THE DEAD-DONOR RULE:
 HOW DEAD DO YOU HAVE TO BE?


SYNOPSIS:

    Organ transplants are only permitted when the donor is dead.
Living donors are only permitted to donate paired organs,
such as a kidney or a lung, where the donor can survive with just one.
Also living donors can donate fluids and tissues that will regenerate,
such as blood , bone marrow, & parts of livers.
All other donations are from cadavers
donors who are dead.

    However, the definition of death is open and flexible, at least to some degree.
Death might be closer to a process than an instant.
And when we are considering organ-transplantation,
it is especially important to have the organs as alive as possible,
so that the organs can resume their functions in the body of the recipient.

    Death must be declared before any cutting and harvesting begins.
Otherwise, the transplant surgeons might be accused of causing death
by removing vital organs.

    And the concepts of death must be acceptable to people who might donate organs.
If there is too-subtle a difference between being alive and being dead,
then those who must approve donations will have qualms and doubts.

OUTLINE:

1.  BRAIN DEATH

2.  COMA OR PERMANENT UNCONSCIOUSNESS

3.  PERSISTENT VEGETATIVE STATE

4.  ALZHEIMER'S DISEASE



THE DEAD-DONOR RULE:
 HOW DEAD DO YOU HAVE TO BE?


by James Leonard Park

    Here is an operating-room story no one wants repeated:
The nurse recorded the time of death as the time when the donor's heart was removed.
This is a natural-enough mistake for laypersons to make:
While the donor is lying on the operating table,
ready to have his or her organs harvested,
the heart and lungs are often still operating
probably with mechanical assistance.
Thus, some observers would say that the donor is "still alive".
But legally and medically, the donation could not go forward
until after the donor has been officially declared dead
by some doctor who will not be part of the transplant-team.

    In the case cited above, the nurse should have recorded the time of death
as whatever time the declaring doctor specified
when he or she announced that the donor was brain-dead.




1.  BRAIN DEATH

    The practice of declaring patients to be dead
on the basis of the death of their whole brains
has been well recognized in medical circles since the 1980s.
Actually the first proposal along this line took place in 1868.

    Since the beginning, there have been continual refinements
of the definition of death
and the tests and criteria that must be met
in order to declare a patient to be fully and irrevocable dead
on the basis of cessation of all brain functions.
We will not go into these technical methods of determining death.
The bibliography linked from the end of this essay
allows the careful reader to look as deeply as wanted
into the continuing controversy about just how to declare brain-death.

     But most of us will just accept that someone is really dead
when he or she has been declared to be brain-dead
by a physician who in well-versed in the necessary tests that must be used
before brain-death can be officially and legally declared.

    The definition of brain-death usually means
that all of the functions of the human brain
have come to a permanent stop.
Drowning and freezing must be ruled out,
since these ways of almost dying
show most of the same signs as brain-death.

    However, in the Western world,
brain-death has been accepted in all modern medical practice.
Laypersons do not always understand
(since they can see the body still breathing and can feel the heart still beating),
but with enough explanation most people can accept
that their loved one has now passed over into death. 

    Some states in the United States have now created laws
explicitly permitting death to be determined and certified on the basis of brain-death.
But even in states where no such change of law has occurred,
doctors routinely declare human beings to be dead
when all of their brain functions have ceased
and will never return.

    Organ transplantation has been allowed from brain-dead donors
for a number of years in places where modern medicine is practiced.
A few countries with strong folk-traditions concerning life-and-death
have not yet accepted brain-death as a definition of death.
But even countries slow to accept scientific medical practice will eventually agree:
When the whole human brain is dead, this person is dead.

    Also, the news media no longer have any problems reporting
that organs have been harvested from brain-dead donors.
At least this is true of news media in the most advanced parts of the world.




2.  COMA OR PERMANENT UNCONSCIOUSNESS


    It is somewhat more controversial to consider transplanting organs from donors
who are 'merely' in a coma or who are permanently unconscious.
Such conditions are harder to define and more difficult to certify.
Just what tests must be performed by the neurologist
to make certain that this unconscious patient will never awaken?
Sometimes people have returned to consciousness
after very long periods of deep sleep.
What if their organs had been harvested at some earlier time?
They would have died as the result of having their vital organs removed.

    So, in order to follow the dead-donor rule,
we must be 100% certain that this donor is really and truly dead.
How long will it take before modern medical practice
recognizes permanent unconsciousness as death?

