On the subject of Brain Death
Your interviewer, Harold Henderson, and his subject, Loyola philosopher Father Paul Quay [January 28] seem bent, like Dickens's Fat Boy, on making your readers' "flesh creep."
We quote your two banner headlines, assuming the interviewer or Editor to be responsible for them (such statements appear too absolute and unconditional to fit the role of philosopher):
(i) "If the idea of "brain death' were rejected, the source of most vital-organ transplants would dry up"; and
(ii) "We're not talking about gross murders. We're talking about refined murders, the worst kind of murders, premeditated long in advance."
If the Reader regards this as a fair portrayal of the complex, intimate, bedside issues of physician and family decision during the final days of some patients, nous mangerons nos chapeaux.
We allude to Charles Dickens and the eating of our hats not to be funny, but to indicate that we have both enjoyed a liberal arts education, which Father Quay is quoted as finding notably lacking in "doctors generally"; such an education, he claims, helps its graduates to make the same distinctions that ordinary people and some philosophers can make! These distinctions are shown to be both "common sense" and "moral." We hope that we can make them too.
However, while not wishing to avoid this commendation, we do not feel that our colleagues who lack a liberal arts education are thereby handicapped in relation to the life and death issues which we all have to deal with. The practice of medicine itself is one of the humanities.
The central argument of the interview is that the notion of "brain death," as invoked by physicians, serves to conceal the theft of organs from the still living; and that this is a pattern of contemporary physician behavior.
As physicians, a neurologist and a primary care doctor at a teaching hospital/medical school, we do not feel personally impugned by the general direction of the article or its specific accusations; but rather are saddened by the possible impact of such disinformation on the readers of a popular and usually responsible weekly.
As we shall attempt to show, the notion of brain death (and, for that matter, of the persistent vegetative state) can be helpful to us and to families. They are never on their own decisive in our behavior; and in the overwhelming majority of cases where such complex notions are invoked and explained, there is no question of organ transplant.
To state where we stand on the issue, we personally feel that many more should be encouraged to give advance directives for the management of their final days and to be specific about the use in transplantation of their healthy tissues. Society should be urging more rather than fewer transplants, including those of donor organs.
Your interview implies that, in cases in which doctors invoke their "evidence" for the cessation of higher cerebral activity, the physician or team which advises the grieving relatives will seek to "harvest" the precious organs; or are in cahoots with those who will. This is not so; and the separation is both right and important. The surgeon (at times inappropriately) tends to be kept at bay; the patient's team makes the decisions with the family and based on the known wishes of the individual. The caring team and the transplant team are different teams, and appropriately so since they may be said to represent the interests of different persons (potential donor versus potential recipient).
It is false of your inteviewer and Father Quay to imply that when physicians talk to families about brain death there is a transplant surgeon breathing down the backs of their necks or standing in the wings. Perhaps regrettably, in the overwhelming majority of cases, the patient will have given no clear guidance about the issue, the family will not raise it and it may be inappropriate for the physician to do so. [Nevertheless, it should not be forgotten that it can be a great (often the sole) comfort to families to accede to such a request, for example in the case of a young person killed in a motor vehicle accident.]
It is also important for your readers to know that the flat EEG is never the sole criterion of decision; many of the criteria are dependent upon patient waiting and observation, are clinical observations tending to the conclusion of death. Most frequently, high among these will be such simple, accessible observations as the failure to respond with as much as a tear to the recognition of a familiar voice, the failure, however feebly, to return a hand grasp, and other such "human" and "common sense" criteria as Father Quay could possibly wish to see invoked.
Modern medicine does attempt to resuscitate those once doomed, and in general society applauds: the patient in cardiac arrest after acute myocardial infarction, the child who has slipped under the waters of an icy pool (where the cold may fortunately extend the four minute limit before irreversible brain damage due to anoxia will occur). The patient is found inanimate, at the wheel of the car, alongside the running track, on the garden path in the snow; and is rescued by CPR, by medication and electroshock. At this moment, this life, whose potential for full recovery must in the nature of things be unknown, has absolute priority. The rescued child may be seriously brain-damaged, but we have no way of knowing this and do not wish to take into consideration the human and economic costs of lifetime support by the relatives and health services.
Judging from the photograph, Father Paul Quay is of a generation which grew up when pneumonia was regarded by many as the friend, the quiet killer of the frail elderly; and when sophisticated life-support systems did not offer the prospect of prolonged, ventilator-supported existence.
It is because no one is any longer allowed to die of pneumonia (except if they have no access to health care), because ventilator support is now a possibility that we have to ask our patients in extremis (and, increasingly, long before) what are their specific wishes, not in terms of curative measures where available, of supportive measures, of the relief of pain and suffering in all cases, but whether specifically they wish to be intubated and ventilated, or resuscitated. If they in the first place, or, when they are no longer able to help in making the decision, their family members, wish to persist against our explanation of the odds, even against "common sense," that is thought to be their right.
Which brings us on to the Father's own home ground! We have spoken of the inanimate person found on the path after shoveling snow, inanimate for how long no one knows. We set about the task of resuscitation regardless, with only the interests of this person in mind. There is no thought of organs to be gleaned.
What in simple terms distinguishes this individual from any other is that, whether we can or cannot detect a pulse, we observe no respiration, no signs of animation.
"Anima" is air, breath, life. An "animal" (including human beings) is a creature which is observed to breathe. By extension, the "spirit" (also anima) occupies the body of the breathing creature and escapes with the last breath (dying). All of this was at one time delightfully simple. Even then, the inanimate might simply have fainted: "He is not dead but sleepeth!"
Father Quay offers two simple paradigms of Nondeath and Death: Condition I has a woman in coma and on life support, already a condition which is not the natural state; the woman's life is dependent upon technology and a supply of electricity to the hospital. This specious case progresses rapidly to Condition II, when, while all supportive remedies are still fully operative, the woman dies conveniently in such a short time that no one need worry about the misapplication of precious resources, a separate ethical issue.
Accepting for the sake of argument this unrepresentative case, may one not ask for the help of Father Quay in advising at what point "ethical" death in fact irreversibly took place; or (to put the boot on the other foot) is it "life" or may it be life, in the ethicist's or theologian's frame of reference, when a person cannot lift a finger, is incapable of recognizing or conveying recognition to a loved one, of offering or receiving comfort, is morally incapable of doing a good deed or a bad deed and cannot be weaned from the ventilator without anoxia. What at this point is the state of the "anima" (the spirit or mortal soul)?
A young person is dying of AIDS, a person who received a corneal transplant to restore vision of Jacob-Kreutzfeld disease; we could equally be discussing a patient dying with Alzheimer's disease. Replay the scenario of Nondeath, Death in this context.
There is no question of organ retrieval. We are not going to offer any of their organs to anyone; they would carry the risk of slowly fatal viral disease. They are examples which may be looked at without sensationalism, without terrifying patients or families, without suggesting to them that their physicians are involved in a Frankenstein conspiracy to steal parts of their body while they are asleep. In such a case, may our definitions of brain death or persistent vegetative state not help us in avoiding responsibility for unnecessary cruelty in seeking to prolong vitality without vita?
Tell us please, Harold Henderson, Father Quay.
Tom Madden, MD
Section of Community Health
Department of Preventive Medicine
Senior Attending Physician
Primary care physician
Donna Bergen, MD
Cook County Hospital