Rest in Pieces

A Monologue: How to Lose Your Body Parts Before You’re Definitely Dead

Listen, everything will be OK. You’re in the ambulance now. You’re pretty banged up (that’s one nasty head injury) but you’re nearly stabilized, and we’re heading to the hospital. Hang in there. I doubt you can hear me—let’s see, weak pulse, unconscious, pupils unresponsive—no, probably not. I’ll keep talking anyway. I’m a medical technician.

Let’s see your driver’s license . . . you’re an eligible organ donor. Good for you! Tens of thousands of people’s lives are extended every year because of organ donation, but over 6,000 still die waiting for one. They say organ donation is the gift of life.

I know, some people get a little queasy about imagining their corneas in somebody else’s head, or having their chests cut and spread open and a surgeon slicing out their heart or pancreas. Just the thought is pretty creepy.

But don’t worry. When we take your organs—er, I mean if—there’s an excellent chance you’ll be dead. Well, quite probably. It depends. This is not China in 2008, you know, where transplant teams were ready and waiting at the executions of political prisoners. This is the United States of America, in the year 2029, and we’ve got ethics. Darn good ones.

Still, maybe I should explain, even if you are unconscious. We’ve got a bit of a ride to the hospital. I’ll start at the beginning.

On the Road

The first successful human corneal transplant was in 1905. The first successful transplant from a living donor, a kidney, wasn’t until 1954, and the first from a deceased donor, again a kidney, not until 1962. The first successful heart transplant was in 1967. The major medical problem then, and still is, that the recipient’s body often rejects the new organ.

The development of anti-rejection drugs and other medical techniques in the 1960s and 1970s led to rising success rates and slowly increasing demand. But there was a problem: Where would the additional organs come from? Most organs deteriorate quickly, sometimes in just minutes, after the flow of blood and oxygen ceases. In most accidental deaths, few organs are usable by the time transplant surgeons can get to the body. But ventilators, which were developed around the same time as transplant technology, can keep the hearts and lungs of patients with severe brain damage pumping and breathing until the organs can be “harvested”— I mean, “retrieved.”

The obvious question, of course, was, How do you know when the patient on the ventilator is dead so you can take his organs? It used to be fairly easy to diagnose death: the person was unconscious, had no pulse or breath, and soon became cold and stiff. But patients on ventilators can stay warm and breathing for weeks, months, or even years. They digest food and produce waste.

So in 1968 an ad hoc committee at Harvard Medical School published a new set of standards for determining death—i.e., “brain death,” the irreversible loss of all brain function—that would allow doctors to remove vital organs without violating the self-explanatory “dead donor rule.” The legal and medical communities gradually accepted brain death over the next two decades to go along with the traditional “cardiac death,” or irreversible heart stoppage, as grounds for determining death. Both brain and cardiac death have been incorporated in various federal and state laws since the 1980s.

You with me so far? Hang in there. We’ve a little ways to go.

Minor Detours

There have always been critics of the idea of brain death, and not just because brain-dead people don’t always look dead. Although physicians insist that the methods for diagnosing brain death are very reliable, on rare occasions patients actually “come back to life,” and that makes people a little nervous.

In March of 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 disconnected the life-support to begin the 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?

Usable organs were still in short supply in the 1990s, when the medical community embraced what is known as “donation after cardiac death.” Basically, when the prognosis is poor enough, the patient’s family and doctors agree to shut off life-support, even if the patient is not quite brain dead. Doctors then wait two to five minutes for his heart to stop beating, plus a few minutes more to make sure, and then they operate.

Critics back then pointed out that defibrillators have revived many people whose hearts have stopped for longer than two or even five minutes. Were those people “dead” too? And what about the definition of cardiac death as “irreversible” stoppage of the heart? If you’re calling a patient dead because his heart stops after he goes off the ventilator, and then you take out that same heart and put it into somebody else and it works, was it really “irreversibly” stopped? Anyway, that’s what some argued.

But let’s be real. It’s pretty unlikely that your doctor will misdiagnose you as dead. And I wouldn’t count on spontaneously reviving after coming off life-support. No, it’s 2029, and we’ve moved beyond that.

You see, the debate over death and its application to organ donation simmered in the background of American society, in the academic journals and the occasional news story, through the 1990s and 2000s. The transplant community believed there was consensus on death, and many, frankly, worried that a lot of discussion would spook the public and make the donor shortage even worse. Doctors thought the whole issue was nonsense; as one told me around 2008, somewhat curtly when I asked, “There is no ambiguity about the definition of death.” So it just never got much public attention.

