From the Editors: In this sobering article, Dr. Heidi Klessig warns of the evil that happens when death is redefined. She shares her personal account of removing organs from a brain dead patient and the history of how this nefarious practice became accepted in healthcare. Her warnings teach us how easy it can be for any of us to act wickedly in a group, and that death and life are in the power of the tongue (Proverbs 18:21).
One evening during my anesthesiology residency training in the late 1980s, I came in for night call and was told to go up to the intensive care unit (ICU) and prepare a brain dead man for organ harvesting. I was unprepared for this. I vaguely remembered hearing a medical school lecture about brain death, but I hadn’t really thought much about it. Not wanting to look stupid, I asked the staff anesthesiologist, “An organ harvesting? Is there anything different about this I need to know?”
He snorted and rolled his eyes. “Just be sure someone has actually declared him brain dead. The transplant team can be a little eager.”
In the ICU, my patient was waiting. He was a young man who had sustained a traumatic brain injury during a motorcycle accident. And yes, the neurologist had checked all the boxes on the brain death protocol and declared him to be dead. But on examining my patient, I was surprised to find that he didn’t look dead. He looked just like every other ICU patient I had cared for, and in fact, he looked better than most! He was warm, his skin was supple, and he had a normal heart rate and blood pressure despite being on very little as far as medication.
This experience made me wonder…when is someone dead?
I went back down to the operating rooms and found the attending anesthesiologist who would be supervising me. I reviewed the case with him, and he asked me to present my anesthetic plan of care. I told him that I planned to use a paralyzing agent to keep the man from moving during surgery, and that I would use a potent pain killer such as fentanyl to decrease any heart rate or blood pressure swings that might damage the organs. My attending then asked me if I was planning to use a drug to block consciousness. I was stunned. “Why would I do that?” I asked, “Isn’t he dead?”
I’ll never forget the long look that doctor gave me over his surgical mask. “Why don’t you give a consciousness blocker…just in case,” he said, and walked away. To my regret, despite my doubts, I did as I was told. During the removal of his organs the young man responded to surgery just like anyone else, requiring the same types and amounts of anesthesia. Later, when I discussed this case with a pathologist friend, she said that when she removes organs during an autopsy in the morgue, she doesn’t have to use any drugs at all.
This experience made me wonder…when is someone dead?
Most faith traditions define death as the separation of our immaterial essence (variously described as the soul, spirit, or life-force) from our physical body. In the year 1312, the Ecumenical Council of Vienne defined the soul as the form -- the immediate principle of life and being -- of the human body. Thus, as long as there are signs of life, we must conclude that the soul is still present.
A respect for the sanctity of human life demands that we be absolutely sure that the soul has departed before pronouncing a person to be dead. But because the soul is immaterial, we do not have any device to determine the exact moment of death when the immaterial nature departs. Therefore, as a safeguard against declaring death prematurely, the loss of heartbeat, breathing, and the sufficient passage of time to preclude any return of these functions have been used for millennia to be absolutely sure that the soul has departed.
Brain dead people make excellent organ donors. For one thing, they can’t object! And because these neurologically injured people still have beating hearts, their organs are continuously supplied with oxygenated blood and remain healthy enough to be put into someone else.
But in 1968, thirteen men at Harvard Medical School suggested redefining death in a landmark article published in the Journal of the American Medical Association entitled “A Definition of Irreversible Coma.” Their article has no scientific references. There were no tests, studies, or evidence that people in a coma (who had always previously been considered to be alive) were now somehow dead. The only rationale given by the 1968 Harvard ad hoc Committee to explain why an irreversible coma should be equated with death was utility: it would free up ICU beds, and it would facilitate organ transplantation.
This new definition of death certainly was of great utility because it allowed doctors to skirt the Dead Donor Rule. The Dead Donor Rule is an ethical maxim that is supposed to maintain public trust in our organ donation system. It states that people must neither be alive when organs are removed nor killed by the processes of organ removal. But by simply redefining people with a severe brain injury to be somehow “dead” already, the letter (though not the intent) of the Dead Donor Rule is met by sleight of hand.
