Organismal death, the dead donor rule and the ethics of vital organ procurement

Guest Authors: 

Xavier SymonsInstitute for Ethics and SocietyUniversity of Notre Dame AustraliaSydneyNew South Wales, Australia

Reginald Mary Chua, PhilosophyCatholic Theological CollegeEast MelbourneVictoria, Australia

Paper: Organismal death, the dead donor rule and the ethics of vital organ procurement

The brain death criterion for death (as it is currently understood in medical practice) was first propounded in 1968 by an ad hoc committee at Harvard Medical School. Since then, there has been persistent debate about whether the the permanent cessation of brain function actually indicates the end of organismal life. Yet recent high profile legal disputes in the United States — such as the ongoing court battle over the fate of American teenager Jahi McMath — have given a human face to some of the key questions explored in this area, and it seems more important than ever to achieve clarity on what counts as an ethically defensible criterion for death.

However, as a survey of recent literature in this journal reveals, the adequacy of the brain death criterion remains strongly disputed. On the one hand, critics have argued that organisms in a state of brain death are not necessarily dead, for the simple reason that, even in the permanent absence of brain activity, the body still remains capable of sophisticated functions, such as respiration, digestion, and the maintenance of homeostasis (with the aid of life-support). For these reasons and others, Michael Nair-Collins and Frank Miller have argued that the brain death criterion is inadequate and ought to be abandoned.

On the other hand, defenders such as Melissa Moschella have suggested that these sophisticated functions are not genuine indicators of life. After all, there are many examples of parts of a human body — such as liver-kidney circuit ex vivo — working together in an integrated way that nevertheless do not indicate the presence of a unified organism. Rather, the real indicator of genuine organismal unity is the presence of a master part — which in mammals is the brain — that exercises global control over the functions of the body. Or so the defenders argue.

Our article adds to this ongoing debate over the brain death criterion. We challenge Moschella’s claim that the real indicator of organismal unity is the presence of a master part. We defend the claim that the persistence of functions such as respiration, digestion and organismal growth, indicate the persistence of organismal life. We argue that these functions — which are “goal directed” in an Aristotelian sense — may be sufficient to indicate the presence of controlled integrated function. To our mind, “control” is more about the expression of goal-directedness in the functions of an organism rather than the localisability of a “privileged organ of control”. If we are correct, then we need not presuppose that some master part needs to be present for integrated functioning to be considered “controlled”.

What implications follow if our arguments are accepted, and the brain death criterion is rejected? It seems necessary to take one of two options. If we retain our current medical practices of procuring organs from brain-dead patients, it seems we must (as Nair-Collins and Miller argue) revise some of the basic principles underlying medical practice, such as the dead-donor rule. There is, however, another option, namely, to maintain the prohibition on the procurement of vital organs from living human beings, and instead, to revise our current medical practices of vital organ procurement from any patient declared brain dead. This is the option we argue for. Rather than weakening the ethical standards for organ procurement, we argue that these standards may have to be raised. Specifically, we suggest that biological markers that typically occur after brain death, such as rigor mortis and algor mortis, may have to be employed as biological events that indicate without a doubt that death has occurred.

Our view is in some respects similar to the account of animal life offered by the philosopher of biology Hans Jonas. Like Jonas, we adopt a phenomenological method according to which life is not just reducible to a series of metabolic processes, but also consists of a vital force present in the body and expressed by the goal directed actions of that body. Where a body is still engaged in functions such as homeostasis and growth (and where a human body is still warm and breathing!) there seems to be at least a possibility that the vital force that defined the life of that particular organism is still there.

 

Competing interests: None declared.

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