Course Correction

A few more minutes and we’ll be there. Let me tell you quickly what happened after that.

A handful of medical ethicists and academics criticizing brain death and donation after cardiac death just never gave up. They weren’t saying that because there might be a lack of clarity about the moment and nature of death, we should stop those practices. Well, a few were, but nobody took those people seriously. It would have drastically reduced the number of available organs.

No, instead, most critics were arguing that we needed to ditch the dead donor rule. In the August 2008, issue of the New England Journal of Medicine, Robert Truog, a Harvard medical ethicist, and Franklin Miller from the National Institutes of Health argued that doctors had been “gerrymandering” the definition of death so they could convince the public that they were following the dead donor rule. Better, suggested Truog and Miller, to admit that the patient might be in some sense alive when the organs come out; but contend that consent from the patient or surrogates made the practice ethical.

In retrospect, that was a key event in the development of transplantation practice—when doctors began to debate publicly whether they should remove vital organs from live patients. Once the idea was on the table, in the 2010s a few doctors began admitting, yes, we do that. And then more started admitting it, and soon, basically over the last two decades, the ethics of transplantation were reversed.

It is now unethical to take organs from anyone who is not at least a little bit alive (via life support, of course)—look at the risk to the recipient if you do otherwise! The organs might deteriorate in the interval between certain death and the operation. As Truog predicted, the big thing is consent. Mostly dead, plus consent, and you’re good to go.

Doctors, remember, don’t decide what’s ethical and then do it; rather, if enough of them start doing it, eventually they decide it’s ethical. As Truog said in a panel discussion connected to his commentary (talking about a transplant team that had waited 75 seconds after heart stoppage before taking the heart of an infant), “We know that if they said, ‘We’re not going to do this until there’s a national panel and we get approval,’ that it’s never going to happen. And the way change happens in medicine is somebody goes out and does it.”

That’s just how life is. Abortion and then physician-assisted suicide went through the same process—from unthinkable to unimpeachable—in about the same amount of time. Likewise, donation after cardiac death was somewhat controversial in the early 1990s because it was pretty close to that dead/not dead line. There were only a few dozen cases per year, but by 2009 there were hundreds of cases a year and transplant doctors regarded it as beyond question.

Green Light

So, as I was saying, consent is the critical issue now. Most Western countries passed a law in the 2000s or 2010s stipulating “presumed consent”—the idea that people are presumed to want to donate their organs unless they opt-out while still alive and conscious. Spain, Austria, Belgium, and some others had it by 2008, Britain adopted it in 2010 after a lengthy but subdued discussion, and the United States followed in 2015.

I’ve checked your driver’s license, and you haven’t opted out. Doctors will do their best for you, I’m sure, but you may end up on life support. The physician who treats you, and who will advise your family on whether and when to pull the plug, has nothing to do with organ donation; there’s no conflict of interest. It’s the only ethical way to handle it. Yes, any M.D. knows that organ donations extend tens of thousands of lives annually, and that thousands more people die waiting for one. But that knowledge will, theoretically, have no impact whatsoever on him.

Of course, your name and status, blood type, and so on, are sent to the regional Organ Procurement Organization (OPO) as soon as you get into the system, whether you’re dead or not. These private, nonprofit, government-authorized entities use nurses and social workers to find potential donors, obtain consent from families, and work with doctors and nurses to recover as many organs as possible.

In the old days, OPO representatives weren’t supposed to contact the patient or his family until he was declared dead. But, as the Washington Post suggested in a 2008 article, some OPO workers were already getting a bit more aggressive even then. They started hanging around hospitals looking for potential donors, for example, and asking doctors to administer drugs to thin blood or expand blood vessels—things that help keep organs viable—without family consent.

We’ve moved beyond that, as I say. My title with your regional OPO is Estimator. You’re reasonably young, in good health apart from your injury, and have no external indicators of any major health problems. I’d say you’re worth at least $15 million. To your family, I mean, of course. How, after all, could anyone put a price on the chance to save someone’s life?

Not Dead on Arrival

Now it’s true that in 1984 Congress passed the National Organ Transplant Act. It outlawed the buying and selling of human organs or body parts for transplantation, but permitted dead donors’ families to receive some compensation for burial costs. And we respect that prohibition. We buy no body parts.