    In the early days of considering this new definition of death,
it will probably only be used in those rare cases
where the patients have given approval in advance
for using this definition of death
for themselves.
If a specific patient and his or her proxies are all in agreement
that permanent unconsciousness can be certified as death,
then the doctor who is called upon to declare death
will merely have to determine scientifically that there is
no chance that consciousness will ever return to this body.

    I have given this permission in my own Advance Directive for Medical Care.
A comprehensive Advance Directive should include a definition of death.
Here is the relevant Question from my book on Advance Directives:

Question 19Which definition of death should apply to you?        152

    A.    Brain-Death.                153
    B.    Coma or Permanent Unconsciousness.            154
    C.    Persistent Vegetative State.            155

If you click the link for Question 19 above,
you will see the complete explanation.

    And my own Advance Directive is also published on the Internet:
http://www.tc.umn.edu/~parkx032/JP-LW.html
Scroll down to Answer 19.
This explains why I prefer permanent unconsciousness
to be used as the definition of death in my own case.

    My proxies are in complete agreement with this definition.
Therefore there should be no problems after my death.
My body can be used as I have directed
after my death has been declared
on the basis of permanent unconsciousness.
My plans for donating my body as a living cadaver
can also be carried forward if and when I am declared brain-dead.

    The news media might not be as cooperative.
Some conservative writer might declare that
the use of my body after my death was not appropriate.
This is a good reason for keeping my medical records private.




3.  PERSISTENT VEGETATIVE STATE

    A more controversial definition of death
would allow patients in persistent vegetative state (PVS)
to be officially declared to be dead.
Persistent vegetative state has only recently been identified and defined.
It has emerged as a end-of-life condition
because of advances in medical science and technology.
Our advances in understanding how the body operates
have empowered us to keep the biological functions of the body going
even when the life of the person is completely over.

    Terri Schiavo was proven to have been in a persistent vegetative state
when the autopsy was performed.
But popular opinion before her feeding-tube was removed in 2005
came down heavily on the side
of believing that she was still 'alive' in some sense. 

    Thus, historically-speaking, it will be some decades
before persistent vegetative state will routinely be recognized as equivalent to death.
And here again, such a definition will first be used
only for those patients who have given their permission in advance
for the PVS-definition to be used in their own cases.

    But because being in PVS is such a hopeless state,
and because future advances in neurological science
will make it even easier to diagnosis this condition,
eventually well-proven PVS will be accepted
as an adequate definition of the death of a human person.

    Such a change will have tremendous implications
for the practice of human organ transplants.
Because there are 10,000 patients in PVS at any given time in the USA,
this would become a huge pool of potential organ-donors.
With the advance approval of these donors (while they were full persons),
appropriate medical measures could be taken to achieve a merciful death.
And after death has been officially declared, certified, & recorded,
the reusable organs of PVS donors could be transplanted
into the bodies of patients who are on the verge of death
because their original organs are failing.
This new practice could save the lives of many people
whose minds are still functioning perfectly.
Without new organs, the potential recipients will soon die.

    If the patient in PVS can be declared dead by acceptable medical criteria,
then harvesting the useful organs would not violate the dead-donor rule.
And the PVS donor (after being officially declared and recorded as dead)
could be maintained on 'life-support' systems
while all the necessary tests and preparations are performed
to make the best possible use of the organs that can save other lives.

    The public and the news media will resist declaring PVS patients to be dead.
But after a few decades of discussion,
the traditional practices will be replaced by more enlightened thinking. 
Eventually, large numbers of patients will have their lives extended
by harvesting the organs of willing PVS donors.
While the donors are still fully-functioning persons,
they will have to document their plans to donate their organs
if and when they fall into persistent vegetative state.
And the PVS donors will have to agree in advance
that it would be fine with them to be declared dead
on the basis of irreversible, persistent vegetative state.
After a physician has officially declared the donor to be dead,
other physicians can proceed with the planned organ-donation.

    For each dead-donor, 7 or 8 other lives can be saved.
These people who will receive the organs would otherwise have died,
since there are never enough organs to transplant
into the patients waiting to receive them.

    The 'life' of the patient in PVS will finally be over.
But the viable organs will live on in the bodies of several other people,
who will be saved from death by the donated organs.



4.  ALZHEIMER'S DISEASE

    People with Alzheimer's disease eventually lose
all of the capacities that make a human being a person.
But the millions of people in the United States with various degrees of dementia
should never be defined as dead
no matter how debilitated they become.

    However, when we foresee Alzheimer's as the last phase of our own lives,
we can leave detailed instructions about what should be done,
including a voluntary death or a merciful death followed by organ donation.

