For millennia, religious authorities have defined death as the stilling of the heart and the absence of breath. But all that changed in the 1960s when organ transplants became medically feasible. In the wake of a Japanese surgeon being charged for a double murder for a failed attempt to transplant a heart, the medical profession put its foot down. It wasn’t long before dead patients were redefined from those without beating hearts to those who might-or might not-have cardio-respiratory function, but whose brain stems had definitely gone to God.
Brain death is the moment beyond which a patient’s brain stem-her body’s supreme regulator-irrevocably ceases to function. When professional guidelines are rigorously adhered to, it can be diagnosed with a high degree of accuracy, and its predictive powers are second to none. A correct diagnosis of brain death means a patient has virtually no chance of meaningful recovery.
But just because brain death is a useful indicator of patient prognosis doesn’t mean it’s problem-free. The dividing line between life and death matters. Death is a prerequisite for relatives to grieve, wills to be read and organs procured. But the switch to brain stem death has posed problems for clinicians and the families of critically ill patients. These problems include a mismatch between the way death is defined and palpable clinical realities (brain-dead women can gestate and give birth to healthy babies, a feat not normally associated with the dead) and between clinical practice and community attitudes.
Australian organ donation rates have remained stubbornly low despite interventions designed to lift them. Despite surveys showing high rates of public support for donation, there may be latent public discomfort with the way patients are declared dead at the bedside and, despite their warm pink skin, pre-treated as organ donors (drugs may be given and tubes inserted while the heart is still beating). In one survey 20% of families doubted whether their brain-dead relative was really dead while another found that among the reasons people give for not signing donor cards is the fear that doctors “might do something to me before I’m really dead” or might “hasten my death.”
Medicos wax indignant at the expression of such fears feeling, perhaps correctly, that their professionalism is being questioned but the truth is that we ignore such conflict-of-interest concerns at our peril. There is a conflict of interest between the establishment of a valid and consistent definition of death and the demands of organ donation programs: a conflict underlined by the involvement of doctors who work in both intensive care and organ transplantation in the establishment of guidelines dictating when death can be pronounced and organ procurement commenced.
What is the answer?
We need to accept that patients may still be alive yet eligible to donate organs, and to amend both clinical and legal definitions of death to reflect this. The Federal Government must consult broadly before developing rigorous, nationally consistent guidelines for declaring death and eligibility for organ donation.
If we really want to tackle Australia’s low rate of organ donation, medicos must stop replying to conflict of interest concerns with defensiveness and support a full and open exploration of the issue. Dissenting doctors and the public-all of us potential donors and recipients-deserve our concerns to be taken seriously and addressed.
Brain death is a convenient fiction about which medical ethicists, clinicians and community members have long expressed concern. We need to fix the problem, not shoot the messenger.
Organ Donation Can Pose a Conflict of Interest Sunday Sun-Herald (Sydney)