Killing the Dead

by Christian Ohnimus                                                                         Wednesday, February 12

Many bioethicists seek to abolish the dead donor rule – which requires that a patient be dead before organs can be removed for donation – by arguing that we already routinely kill patients anyway. Like some well-intentioned pro-lifers, advocates for organ killings equate residual biological functions with signs of life but unlike pro-lifers they do it to intentionally deceive and misconstrue the facts in order to rationalize killing. If the “brain dead” are actually alive then we are already routinely killing them and harvesting their organs. Why shouldn’t we do the same with other persistently brain damaged individuals for the greater good?

In an article published by J S C Med Assoc. entitled Brain Death, Cardiac Death, and the Dead Donor Rule, Robert M. Sade, M.D. argues that:

If brain dead patients are near death but not really dead, recovering vital organs is nevertheless ethically well-grounded. Since 1968, the diagnosis of brain death has been understood to validate both withdrawal of life support and recovery of vital organs, and this does not change at all when brain dead individuals are understood to be in a state of irreversible coma, although still alive . . . if it is acceptable to cause a brain dead patient’s death by withdrawing life support, then it logically must be acceptable to cause the patient’s death by recovery of vital organs before withdrawal of life support.

Note Sade’s insistence on repeatedly using the term “brain dead” to refer to people still alive in an attempt to justify their deaths. This is “ethical” to Sade because we already “kill” brain dead patients who exhibit biological activity like temperature regulation. To Sade, this must signify some integration of the brain. Last week, however, I shared the case of a brain dead 4 year-old whose body continued to function for twenty years. Yet, on autopsy his brain was completely calcified, including his brain stem and zero neurons were found to exist at all. Performing an incredible feat of linguistic acrobatics, Sade declares that the brain dead are alive and that those whose brains are impaired but live are actually dead and that the only logical conclusion from all this is that we should have no moral qualms about killing dead people – a feat I hadn’t even thought possible much less ethically acceptable. But wait, it gets better.

Another argument in favor of killing for organs begins by distinguishing between different kinds of brain death. There is “whole brain death” which refers to the irreversible cessation of function of the entire brain. The medical term for whole brain death is “brain death” and we have already addressed its meaning extensively in previous articles here and here. It is the total and permanent destruction of the entire brain from which no one may return. The other kind of supposed brain “death” is “higher brain death” which refers merely to injury to the higher parts of the brain responsible for consciousness and is something like being “mostly dead.” Bioethicists seeking to increase the volume and quality of organs advocate for the latter definition as the prevailing criteria by which we should declare “death.” Never mind that those who have suffered higher brain “death” sometimes go on to live happy, healthy lives for years to come, like Steven from last week’s article for example. If our consciousness is impaired, however, we are no longer alive they argue and this opens up all new avenues for the butchering of some of the most vulnerable living human beings among us. By the consciousness criteria brain death is extended beyond those who have been physiologically decapitated to the comatose and even to those living in persistent vegetative states – even though they maintain some modicum of consciousness!

In the same article cited above, Dr. Sade argues that the dead donor rule may be “saved” by “changing the standard from the UDDA’s [Uniform Determination of Death Act] “irreversible cessation of all functions of the entire brain, including the brain stem” to a higher brain standard, that is, to permanent loss of consciousness, without requiring loss of brain stem function.” Sade at least has the sense to backpedal, recognizing that such a definition would include people in permanent vegetative states as “dead” despite the fact that, in his own words, “these patients do not even vaguely resemble a state of death.” While many of his colleagues support the concept of “higher brain death,” Sade abandons it, but only because its just as “counter-intuitive” as “whole brain death” and therefore not useful to his predetermined ends. Instead, Sade concludes, we should simply throw out both neurological criteria and the dead donor rule. Only circulatory-respiratory criteria should be used in declaring death (and Sade questions whether this really constitutes death either) and, as for the living, Sade has no problem with harvesting their organs.

When utilitarian argumentation begins by declaring people both alive and dead (everyone who exhibits residual biological functions are alive but anyone whose consciousness is impaired is dead) what objective standard can we expect to stand in their way? The logical end is that people will be killed or spared based on value judgments made by the bioethicists themselves and that’s what they want.