    This is the route I have chosen for myself.
I choose (now while I am fully a person) to have my life peacefully terminated
if ever I sink to the level of a former person.
Just when I might lose personhood is defined in my small book called:
When Is a Person? Pre-Persons and Former Persons:
http://www.tc.umn.edu/~parkx032/PERSON.html
This book offers about 200 questions that can be asked by proxies
when discussing the level of personhood in anyone they know.
These questions are organized around the four capacities that make us persons:
(1) consciousness, (2) memory, (3) language, & (4) autonomy.

    If and when I lose most of these capacities that make me a person,
it is the responsibility of my Medical Care Decisions Committee
to decide what should happen to James Park next.
My proxies must make all further decisions for me,
since by the fact of my advancing loss of autonomy, language, & memory
I will no longer be able to make my own medical decisions
including all of my end-of-life decisions.

    I have laid out my end-of-life plans in great detail in my
Advance Directive for Medical Care:
http://www.tc.umn.edu/~parkx032/JP-LW.html

    See especially my Answers in the Quality-of-Life section:

~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~

PART II.  Quality-of-Life Issues                    81

Question 4What level of personhood
    do you wish to preserve thru medical care?
    When—according to your own criteria—
    would you become a former person?
            81

    A.    Questions for Proxies
            about Consciousness and Self-Consciousness.        82
    B.    Questions for Proxies about Memory.            84
    C.    Questions for Proxies about Language and Communication.        85
    D.    Questions for Proxies about Autonomy.            88

Question 5Where do you draw the line between a quality of life
    worth preserving and the remnants of biological life
    that should be mercifully shut down?
            94

Question 6How do you want to be treated
    if you get Alzheimer's disease
    or some other condition that limits your mental abilities?
        97

~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~

    As you can see from the above section of the table of contents
from my book on Advance Directives,
Question 6 directly asks about Alzheimer's disease.

    If I have Alzheimer's disease at the end of my life
(or any similar condition that would make me a former person),
then my Medical Care Decisions Committee
should arrange the most appropriate means to bring my life to an end.
And if possible, I wish to donate my body for all appropriate medical uses.
(This is also explained in my Advance Directive.)

    In short, Alzheimer's disease should NOT be a definition of death,
but it might be a sufficient condition to bring a human life to an end
especially if organ donation might be wise.

    Alzheimer's victims will probably not become
a common source of organs in the near future.
But in the next century, it might become common

to save the lives of fully-functioning persons
by recycling the organs of human beings who unfortunately have ceased to be persons.
And such re-use will first happen for those donors
who have clearly stated such wishes while they are still full persons.
How soon will modern thinking permit merciful death followed by organ donation?




CONCLUSION

    The dead-donor rule should continue to be observed in transplant medical practice.
But the definition of death can advance over the centuries,
as science develops more precise tests of brain function.

    Progressively, we will accept organs from the brain-dead,
from former persons who are permanently unconscious,
from former persons who are in persistent vegetative state,
and from patients who have lost their personhood to Alzheimer's disease.

    Giving our organs to people who can make good use of them
will allow these other persons to have many more years of meaningful life.




AUTHOR:

    James Leonard Park is an independent
existential philosopher and medical ethicist.
He would like to donate his body after his life as a person is over.
Much more can be learned about him on his website,
An Existential Philosopher's Museum,
which has more than 1,000 rooms.



See several other related essays on the Internet:

Life-Ending Decisions for Alzheimer's Patients  .

Choosing Your Date of Death:
How to Achieve a Timely Death
Not too Soon, Not too Late

The One-Month-less Club:
Live Well Now, Omit the Last Month
.

One Million Chosen Deaths per Year?

Losing the Marks of Personhood:
Discussing Degrees of Mental Decline

Advance Directives for Medical Care:
24 Important Questions to Answer
.

Fifteen Safeguards for Life-Ending Decisions .

Do I Lose the Right-to-Die When I Lose Consciousness?

The Living Cadaver:
Medical Uses of Brain-Dead Bodies

Voluntary Execution Followed by Organ Donation



Three bibliographies on the Internet:

Definitions of Death

Personhood Bibliography

Advance Directives for Medical Care—The Best Books


Created March 4, 2010; Revised 3-5-2010; 3-18-2010; 4-29-2010; 7-22-2010; 12-16-2010;
10-23-2011; 4-15-2012; 6-30-2012; 12-13-2012; 3-19-2013; 12-28-2013;


 
The dead-donor rule would also apply to organ donation from executed inmates.



Go to the opening page for this website:
An Existential Philosopher's Museum








The views and opinions expressed in this page are strictly those of the page author.
The contents of this page have not been reviewed or approved by the University of Minnesota.