To get organs, thirty years ago, doctors decided to make the criteria of “Brain death” the new criteria for death.

This is because a valid diagnosis of complete brain death means that the person’s body is being kept alive with machines.

But with the push to get more and more organs, there is now a push to change the criteria to include “Cardiac death”.

Well, that’s the old fashioned way, isn’t it?

Except that this means taking a person that the doctors decide only has a little brain function (so is NOT brain dead), and then giving oodles of sedatives (so the person feels no pain) and then taking them off the machines until they die.

This is a bit more problematic: since if you didn’t sedate the person, maybe the person would continue to live, even without machines. There is one case in California where a person kept living so his doctor kept giving huge doses of sedatives because dang it the man wouldn’t die.

Predicting who will die and who will live (although they might live with brain damage) is not an exact science, and in medical school, we always went all the way with resuscitating kids, because it was know that the cells of a baby’s brain was “plastic” and that you would see remarkable recoveries in some of these kids–although again a lot of these kids would end up with retardation or cerebral palsy from the brain damage.

So there are very real questions on the “Heart death” criteria used by Denver doctors to take hearts from sick infants.

One, the kids were all under five days of age, when the “edema” of brain damage is at the maximum and prognosis is less easy to figure out. EEG, and neurological exam might not reflect the ultimate prognosis. This is especially true in kids who received medicines for seizures or sedatives so they were “comfortable”.
Two: All the kids were suffering from “birth Asphyxia”, which means if the kids did live with severe brain damage, their doctors could all be sued for lots of money.

Three: The children received “analgesia” as part of comfort care with death; but analgesia will depress the respiratory reflex, so the kids were more likely to die.

Despite the “comfort” analgesia,it took the kids 18 to 30 minutes until the hearts stopped…and then the doctors waited 1.25 to 3 minutes to make sure the heart didn’t restart before taking out the heart.

A lot of people are upset about this short interval: My complaint is that 30 minutes to die even after “comfort sedation” was given suggest the kid was able to breath or gasp…

The real question is would these kids have lived if given full medical care? Was the care “Futile”? and if so, what were your criteria for deciding that?

I’m not alone in worrying about this:

Those concerns were echoed by Dr. Steven LeFrak, director of the humanities program in medicine at the Washington University School of Medicine.

“While it sounds very erudite for the authors to refer to withdrawing ‘futile’ care in their population, what exactly this means is neither defined by them nor is there a generally accepted meaning of this term in medical or medical ethics circles,” he said.

“As a result of these problems, this paper is more disturbing than groundbreaking. Perhaps that is because in fact the ground it breaks, the elephant in the room if you will, is the elephant of taking vital organs from living patients so that others may live.”

The “unspoken” ghost in the entire discussion is the ethical decision that there is a decision here that fighting for the life of a kid who will probably either die or live mentally and physically disabled isn’t worth it. So since we aren’t going to waste money keeping the kid alive, why not use his organs?

“Once it is determined that it will be acceptable for a family to have artificial life support discontinued, not using viable organs wastes precious life-saving resources,” said Rosamond Rhodes, director of bioethics education at Mount Sinai School of Medicine. “Using the organs to preserve life has to be ethically better than wasting them, particularly when it costs the lives of other babies.”

All of which ignores the elephant in the room in the discussion: Was the decision made because the kids wouldn’t live, or because their chance of living was small, and their chances or complete recovery even smaller, so why keep the kid alive if he’ll be retarded?

This can be ethical: Catholics argue that using extraordinary means to keep a person alive is an ethical option, but not mandated.

But it’s quite another thing to decide to withdraw extraordinary treatment to get organs out. Indeed, ethically the altruism (to help another child) interferes with the rights of the child involved, since parents might be more willing to stop treatment if “something good” could come from their child’s death…especially when doctors tell horror stories of how horrible their child’s life would be…

Finally, there are legal problems with what was done here:

State laws stipulate that donors must be declared dead before donation, based on either total loss of brain function or heart function that is irreversible. Some commentators contended that the Denver cases didn’t meet the rule since it was possible to restart the transplanted hearts in the recipients.

“In my opinion, it’s an open-and-shut case. They don’t have irreversibility, and they don’t have death,” said Robert Veatch, a professor of medical ethics at Georgetown University.

And if you think the “slippery slope” isn’t an argument here, notice this:

But others argue the definition of death is flawed, and that more emphasis should be on informed consent and the chances of survival in cases of severe brain damage.

That assumes doctors are infallible in their advice…an assumption that a lot of people just don’t think is true.

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Nancy Reyes is a retired physician living in the rural Philippines. Her website is Finest Kind Clinic and Fishmarket.

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