Under the sober disguise of “medical research” advocates of euthanasia, physician-assisted suicide, and killing for organs have abandoned not only the scientific method and actual ethics and morality but reason itself. In the Journal of Medicine and Philosophy, Samuel H Lipuma, in an appeal to the consciousness criteria, goes so far as to make the absurd claim that sedating a dying patient until he passes as an alternative to abandoning him to intractable pain is the same thing as committing euthanasia and outright killing him. That the patient’s brain may be entirely healthy and that the sedation may be reversed at any time does not matter. Without consciousness the patient is dead. The patient is not in a state mimicking death, the sedation does not destroy his brain or stop his heart thus inducing death. The sedation and the unconscious state it causes is death itself. Any disinterested person would disagree. Death requires cessation of function; sedation merely impairs. Death is irreversible; sedation is not. How is such a marvel possible? Because Lipuma says so. Apparently seeking to herald in a Death Revolution, Lipuma declares that we have been forced to accept a “less desirable one-size-fits-all” definition of death. Apparently, so out-of-touch with reality are many bioethical experts that “death” is understood to mean whatever the individual wants it to. “Death” to one person may be entirely different than to another and that’s OK, even if its in defiance of objective medical facts, so much so that clinical decision-making should be based on these subjective feelings and not on clinical examination or test results. I decide when I’m dead . . . or someone like Lipuma does for me. Because unfortunately, such amorphous definitions of death don’t do much for the unconscious patient in the hospital. It does give a whole lot of power to whoever is making decisions on the patient’s behalf, whether it be family, doctors, or, God forbid, bioethics committees made up of deranged bioethicists like Lipuma or Sade.

When life and death are clearly defined according to objective standards independent of personal opinion or agenda utilitarians like Sade or Lipuma don’t have a leg to stand on. As a result, there exists an overwhelming incentive for anyone who advocates killing for organs to muddy the waters and blur the line between life and death as much as possible. The human body is complex and sometimes its genuinely hard to tell if someone is alive or dead. Instead of employing investigative medicine to overcome our own human confusion and discover the truth, bioethicists like Sade or Lipuma exploit the complexity of such situations in order to maximize public confusion. By making it impossible to declare life or death according to objective standards, utilitarians can decide who lives and who dies according to their own ends.

Its my hope that anyone reading this series will leave with an objective, factual understanding of brain death as well as a respect for the necessity of appropriate neurological criteria in declaring death. It is absolutely vital that we understand the medical, ethical, and legal aspects of brain death for many reasons. We all must face death. Hopefully, we will not face it with eyes closed but armed with the truth so that we may make medically and morally sound decisions – for ourselves and for anyone whose life we may be responsible for. Also, we must understand this important issue so that we may stand as advocates for the weak and the impressionable lest the culture of death seek to kill them or poison their minds. Its important that we know what we’re talking about, not only so that we may know and accept when someone has died but also so that we may know when they still live and fight on their behalf.

Christian Ohnimus is a husband and registered nurse in Grand Rapids, Michigan. He holds a Bachelors of Science in Nursing from Franciscan University. He hopes to raise a holy family with the help of his better and more beautiful other half.

When the Dead Look Like the Living (and the Living Look Dead)

by Christian Ohnimus                                                                         Wednesday, February 5

Last week I discussed what “brain dead” means, medically. It does not refer to a person in a coma or a vegetative state. “Brain dead” means that the brain is dead, it is destroyed, its function is completely lost and will never be restored. Brain dead is no less dead than cardiac death. There’s no switch to flip back on, you will not wake up. The soul has departed and the union of body and mind has permanently disintegrated. With that said, serious concerns surround the issue of brain death.

Steven Thorpe, aged 17 at the time, suffered severe injuries in a car crash. Surgeons performed a craniotomy to relieve pressure on his brain but he was nevertheless declared brain dead after doctors failed to detect any brain waves. Thankfully, Steven’s parents got another, unaffiliated neurologist to re-examine him. This second opinion saved his life. The neurologist found brain activity and Steven has since made a near-full recovery. So what happened? Steven was “brain dead” and then he woke up! Not quite. He was never brain dead and the brain activity that the second neurologist found is objective evidence of this fact; Steven was misdiagnosed. We rely on medical experts to make clinical judgements at every step of the health-care process but they are fallible and, sometimes, incompetent human beings who can err, sometimes gravely so. Such was the case with Steven when he was erroneously declared brain dead by his doctors. The fallibility of doctors is in no way unique to diagnoses of brain death. Doctors have made every mistake under the sun, including misdiagnosing cardiac death as well. Yet, misdiagnoses of brain death get a lot of attention and its not unwarranted. There are no uniform criteria for establishing brain death. Requirements differ state by state and, often, even from one hospital to another. When we do not hold our medical personnel to basic standards of care then we are asking for incompetence or, worse, abuse – but more on that next week.

