[tt] Economist: Defining death: O death, when is thy sting?

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Defining death: O death, when is thy sting?
http://www.economist.com/science/PrinterFriendly.cfm?story_id=12332939
Oct. 2nd 2008

Some bioethicists reckon that the definition of death is starting to
embrace the living. Indeed, some reckon that it should
IN THE summer of 1968, while youth was redefining itself in Paris,
San Francisco and elsewhere, a committee at the Harvard Medical
School was busy redefining the end of life. Following its
recommendations, almost all rich countries adopted a definition of
death based on the extinction of activity in the brain, rather than
in the heart or any other organ. In some places, notably America,
that means monitoring the brain's electrical chatter to make sure
the whole organ has died. In others, such as Britain, the brain's
stem is regarded as the crucial part. In this case simpler tests can
be applied, such as whether a patient's pupils react to light.
Either criterion, however, seems more reasonable than just
registering a pulse, since it is the brain, not the heart, that
makes the individual.
At the time, there were some objections to the change on religious
grounds. But the western world's most organised religion, the
Catholic church, did not object. It asked only for moral certainty
that death applied to the whole being, and left the judgment of when
that happened to the experts with the encephalograms. Forty years
on, however, those experts are divided, and the church is under
growing pressure to reject criteria based on brain death, and return
to the alleged unambiguity of permanent cardiac arrest.
The debate has flared up ahead of a conference on organ donation
that will be held in the Vatican in November. One of the triggers
was an article in the Vatican's newspaper, L'Osservatore Romano, by
Lucetta Scaraffia, a religious historian at La Sapienza University
in Rome and a member of Italy's National Bioethics Committee. What
worries Dr Scaraffia is that, as the demand for organs rises,
doctors are under pressure to shift the line that divides life from
death, so that they can get hold of organs for transplant at a time
when they are more likely to be in a healthy condition.
One of the aims of the organisers of the conference, who include the
Pontifical Academy for Life, which ponders these matters on behalf
of the world's Catholics, is to discuss "the importance of spreading
the culture of organ donation". Dr Scaraffia, however, believes the
church is jumping the gun. First, she says, it must address the more
difficult question of when a person can really be said to be dead.
And other doctors, though not necessarily opposed to moving the
line, agree the matter needs to be cleared up.
I'm not dead yet!
In August, for example, Robert Truog of the Harvard Medical School
and Franklin Miller of America's National Institutes of Health,
bioethicists both, published a paper in the New England Journal of
Medicine describing a recent trend to revert to using cardiac death
as the critical marker. But that is not good news for Dr Scaraffia
and her followers for, according to Dr Truog and Dr Miller, the
definition of cardiac death has changed over the years in just the
sort of way that Dr Scaraffia predicted that it might.
Dr Truog and Dr Miller posit the example of a patient who has given
informed consent to the withdrawal of life support in the case of
his suffering devastating brain injury. The doctors respect his
wishes and his heart stops beating. So far, so ethical. But instead
of waiting a few minutes for his brain to die as well, they
anticipate this inevitability and declare him dead immediately, so
that they can hurry along with the business of removing his organs.
Death in such cases is therefore based on a decision not to
resuscitate, not the impossibility of resuscitation. And their
hypothetical case does seem to be happening more frequently in
reality. In America, data from the Organ Procurement and
Transplantation Network, an organisation that matches donors to
recipients, show that those classified as cardiac-dead but not
brain-dead represent the fastest growing proportion of donors,
having risen from zero ten years ago to 7% in 2006.
Dr Truog and Dr Miller reckon this gerrymandering of the division
between life and death will continue as long as doctors have to
abide by the dead-donor rule--that although a living person can
consent to have a non-vital organ removed for transplant (a single
kidney, for example) vital organs can be removed only from dead
bodies. Instead, they propose that someone whose brain is
devastatingly and irreversibly damaged, and who has previously given
his informed consent, should be able to donate vital organs while
still alive.
In practice, says Dr Truog, this would not differ much from what
happens now, except that doctors would be released from the
temptation to fudge the definition of death, or to accelerate it by,
for example, withdrawing life-sustaining treatment. Indeed, the
British government is considering changing the regulations in a way
that would allow just that to happen.
The prospect of having their vital organs removed while they are
still alive might put some people off carrying donor cards
altogether, Dr Truog admits, so the plan would have to be
accompanied by a public-education programme about what irreversible
brain injury means. Nevertheless, his views have alarmed some
people, including delegates to the forthcoming Vatican debate.
Antonio Spagnolo, a bioethicist at the University of Macerata,
Italy, and an expert on the Catholic view of death, says that to
violate the dead-donor rule would be to violate the primary duty of
a doctor, which is not to inflict harm. The definition of death may
have to evolve as science advances, Dr Spagnolo says, but doctors
must continue to declare it based on "humanly reasonable certitude",
and with no ulterior motive--a task, it may be noted, that once went
to the priests.