Brain dead people make excellent organ donors. For one thing, they can’t object! And because these neurologically injured people still have beating hearts, their organs are continuously supplied with oxygenated blood and remain healthy enough to be put into someone else. Thus, the new idea of brain death yielded the important social utilitarian benefits of providing viable organs for transplantation while simultaneously protecting transplant doctors from accusations of homicide.
But of course, changing a definition does not change reality. People with a severe brain injury are not dead. First, there is no evidence that these neurologically injured people’s souls have departed. Second, brain dead people are obviously not biologically dead: they have vital signs, ongoing metabolism, wound healing, absorb nutrients and excrete waste, heal their wounds, fight infections, and even gestate healthy babies.
Studies have repeatedly shown that about 20% of people declared brain dead still have brain waves on their EEGs, and over 50% still have a functioning hypothalamus – a part of the brain controlling body temperature, blood pressure, awareness, sex drive, and pain.
Third, people properly diagnosed as being brain dead have recovered brain function and improved. Dead people don’t get better! Jahi McMath, a young teenager who suffered cardiac arrest following complicated tonsillectomy surgery, was declared brain dead in California in 2013. She was diagnosed as being brain dead by three doctors (one of whom was the chief of child neurology at Stanford), failed to breathe spontaneously when her ventilator was withdrawn on three separate occasions, had four flat-line electroencephalograms (EEGs), and a “no flow” brain blood flow scan. Yet, after she was statutorily resurrected by being transferred to New Jersey (the only US state with a religious exemption to brain death), she improved to the point of being able to follow commands. Two neurologists who examined her in New Jersey found that she no longer met the criteria for brain death, but was showing signs of consciousness. Death is an irreversible state. The case of Jahi McMath proves that the American Academy of Neurology’s (AAN) brain death diagnosis guideline, the way most doctors diagnose brain death, is unable to predict irreversibility.
And lastly, in the United States, brain dead people are not even legally dead. This is because the US has a ‘whole brain’ legal standard for death, but the AAN brain death guideline explicitly allows people with ongoing brain function to be declared “dead.” Studies have repeatedly shown that about 20% of people declared brain dead still have brain waves on their EEGs, and over 50% still have a functioning hypothalamus – a part of the brain controlling body temperature, blood pressure, awareness, sex drive, and pain. Yet the AAN brain death guideline allows people with these continuing brain functions to be declared dead, and has done so for years in a long-standing disconnect with US law.
Life and death are realities, and as realities are independent of what we think of them. They are not determined by definitional authorities nor decided by majority rule. When a doctor says a person with ongoing biological signs of life is dead, that person does not thereby become dead.
“Brain dead” people are severely neurologically injured, and their prognosis may be death, but they are not dead already. There has been a great lack of transparency as well as semantic obfuscation surrounding this diagnosis since its inception. While doctors, lawyers, and philosophers hotly debate the legitimacy of “brain death” in the academic literature, the public is never told that any controversy exists. Law professor Thaddeus Pope stated correctly in a recent New York Times article that there is no consensus on brain death.
The idea of declaring people to be “brain dead” has always been based on the utilitarian value judgment that freeing up ICU beds and facilitating organ donation is more valuable than preserving the human rights of vulnerable patients. People, especially those registering in good faith to become organ donors, deserve to know that their deaths are not currently being determined based on biology or on a Western understanding of the human person, but on these utilitarian beliefs. Harvesting organs from brain-injured people labelled as “dead” is in fact a concealed form of euthanasia.
People have a right to insist on a death determination that adheres to reality. A compassionate society cares for its most vulnerable members.
Heidi Klessig, M.D., is a retired anesthesiologist and pain management specialist who writes and speaks on the ethics of organ harvesting and transplantation. She is the author of The Brain Death Fallacy (https://a.co/d/30IKlr1) and her work may be found at respectforhumanlife.com (https://www.respectforhumanlife.com/).