Even when brain death is not misdiagnosed, however, many people, under the noble intent of erring on the side of protecting life, still insist that the brain dead are actually alive or, at least, that we cannot be morally certain of their death. The reason behind this belief is that mechanically ventilated brain dead people exhibit so-called “signs of life” like assimilating nutrients, fighting infections, maintaining homeostasis and body temperature, growing hair, healing wounds and even gestating fetuses and undergoing puberty. In one case, “a ‘brain-dead’ four-year-old boy lived on for 20 more years. He fought off serious infections and went through puberty before succumbing to pneumonia.” and yet, “An autopsy showed that his brain and brain stem had calcified; there were no neurons at all.” He was truly brain dead. His brain was destroyed and he would never wake up. What were so-called “signs of life” were what are medically termed “residual biological functions” resulting not from life but from mechanical ventilation and artificially sustained perfusion. The brain is dead but the tissue, organs and endocrine glands necessary for residual biological functions are kept viable by machines. With the brain obliterated the body has been physiologically decapitated and, like an anatomic decapitation any residual biological function that may occur is not a sign of life but merely evidence that the other constituent parts of the body have yet to lose all function of their own. The person is gone. While these functions may be sustained seemingly indefinitely by machines some may linger hours or even days after the heart has stopped as well. Cell lines can be procured from cadavers days old, meaning these cells must be alive and still functioning, even long after death of the person.

The actual signs of life looked for on clinical examination when considering the possibility of brain death are responsiveness, brain stem reflexes, and breathing. These signs differ from functions like cellular respiration in that they are nor merely indicative of tissue viability but demonstrate that the seat of the mind, the brain itself, still possesses some function. Conversely, if all of these are wholly absent then the patient may be presumed dead. If their heart is beating it is only because it functions independently of the brain and is being oxygenated by a machine. In the absence of this machine the heart would stop. Does this method of declaring death sound much different than how it has been done for millenia? Its vital that the well-intentioned seeking to save the brain dead understand these realities, not primarily so they may accept the mortality of the brain dead but so that they may adequately oppose those who seek to undermine or pervert neurological criteria for declaring death for their own utilitarian purposes. I am talking about those bioethicists who agree with the pro-life sect seeking the abolition of brain death, not so that they can protect patients but so that they can kill them. These bioethicists who seek to undermine the concept of brain death and redefine the neurological criteria for declaring death do so in order to justify killing for organs, and they will be the topic of conversation next week.

Christian Ohnimus is a husband and registered nurse in Grand Rapids, Michigan. He holds a Bachelors of Science in Nursing from Franciscan University. He hopes to raise a holy family with the help of his better and more beautiful other half.

Are the Brain Dead Really Dead?

by Christian Ohnimus                                                                         Wednesday, January 29

The Culture of Life naturally seeks to preserve human life and defend human dignity. This is a wonderful thing, but sometimes we can let our emotions get the best of us and, in our good intentions, argue from ignorance. This is often the case regarding the bogeyman of “brain death.” Its a scary medical term that we don’t always understand, summoning images of people, sometimes children, with beating hearts on life support, declared dead by a seeming technicality so that utilitarian doctors can harvest their organs, fresh and still warm. Its a chilling image indeed but its power is in emotion and not facts.

So, let’s lift the veil and take a look behind the curtain. What, exactly, is brain death and are the brain dead really “dead”? According to Catholic Health Care Ethics: A Manual for Practitioners brain death “typically refers to the irreversible loss of all functions of the entire brain, including the brain stem.” Blessed John Paul II affirmed the ethical use of brain death criteria in his address to the 18th international congress of the transplantation society Tuesday 29 August 2000, where he stated, the total disintegration of that unitary and integrated whole that is the personal self” takes place when there is “the complete and irreversible cessation of all brain activity (in the cerebrum, cerebellum and brain stem). This is then considered the sign that the individual organism has lost its integrative capacity.”

