New Yorker Annals of Medicine (link from David Brake): As Good As Dead:
“Confusion about the concept of brain death is not
unusual, even among the transplant professionals,
surgeons, neurologists, and bioethicists who grapple
with it regularly. Brain death is confusing because
it’s an artificial distinction constructed, more than
thirty years ago, on a conceptual foundation that is
unsound. Recently, some physicians have begun to
suggest that brain-dead patients aren’t really dead at
all—that the concept is just the medical profession’s
way of dodging ethical questions about a practice
that saves more than fifteen thousand lives a year.”
In essence, the paradox is this. Most people think it would be unethical to kill a person for their organs, even if they are irreversibly moribund. So they have to die of some other cause before their organs can be harvested. Yet, it is physiologically ideal that the organs still be perfused and oxygenated right up to the time of harvest and transplant, i.e. come from a living body. The solution? The concept of brain death, when it is asserted that, no matter what other functions remain, the neocortex or seat of consciousness is irreversibly defunct.
Critics say this is “conceptual gerrymandering”, in reality a quality-of-life judgment and places us on an ethical slippery slope — would some profound degree of impaired self-awareness, e.g. in extremely brain-injured patients or the senile elderly, qualify? Can someone become “so
devastated that they had lost their claim on
existence”? Persuading the family of a dying person that ‘brain death’ is ‘death’, to obtain their consent for organ donation, is a matter of semantic niceties. But if, as extreme critics insist, someone ‘brain dead’ is not ‘dead’, where does that leave us? Are they ‘alive’? Are they, philosophically, a ‘body’ or a ‘person’?
Even proponents of the ‘brain death’ concept are known to express anxiety that “the public” not know what doctors have come to know about the practice. Critics suggest that, in the interest of ethical explicitness and scientific rigor, we begin to say we are harvesting organs from patients who are “as good as dead.” Then we can start to discuss the overwhelming ethical dilemmas that would bring up.
[I have always carried an organ donor card. Now my head is spinning with degrees of the complexity of my decision I had not even considered, and I am a physician! For the sake of the position my wife or children might have to be in to carry out this wish of mine, I will have to rethink my preferences carefully in light of this article.]
