Brain death and organ procurement: New insights from the President’s Council
This issue is much more of a bioethics issue than a research ethics issue, but I think it bears some discussion here.
The President’s Council on Bioethics has recently released a new White Paper addressing the issue of determination of death for purposes of organ transplantation, entitled Controversies in the Determination of Death: A White Paper by the President’s Council on Bioethics
This paper does two things. First it attempts to revisit the debate over the older, more traditional definition of death, i.e., cardiopulmonary death, versus the newer, more widely accepted but less well defined definition of death, i.e.,“whole brain death”or neurological death. In doing so, the Council reiterates the validity of whole brain death as the accepted standard for death and therefore, in this context, the standard definition of death for purposes of organ procurement. Second, it tries to provide new philosophical arguments or rationales for the continuing emphasis (the original President’s Report in 1981 first highlighted this concept and debate) on the validity of neurological death as the accepted standard for determination of death. It essentially does this by redefining the notion of what whole brain death means, from thinking about it in terms of cessation of the brain’s control over our physiological processes to cessation of our meaningful engagement with the world.
While the paper is relatively firm in its discussion of whole brain death, there are clearly still ongoing debates over the definition of brain death. Here are just a couple that both relate to the fact that many feel the definition of whole brain death is still, at best, unclear:
1. Are patients in persistent vegetative states in a state of whole brain death? Traditionally, no. But there is enough disagreement on what constitutes whole brain death that some Council members feel that changing organ procurement practices based on the idea of whole brain death is not wise.
2. Does whole brain death equal death of the human being? Most of us would say “yes” but even still, some would disagree. Again, with disagreement over whether or not the irreversible end of all brain activities, including those that sustain basic life functions constitutes death and therefore an appropriate time for the possibility of organ procurement, is problematic.
The purpose of the paper is to try to clarify brain death in order to make organ donation and timing to donation clearer and less controversial. Some have claimed that this paper has “saved organ donation” by changing the way that we think about neurological or “whole brain death”, from the cessation of control over physiological functions to a complete lack of engagement with the world.
In terms of research ethics, while many organ procurements are carried out with the goal of saving another person’s life through transplantation, it remains that organs are harvested for purposes of research. Transplantation is an evolving science. The White Paper may have implications for procurement of organs for research purposes. It may also have implications for consent and substitute decision-making (in both clinical and research contexts), with the new thinking about what whole brain death means. It is important that research ethics board members are, at the very least, aware of the iterations in the debates over these important issues in the world of bioethics and medicine and take some time to reflect on how these evolving notions have an impact upon the world of medical research that we review and oversee.
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In my personal experience, I feel as though we are limited in our abilities to firmly and conclusively determine when brain death occurs.Just two days ago, I asked an unresponsive patient if he was okay, and told me responded “I am alright.” Two months ago, his wife was told that multiple EEGs, CTs and other tests confirmed that had no meaningful movement, was blind, and would never be able to speak following multiple strokes. At this point, neurologists are uncertain about a prognosis since he is responding in ways that should not be possible.Brain death is an ideal diagnosis for organ donor recipients because it allows for live organs to be properly prepared for donation. However, doctors are not always accurate with their determination.
Anonymous:Your example may show that physicians are poor at prognostication when it comes to states other than brain death, but it doesn’t support your initial statement. Based on your description, the patient was not considered brain dead at any point.I am a conceptual critic of the brain death concept (and a neurologist,) but I have no doubt that patients who meet properly-tested brain death criteria will never ever recover any brain function.