But you know how it is. Some folks began arguing that live organ donors deserved a little something for their trouble (take a look at Sally Satel’s 2009 classic, When Altruism Isn’t Enough—The Case for Compensating Kidney Donors), and from there it was a pretty small step to saying that the families of dead donors deserved some appreciation, too. In 2016 a federal court agreed with an Ohio woman that there is no significant ethical difference between covering burial costs and compensating a family for emotional distress from imagining their loved one all sliced up on the operating table.

So that’s what I mean when I say you’ll “almost certainly” be dead when—there I go again, I mean if we take your organs. You may not be technically brain dead if they shut off your life support, but you wouldn’t have any sort of quality of life, anyway. You’ll definitely be mostly dead. And all that money on the table, so to speak, will have absolutely no impact on the decision regarding life support—trust me.

The odd thing is, it might not have been this way. If the public had complained loudly enough when all these things started, the ethics of transplantation wouldn’t have gotten to where they are right now.

Well, here we are at the hospital. Shall we go in? Are you with us? •

When Altruism Isn’t Enough

In her 2009 book When Altruism Isn’t Enough: The Case for Compensating Kidney Donors, Sally Satel, herself the recipient of a donated kidney, argues that we should stop relying on the generosity of others when it comes to organ donation. Citing the fact that 78,000 people around the world are awaiting kidney transplants, not to mention that 4,000 people die each year because friends or loved ones do not give their kidneys to them, she proposes an incentive program as the only viable solution to the kidney shortage, one in which donors would receive tax credits or lifetime health insurance for their donations.

It’s not the first time that such a proposal has been advanced, so it already has its detractors. There are two basic arguments against creating incentives for donors. The first is that people who are desperate for money might donate on this basis alone, and the second is that paying for organs ultimately diminishes the dignity of human beings. However, Satel believes that she has anticipated these concerns, insisting that non-cash rewards would take care of the first problem, while the second would merely require that we consider whether altruism is ever truly altruistic. In so doing, she contends, we would come to realize that gifts are never actually free, and thus are no better, at least in an ethical sense, than receiving compensation for one’s munificence.

Of course, Satel’s answers inspire their own set of questions. Does she really believe, for example, that a couple desperate for healthcare coverage or a college scholarship for their children would not be tempted to sacrifice a body part or two for a chance to realize these dreams? Do we really want people to relinquish organs they might need in the long term to satisfy their short-term desires? And how would cynicism regarding the goodness of mankind ever enhance human dignity? Wouldn’t those who actually believe in the concept be even further affronted by a policy suggesting that they are inherently selfish? All are questions that Satel fails to answer in her book, making its thesis, however well-intended, extremely problematic if not untenable.

Death Before Donation?

According to a 2008 article titled “The Dead Donor Rule and Organ Transplantation,” which was published in the August issue of the New England Journal of Medicine, not one of the medical community’s current definitions of death is satisfactory from the perspective of transplant medicine. Whether you’re talking brain death, heart death, or just plain death (i.e., “cold, blue, and stiff”), you run into difficulties. To wit:

- Brain Death

Situation: A patient declared brain dead on the basis of “devastating neurologic injury” can still “digest and metabolize food, excrete waste, undergo sexual maturation, and can even reproduce.” He also can “breathe spontaneously” and “survive for many years.” Hence, to remove his vital organs is to take them from someone who is not really dead. He is killed by the organ-harvesting surgery. Problem: Ethical

- Heart Death

Situation: Organs must be harvested “2 to 5 minutes after the onset of asystole” (cardiac cessation), but patients have also been “resuscitated after an interval of 2 to 5 minutes.” Plus, “the hearts of patients who have been declared dead on the basis of the irreversible loss of cardiac function have in fact been transplanted and have successfully functioned in the chest of another,” meaning, of course, that the loss of cardiac function wasn’t irreversible after all. Hence, to remove vital organs from a heart-dead patient is to run the substantial risk of taking organs from a living patient, killing him in the process. Problem: Ethical

- “Cold, Blue, and Stiff”

Situation: These patients are definitively dead, but so are their vital organs, rendering them unusable for transplant. Problem: Practical

One would expect the authors to conclude, however sorrowfully, that there is no way to conduct vital organ transplantation that is both ethical and practicable. Alas, they instead argue for chucking the dead donor rule altogether, thus supporting medical “progress” at the expense of vulnerable patients. Problem: Practical

From Salvo 8 (Spring 2009)
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