical experiments on some "brain-dead" people; for example, the Washington Post reported that in 1981 Philadelphia surgeons implanted an artificial heart "into the functioning bodies of five brain-dead people to test ways to implant the device," and in 1988 the Post reported that New York doctors "kept the heart of a dead man beating to test a new drug";
* There have been proposals to keep "neomorts" on life support indefinitely so their bodies can be used for medical experiments or as organ sources.
Although brain death currently is supposed to mean total loss of function of the entire brain, there are many different sets of criteria used to diagnose it. Some people diagnosed as brain-dead have regained consciousness.
When "organ donor" patients are declared brain-dead, they are kept on ventilators and treated as intensive-care patients until their organs are removed. Their bodies are warm; their hearts beat; they produce urine; and some receive antibiotics to prevent infection. Some are even resuscitated when - despite life support - their hearts stop beating. "Immediate resuscitation should proceed according to established guidelines" in such cases, wrote Dr. Ake Grenvik and others in a 1989 journal article. Grenvik is another potential member of the national bioethics commission.
As reported in the Feb. 5 issue Register, some people suggested for the commission support physician-assisted suicide. Rita Marker, the euthanasia foe, complained about their "Kevorkianesque leanings" and remarked that "they just say it with a bit more class" than Jack Kevorkian, the Michigan physician who has helped many people commit suicide.
More than 70 people have been recommended for the commission by medical groups and others. Included are supporters of human fetal research such as Dr. Norman Fost of the University of Wisconsin, Madison; Dr. Robert Levine of the Yale University medical school, and former Sen. John Danforth (R-MO.).
Mary Meehan is the Register's medical ethics correspondent.
Taken from the "National Catholic Register," March 5, 1995. For subscriptions contact the "National Catholic Register", P.O. Box 260380, Encino, CA 91426-0380, (800) 421- 3230.
