The deadly dilemma
Here, literally, is a life and death decision. When do you know someone is dead, irreversibly, so that you may safely take her organs for transplant into people who need them desperately? The answer is not always so simple as one might think, especially when the patient is in intensive care, hooked to various life support machines, the body’s systems being kept alive artificially. It’s a very contemporary problem, thanks to advances in medical technology.
Not so long ago, when a person’s heart or lungs or brain stopped functioning, death followed swiftly. Now, apparently, we can keep a brain-dead woman “alive” through the latter stages of pregnancy until the baby can be born.
'Not so long ago, when a person’s heart or lungs or brain stopped functioning, death followed swiftly. Now, apparently, we can keep a brain-dead woman “alive” through the latter stages of pregnancy until the baby can be born.'
In today’s Age, I have an article about a dispute between three professors – all, so far as I know, men of impeccable professional standing who are concerned to behave ethically. Their argument is about what it is to be brain-dead, which all three accept as the decisive measure in pronouncing someone dead.
And why is this apparently medical matter a proper subject for a religion blog? Because religion and ethics converge, of course, and because there is a religious element: more below. Meanwhile, here is a quick and simple summary.
Bioethics professor Nicholas Tonti-Filippini is concerned that medical practice has advanced beyond the law and is certifying as dead people who might still be legally alive, so that their organs can be donated.
He is backed by Royal Children’s Hospital intensive care expert Professor James Tibbals, also medical director of the hospital’s organ donor program, who puts it even more strongly. He has said that the current test for brain death in most Victorian hospitals is neither legal nor ethical, and that most donors cannot be proven to be truly dead when their organs are removed.
Tonti-Filippini and Tibbals back the existing legal definition of brain death, which is the irreversible loss of all brain function (or the irreversible cessation of circulation). They say it requires an imaging test to be certain of death – that if it shows there is no blood flow to the brain, the patient is definitely dead. The presence of blood would not necessarily prove the patient was alive, but the absence definitely proves death, and that is the only safe circumstance for taking organs for donation, these professors say. Tibbals’s position was put in an important and controversial 2008 scientific paper.
They say the practice in hospitals has moved to a different set of tests, based on the patient’s absence of consciousness, which may leave the mid-brain still functioning (performing such duties as regulating hormones and blood pressure) but allow the patient to be pronounced dead. But they say that if the mid-brain is still functioning, that does not meet the legal definition of irreversible loss of all brain function.
They want the imaging test, which they say is relatively simple and inexpensive, used for each patient.
But the third professor, Bill Silvester of the Austin Hospital, says the clinical tests used in most hospitals, such as testing breathing, are reliable, so much so that no patient on whom the tests have been properly conducted has ever recovered. Silvester, who chairs the death and organ donation committee for ANZICS (the Australian and New Zealand Intensive Care Society, which sets the practice in hospitals) says the other two are wrong about mid-brain function.
Not surprisingly, he is very upset at the suggestion that current practice is inadequate because “these unsubstantiated claims by Professor Tonti-Filippini risk damaging public confidence in a very rigorous process” and “potentially put at risk the lives of critically ill people awaiting organ donation”.
Where does religion come in? According to Tonti-Filippini, this brain-death distinction is particularly important to religious people in Australia because most have a particular view of death: that it involves the separation of the soul from the body. The legal definition, irreversible loss of all brain function, clearly satisfies that, but if there is mid-brain function, with the brain still controlling hormones and blood pressure, a definition which accommodates that does not satisfy the religious understanding.
"It’s enormously significant to the church because people are being diagnosed as dead and their organs are being taken when, as a matter of faith, you’d say they were alive. It’s enormously troubling,’’ he told me.
‘‘I would say such a person is severely disabled, but you can’t say dead.
‘We have moved from wanting to be absolutely certain that this person is dead to saying, ‘This person is in such a state they might as well be dead’.’’
Of course, this is not simply a religious divide. Many religious people will agree with Professor Silvester, and many non-religious people will share the concerns of professors Tonti-Filippini and Tibbals. Both support the principle of organ donation.
I’m interested in where you stand, but particularly how you got there. What factors should count most in weighing this dilemma. To the extent that lay people (like me) can understand the medicine involved – and I have done my best to present the facts accurately and simply – how can we go about deciding such dilemmas?
How would you describe the issues involved?