Thus, for someone to be brain dead, their brain must cease functioning entirely and this cessation of function must be determined irreversible. Brain death is not the same thing as being in a coma or a vegetative state. There is no coming back. Yet, we’ve heard the stories of patients who were “brain dead” making miraculous recoveries. The truth is that they were never really brain dead and were declared such erroneously. Believe it or not, whether declaring brain or cardiac death, sometimes doctors are wrong. Its actually not always easy to tell if a patient has passed on. Thus, certain biological traits of death must be observed so that death may be declared with moral certainty.

To declare irreversible cessation of function of the brain, the patient is clinically examined and must be totally unresponsive, completely lacking all brain stem reflexes, and unbreathing. Additionally, the medical team rules out any conditions that may mimic death like locked-in syndrome, hypothermia or drug intoxication. Clinical examinations are often repeated after an interval of hours or even days of observation, sometimes multiple times by different doctors, and additional and more sophisticated testing may also be performed. All of these steps are not performed because brain death represents some hazy technicality but because it is important that, when declaring a patient dead, doctors can demonstrate with moral certainty that a genuine total loss of function has occurred and that this loss is irreversible. Highly sophisticated “life support” can give a dead body the vague appearance of life. A dead person may exhibit “residual biological functions.” For example, inotropic drugs can maintain a blood pressure even in a dead body and mechanical ventilation can inflate and deflate the lungs and “breathe” even after both the brain and heart have stopped. Life support can keep a body warm and pink long after the person has died and well perfused organs and tissue can still maintain some modicum of function even completely separated from the body. Hair can grow and wounds can heal; this is also why organ transplants are even possible at all in the first place. Transplanted hearts and kidneys remain alive the entire time as they make the journey from donor to recipient but that doesn’t mean that their original owner is still alive.

Kenneth Iserson, MD offers a good analogy for understanding just how concrete brain death is:

In death by brain criteria, the body is physiologically decapitated. In an anatomic decapitation, the head is actually chopped off but the heart continues to beat for some time, spraying blood from the severed neck arteries. Yet, despite the continued pumping of the heart, there is no question that the person is irreversibly dead.

The body, even when kept alive on machines, is no longer a living person when anatomically or physiologically cut off from the head. The tissues and organs may remain perfused but the person is gone. The death of the brain results in the disintegration of the person; the soul has departed and only the body remains. Any living tissue exists only in a mortally disintegrated state. To be brain dead is to be truly dead.

Circulatory-respiratory criteria, the criteria for declaring cardiac death, is far more straightforward. The heart stops beating and the patient’s code status determines whether efforts are made to resuscitate them. Either immediately after the heart stops or after exhaustive resuscitative efforts are made the patient is declared dead after two to five minutes of no circulation or respiration. It should be noted that, even in cardiac death, which to many has come to be viewed as “more dead” than brain death, organ function and even resuscitation can remain possible for a surprising amount of time. Two to five minutes is not long enough to guarantee irreversible loss of either cardiac or even brain function. To declare absolute certainty of death, even when adhering to circulatory-respiratory criteria, would require letting the patient sit cold on the table for hours. It could be days or longer before the body is no longer viable on the cellular level. Such would be an unduly burdensome as well as unnecessary endeavor both for medical professionals and families alike. Moral certainty suffices in declaring cardiac death and it suffices in declaring brain death as well.

It should be clear from this explanation of brain and cardiac death that a patient who is brain dead is actually dead and not merely declared so on technicalities for convenient legal purposes. In fact, the diagnosis of “brain dead” is far more rigorous and exhaustive than that of cardiac death which, while truly irreversible when properly diagnosed, can occur before the brain has actually lost all function irreversibly – meaning that metaphysical (and brain) death may yet still occur some minutes after cardio-respiratory arrest (cardiac death).

Brain death is not something to fear. The neurological criteria to determine death is a tool, one we must seek to understand so as to assure that it is used properly. The conversation does not end here. Real problems exist regarding brain death. Brain death is misdiagnosed, abused, and confused and we must possess a mature moral and medical understanding in combating such ailments lest our good intentions be drowned by our ignorance. I will address the issues surrounding brain death’s misapplication next week.

Christian Ohnimus is a husband and registered nurse in Grand Rapids, Michigan. He holds a Bachelors of Science in Nursing from Franciscan University. He hopes to raise a holy family with the help of his better and more beautiful other half.